24278 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PFRh9TN �] Q
Building 3SO eS'F �N/V V I L L 27
I U
wnera a IAL DAIE
F}jjiQ,ELR '�(�—WS CITY OF CUPERTINO-BUILDING DIVISION ?� .Z-
1Wonlj[}pc(tloreName: a1 /.,, Lic.Nr:/ APPLICATION / PERMIT
m ` o'j �4A wti 317 122'43 BUILDINGELECTRICAL-MUMBING-MECIiANICAL - CATEGORY CONTROL N
Architect/Engineer. Lk.No:
Co '� QTY ELECTRICPERMIT FEE, BUILDING PERMIT INFO
Addrcu 4S f..kJ Pd'f PERMTIS5UANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATIO
I hereby afflrmthat l am licensed under provisions of Chapter 9(comurac. APPLIANCES-RESIDENTIALJOBD 2IPC[ON -
IngwithSad1on7000)of Divblon3 ofthe Buslneaand Pmfasi.n.Codgand my
licenx l.I.fo o adeffed. PANELS
Licen �I Ian Lic.#
Date �Contndor t 1 Ls
ARCHITECT'S DECLARATION 201-1000 AMPS
{Q++aO Zp I understand my plans shall be used as public records. OVER IODO AMPS SQ.Fr.FLOOR AREA $/SQ.FT.
E (� Licenacd Professlmal SIGNSELECTRICAL
«<< w OWNER-BUILDER DECLARATION
�n�Fla SPECULCIRCUIT/MLSC
Io„ 7�. !hereby afRrm that lam exempt(romthe Contrac[ole Licence law(orthe
•09 following reason.(SeR1an 7QI15,Business and Profeealone Code:Any dty or TDARMETPRORPOLEINST,
G� county which requires a permit to constmcgalteq Improve,demolish,orrepalr
an stmdure riortoita ame,al b thea Umntforsuch rmitto 0—�
O a file a signed statement that he h licensed pursuanttothe provisions of the POWER DEVICES —• I\F n �I 11 '1
Contract.e.License law(Chapter 9(commencing with Section 7000)of Divi- I L_✓
sion3ofthe Buslnesesnd Profewbm Code)orthathebexempttherefmmand SWN4MINC R�OL ELGCTItIC .. r1 - F--) VALOKION
6$ the basis for the alleged exemption. Any violation of Section 7WIS by any
applicant for a permit subjects the applicant to a civil penalty of nor room than NEWOUTREST WfILAL FLETIIR
O five hundred dollars($500).
I,a owner of the property,or memployees with wa es as their sole al RESIDLNTIAL EIEC OIZI TYPE CONSTRUCTION
�n ❑ P orltand
Y6
< compenatlon,wUldoNewoPrf.1he Cda:rehno[Intended oroffered.Linfor _ _ _ _.�,
$ ❑ sale(Sec. pply Business and f property
Code:Th^Contractors License fa d
(i $ dos notapplytoanowner ofthmaig ywhobuildsorimprovvidedtatand such OCC.GROUP RES.UNITS
who
provementsam khimself dedorwgh hlaawne.If,hoe;pravldNilding or
Improvementsarenot Intended earofred(oracle.If,h ner-p cider ldingve TOTAL:
improvenr•nthwld withinoneyearofcompletion,theowner-builderwlllhave
tllp„);urdcn of proving that he did not build or Improve for purpose of sale.). QTY, PLUMBING PERMIT FEE FTOODTDNE —TPN
—
a.L ae owner of the property,am exclusively contracting with licensed I PERMIT ISSUANCE
O
contractms to comLuct the project(Sm 7014,Business and professions Code: Q
The Contrsdora License law doe,not apply to an owner of property who ALTER-DRAIN kVENT-WATER(EA)
builds or Impr. .thereon, and who contracts for such pWieds with a
r9aliad.r(s)licensed pursuant to the Contradm'a License law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec B h P C for this reason
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N—
• Owner Date ftCCFR'f a
WORKMAN COMPENSATION DECLARATION FD(TURES PER TRAP SCHOOL TAX Y— N_
D/hereby affirm that 1 have o lmumne of convent to pythemo (Sa RWELpr N
