24057 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Bulldln Pru ed ldentlflotlon 't PERMITNO
Buildin/g�A�ddlress:
ne 'ld\ SRS%OWIV— SU N Pi<V W4_- 11. n
O C
�` SUBMITTAL
E4(a—'
CITY OF CUPERTINO-BUILDING DIVISION
con °ra
Lie,No: APPLICATION /PERMIT �—
s gl'.q BUILDING-MPCTRICAL.PLUMBING-MECHAMCAL CATEGORY CONTROL#
Architect/Engineer. Lic.No:
Qn ELECTRICPERMTT FEE BUILDING PERMIT INFO
Address J3� ` GISla t s PERMITISSUANCE X ❑
LICENSED CONTRACTOR'S DECLARATION
IherebyaHkmthat l am licensed under provisions of Chapter9(commene- APPLIANCESRESIDENTIAL JOB DPSCRD7ION
Ingwlth5 dlon7000)ef DiWsion3ofthe Buslnemand ProfesslonsCocia melery -
IicenselelnluBforce ddfed. PANEIS /� 1
Limnsegla Lk.#�'J&
Date Contractor V % -it %40. UP TO 200 AMMI` vY` VVV _,i
ARCHITEC75 DECLARATION 301-1 DJO AMPS �l
NO Zp lunde.tand my plaru sM1all be used as publlcremSQ.FT.FLOOR AREA rds. OVER 1000 AMPS $/ .FT.
oLicensed Professional SIGNS ELECTRICAL
caw OWNER-BUILDER DECLARATION
Fd
{"n SPECIALCDRCUT/MISC
0FR owing raf0rmthatlam 31.5,Business
d Proctors License Gov fmthe
qqqqqq following reason.(Section 7001.5,Business and Professions Code:Any city or
F I"uy rountywhlchmqulresaperrNttommtmd,alter,Impmvgdemolhh,orrepair, TFMP.MEfTiROR POLE INST.
`S 3 anysimaumpdortoib Wuancgae requU theappU=tforsuchpemtto
ryE ills a signed atatement that he is licensed pursuant to the provhin.of the POWER DEVICES
Contractor's License Low(Chapter 9(mmmencingwith Section 7000)ofDivi.
CO slon3 oflhe Busluessand Pro(essioru Code)orthat he Is exempt therefromand SWIMMING POOL ELECTRIC ,V(ASLUATION
the basis for the alleged exemption. Any violation of Section 7631.5 by any OUTLETS-SWITCHES-FIXTURES
applicant fora permit subjects the applicant to a civil penalty of not more than J
five hundred delta.(5500). NEW RESIDENTIAL ELFCTR
11,.....er of the property,or my employees with wages as their sole SQ'FC. STORIES TYPE CON91RUCTION
�7a compensation,will do the work and the structure is not Intended or offered for
F N O vie(Sec 7014,Buttes.and Pnefeasku.Code:The Contractors License law
does not apply to an owner of property who Wilds or Improves thereon,and - OCCGROl1P RP5.UNITS
who does so&work Mm+eBorthrough his own employees,provided that such
Improvements are not intended proffered forsale.If,however,thebuilding or TOTAL:
Improvement hsoldwithlnoneyearofcompletlogtheowner-W Bderwlll have
tt(„}iurden of proving that he did not build or Improve for purpose ofule.). QTY. PLUMBING PERMIT ' FEE
LJ FLOOD ZONE APN
I,as owner of the property,am exclusively Business
and
with licensed PFITISSUANCE
noconContractor'.
construct iventhew jectdoe(Sec,70Kapply
8uslne o and of feadoes,property
Code: -
The Contractor's U¢Me law aces rad apply tct; f owner d property who ALTER-DRAW k VENT-WATER(EA)
W lids or Improvar tpursua and who contracts; for such plajects,with a
offIcai'm a empt under
See,
the Contractor's License Law. BACK FLOW PROTECT.DEVICE' .FEE SUMMARY
V I am exempt urWer Sec B 4 P C /or Mh reason
OUTSIDE
DRAINS FLOOR.ROOF, GOND, SANITARY Y T#
Owner Date RpIP.p p
WORKMANCOMPENSATIONDECIARATION❑ FIXTIIRFS PER TRAP SCFIOOL TA% Y N I hereby affirm that I have a esrllRote of consent to self-inwre,or RECEIPT_ NM
3800,Lab C.)
