24217 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Pr.en Identification PERMIT
Building Address: N2421 7
Q. 4217
nems am: A
A?q (�P7kQ x�L.Aa� 9IV- CITY OF CUPERTINO-BUILDINGDIVISION
Contradore Name: L m APPLICATION / PERMIT (5
BUILDING-!].ECTRICALPLUMBINGMFCHAMCAL N
At hlted En neer. CATEGORY CONTROL
QN ELECTRIC PERM IT FEE BUILDING PERMIT INFO
Addre e PERMITISSUANCE ❑ ❑ }Q ❑
LICENSEDCONTRACTORISDECLARATION �JJ
I hereby affirm that l am licensed under provisions o(Chapter (Co enc- APPLIANCESRESIDENIIAL JOB DESCRIPTION
Ingwhh5nctbn 7000)of d affeon3.(the BuNnessand ProtesalonaCode,and my �
license's in tun ice and affect. a PANELS
Lire Lle N v aRa1F\rl1!'_S}VC
Dat Cmdra 10 UP TO 200 AM
ARCHITE DEC 1 N ]01-1000 AMTS '
GlG�uv rc0 O I understand my plaresshall be used as reCords. OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
E Licensed Professional SIGNSELECTRICAL
<<� OWNER-BUILDER DECLARATION BPECIALCIRCUIT/MLSC
t.., thereby a(@m that l am exempt fromthe Contradors License Law for the
p pppp following reasom(Section 70115,Butlnemand Prefestome Code:An ci or
�ZI"' county which requlresa permit tormented,alter,Improve,demolish,Any
- TEMP'METER OR POLE INST.
anystmmmpdortoltsimance,al mquimstheappllcantforsuchperMtto ROWER DEVICES
O a file a signed statement that he s licensed pursuant to the provisions of the
y C.ntrzctora License Low(Chapter 9(Commencing with Section 7000)of Diel-
SWIMMING POOL FFLFCTRIC VALUATION
BOJ slon3olthe Business and Prefemlore Ccul0tolhat he s exempt therefromand
the bass for the alleged exemption. Any violation cef Sedlon 7611.5 by any OUTLETSSWITCHESFDlTURES
applicant fora permit subjects the applicant to a civil penalty of nor more than
five 1, dred•owner onhe B.
pro NEW RESIDENTIAL ELECTR SQpL STORIES TYPE CONSTRUCTION
7 G ❑I,as owner of the pthe roperty,or my employees with wages r[herr sole
compensation,7044,Busiwill ness
awork and toes Code:dere t dol Intended o coffered far
O sale(Sec. pply to anowandf pmperty buldsThe Contractors License law
$$ docs nonsuch toanowner of or throng hisonem oymproovidedves reoryand OCC.GROUP RIS.UMTS
whodoeawch am net intended
hisownemployees,providedthatsuch
improvementarcnotintended earofco mortal,.ILhowever,the
er ldingoe TOTAL:
Impr.vem.nttsold withinoneyrarofcompletioRtheowner-bu0derw111 have
the burden of proving that he did not bund or improve for purpose.(sale.). QTY. PLUMBINGPERMIT FEE ' FLOOD ZONE APN
u L as owner of the property,am exclusively Contracting with licensed PERMIT ISSUANCE
contractors to Conslrud the project(Sec.701y Business and professions Code:
The Contractor,License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER CEA)
or Improves,theorem, and who mntnda for such pUojecs with a
dor(qumnndpunuantrome C.ntrad.e.Li. s.Law. FEE SUMMARY
BACK FLOW PROTECT.am exempt under Sec. B k P C for this reason DEVICE-
DRAINSFLOOR,ROOF,AREA,COND. SANITARY Y N
Owner Date
WOR COMPENSATION DECLARATION RECEIPT Y
❑1 hereby affirm that I have a certificate of consent to self-insure,ora FIXTURES PER TRAP SCHOOL TAX Y N
i^ mdRiate.fwarkers Compensation Insurance ora ceniRed copy thereof(Sec. RFLEPTM