certificateofWorken'Compeaatl.nlaursnceoracertlfLd copythemof{Seco GAS FA.SYSTEM-1 INCAOTILEIS #�
3800,Lab CJ # tfD PARK FEE Y_ N_
Polity p I2FCEE'f p
Com GAS EA.SYSTEkf-DYER 4(EAJ
^Y BUILDING DI VISION Fr.ES
Certified copy h herebyFurnishedthe
city CREASE/INDUSI'RL WASTE INTERCEPTOR PLANC14ECK FEE
�Certlfled copyh(iled with the city lmptt[lon division. '
CERTIFICATE OF MMPFION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER- STORM EA 200FT Date Recei t#
(Ihh session need fid be complded If the permit h(.cone hundred dollars
(410 WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
Imitify rtlfy that lathe perforrtunce of the work(orwhich this penult le issued, N—
I shall not employ any person in any counter so as to became subject to the WATER SYSIA(/TREAHNG
Worker!Compenutlon LawsnfC Ufor^ia.Date PAID'
O Z Applicant Date Recei t#
Z O M
NOTICETO APPLICANT-.If,after making this Certificate.(Exemption,you NEW RESIDENTIAL PLMB. SQ•FT,
Hshould become subject to the Workers''Compemat ion provhlom of the Labor TOTAL:
CN Code,you most forthwith comply with such provisions or this permit shall be
j deemed revoked. BUILDING
dCONSTRUCTION LENDING AGENCY - SEISMIC FEE
I hemby affirm that them h a construction lending agency forthe perform ELECTRIC FEE
M Z once of the work for which this permith Issued(See. CN.C.) TOTAL: Q"p
(� O Lenders Name 14Z
PLUMBING FEE _0
U. Lenders Add., QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W 1 certlfythat l have read this application and state that tbeaboveinformatim,
4 hconect.l agreeto comply with all city and county ordinances and nate law, PERMIT ISSUANCE FEES PAID:
>. relating to building construction,and hereby authorize representatives of this
(. 2 city to enter upon the above-mentioned property for inspection purposes. ALTERORADDTOMECH.
(We)agree to save,indemnify an d keep harmless the City of Cupedlno Date Rcceipt#
V against llabllitles,Pdgne ts,costs and expense hichnoylnanywayacdue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
aga Luta City In consequ of the at this permit.
AIR HANDLING UNIT(OVER IO,ODOCFM) CONSTRUCTION TAX
Sig na o RI
Applicant/Con r dor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUSMATEALS ISCLOSURE
Will the applicant or future building occup tit store or handle hazardous HEATING UNIT(TO 100,0DO BTU) Date Revel t#
material as defined by the Cupertino Municipal Cade,Chapter 9.12,and the -
IlealthandSafetyCode,Sectlon 25537(.)? HEATING UNIT(OVER 100,DM BTU) TOTAL:
❑ Yee No
Will the applicant or tum Wilding occupant use equipment ordevices VF11rnUTION FAN(SINGLE RES[D) ISSUAN E.DATE
which emit hazardous air contaminants as defined by the Day Area Air Ng to31�
• Qrality M.nagemem t ct? BOILER-COMP C3HP OR 100,0(0 BTU) (G W '
4Ya o
have read lealthhe a us mater,Sod iom
25505,5533 anChapter 255346.95 of BOILER-COMP(OVER 100,OW BTU) S
theersUadt Health he bSafety Code, oteu ently have a Land,that
SEP 8 992
understand that n tIfy the ing occupant
oft emq i haves tenant,D at b mat NEW RESIDLN77AL METH. SQ.FT.
responsibility to ndify the mxvpant.(the requl mems which at be mat OF vUr IIVsJ
priort^Lcs nm ora Certifi^cateof Occupancy Ys I_I 1T Gfsl
vVel -�u k
Own( authorized agent Date ISSUED DY: A
TOTAL:
OFFICE COPY