certificate of Workers!Compensation]vumore or a certified ropy thereof(Sec. CAS EA.SYSTFM-0INC40UTLEfS PARR FEE Y N
Co11ry N GAS EA.SYSTEM-OVER 4(EA) DFNGD'T M
Cray BUILDING DIVISION FEES
[Certified copy is heed with the
- GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
'
F-1 Certified copytaflled with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GRFASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200FT. Date Rem [It
(Thio section need net be completed tithe permit h(Drone hundred dollars
($10()orleas') WATER}iEA7ER W/VENT/}yFC.I.R ENERGY FEE Y N
Icertifyth Int mance r
ofthe work forwhich this permit is issued,
1 ehaR not cent, ray pe n In any manner soas jo gGco�a subject to the
tl'Y WATER SYSTEM/TREATING
Werkers'Compe V of CalDornta. Date PAID
0 Z Applicant NEW RESIDENTIAL PLMB, SQFr. Date Remi tic
ZO NOTICEco APPLE he orkersfter k Compensation
ateof Exemption,you
sM1widbecomesubjecttothe Workers'Compewtlonpmvhis p ofthe Labor TOTAL:
LUN Cade,you must forthwith comply with each provisions orthh permit shall be IN 0
W > deemed revoked. •
IL F3 CONSTRUCTION LENDING AGENCY SEISMIC FEE a
lherebyaflmitthat there Is a construction lending agency forthe perforro- ELECTRIC FEE .r
Z ance of the work for which this permit h Issued(Sec.3097,Civ.Q TOTAL: '
f1 O LeMer'a Name PLUMBING FEE
IL h lander.Address QTY. " MECHANICAL PERMIT FEE MECHANICAL FEE
O W p
I certlfythat l have readthhappheationand statethattheabove Information
a is corned.I agreeto complywlth all city and county ordinances and Mate laws PERMITISSUANCE �Q FEESPAID:
} W relating to building construction,and hereby authorlm representatives ofthts
F Z city to enter upon the above-nr.u.ned property for impaction purposes. ALTER OR ADD TO MECH. Date ReCef til
_ e)agr to save,Indemnl(y an d keep M1armiess the City of Cupertino P
agaW b lk pdgment7=.%:nd expenses which may In anywayacerue AIR HANDLING UNIT 10,000 CFM) SUBTOTAL•
againsi s lid
cmi ,race o(the granting of this permit.
AIR HANDLING UNIT(OVER 10,000CIM) CONSTRUCTION TAX
Signature of Appllcntrador Data IX}IA[J57 HOOD(W/DIKT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazanlous ' HEATING UNIT(TO 100,610 BTU) 00 Date Recel t#
material as defined by the Cupertino Municipal Code,Chapter 9.1Z and the
I lealth and Safely Cade Section 25532(a)T HEATING UNIT(OVER 100,000 BTU) TOTAL: .010
qYes No
illthc applicantor tore building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit haurdous air contamiunts as deflned bythe Bay Area Air PAID p #y
Quality Management District? BOILER-COMP DIIPOR 100,000 ITU) eve IIT A 1 D
Yca ❑❑No
Tuve read the hazzrdouseratenata requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) 4 1992
the California Health k Safety Code,Sections 35505,25533 and 25534, L WAUG
1 UG 1(�
understand that if the building does not rrently have a tenant,that it lsmy NEW RESIDENTIAL MECII. A
SQ.IT
resporulbilily to notify the occupant of the requirements which=at be and '
prior to Issuance of a Certificate of Occupancy. CITY ser -U"CnI INQ
Owner or authorised agent Date 'fix x
TOTAL: 3 ISSUED BY:��1 Vic
OFFICE COPY