MOD Lab C.). CAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y_ N_
Policy N I Z RECEIPT M
AC� n GASEA.SYSTEM-OVER 7(EA) BUILDINGDIVISIONPEES
ed ed copy therebyhomis a ertified ropy is filed with the city Inspection division. GREASEANDUSTRL WASTE INTERCEPTOR PLANCHECICFEE
CERTIFICATE OFF DIPTION FROM WORKERS' GREASE TRAP PAID
R !�(/�
COMPENSATION INSURANCE SEWER-SANITARYSTORM EA 700F'-T Date Recei t# Size
hssneed norbe completed[(the permit,Tamen,hundred dollen
($100)orlmsrss.).) WATER HEATER W/VENT/IIECTR ENERGYFEE Y N
Icertifylhat In the performance o(lhe work forwhich this permit is ued,
I shall not employ any person in any manner so as to become subject to the WATER SYSTEM/TREATING
Workera'Compensatio V of California.Date PAID
zO Z A IICnt NEW RESIDENTIAL PLMB. SQFT. Date Recei t#
AOlicart MPLIC R,aftermaking thsCenlliate ofE imp tors,you
Hs mldbemmesubject oche W.rken''Compematlonpmvtiomo(the Labor qq ` TOTAL:
N Code,youmustfonhwlthmmplywithauchprovslonsorthspeeo tshall be I -) [' T ,�
> dermrd revoked. BUILDINGF '
CL C CONSTRUCTION LENDING AGENCY ,Q SEISMIC FEE
Ihereby affirm that them samnsnmctlon sndingagency for the perform TOTAL: ELECTRIC PEE
Z ance of the work for which this permit is Issued!(Sm 3097,Civ.C.) .��
V O Lender.Name '�b PLUMBING FEE
LL I— Lender,Address QTY. MECHANICAL PERMIT FEE ' MECHANICAL FEE
O W Iceni(ythatlha read[ Is ppnation and Asia thattheabovelnfemnation
Ismrred.l agree to comp) with all city and county ordinances and state Taws PERMIT ISSUANCE FEES PAID:
IL relating tolerlding mrutrudion,and hereleyauthorme representatives ofthis
Zcity to enter upon the ab.vcnentloriM property for inspection purposes. ALTERORADDTOMECH.
(We)agree to save,Indemnlly an d keep harmtss the City of Cupenso Date Receipt#
V against liabilities,jodgmenta,ms.and expenses which may In any wayamue AIR HANDLING UNIT(T010,OD0 CFM) SUBTOTAL:
.�
against said City In consequence of the granting of this permit.
AIR HANDLING UNIT(OVER 1 BOX CFM) CONSTRUCTION TAX
Signature of Appliant/Contractor Data EXHAUST HOOD tW/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the appllesnt orfutum building occupant store or handle haaardous HEATING UNIT(TO 100,000 BTI[) Date Recei t#
materials,defined by the C pectin.Munldp.l Calc Chapter9.IZandthe
Health and SafetyCode Ion 75531(•)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: ,/ID
Yea No
Will the appilcant turn building occupant use equipment or devices VENTILATION FAN(SINGLE RESN) ISSUANCE DATE
which emit havrdoue Ir lamimntaa defined by the Bay Area Air
Quality Management st 7 BOILER-COMP tlHPGR 1W,IXq BTID -
Yes No
have read the hoz ou,materials requirement under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU)the Callfornla health Safety Code,Sections 15505,75533 and 15537.1
undent ed that if the building does not currently have a meant,that it is my NEW RESIDENTIAL MECH. SQ.IT
rnp.nslbillny to notify the occupant of the requirements which moat be met o(aT 1yDL.
pri.rto�anceo(a Cxnlficat f mpancy. VV!
Z7 .+g177sl7`d
.meth.' agent Date ISSUF.DBY:
TOTAL:
OFFICE COPY