23998 (2) PPLICANT TO FILL IN INFORMATION WI (THIN RED LISE BALL POINT PEN ONLY PERwiNo.
ildingAddress: i C , amu: 239.98 .
Wn Bim/BIIIe: ,jOn¢: .
251-- 2� - CITY OF CUPERTINO-BUILDING DIVISION
G°ntatt°`°N'"e` Lle.N°: APPLICATION / PERMIT
Architect/Englnar;
BUILDING-ELTE:]RfCAL-PLUMBINGMECHAMCAL - CATEGORY CONTROL
Lie.No:
r. - n• 'f "' " t _ BUILDING PERMIT INFO, .'
Address'
ELECTRICPERMIT .4s1 �¢, $FE ' l{� -'
. .
ISSUANCE r . I ❑ ❑
L�
LICENSED CONTRAROR'S DECLARATION ..Z�"� '
I hereby affbm that!am Blamed uM^ Ido 1. f Chsr'_t',;,.nman APPLIANCESRESIDENTIAL JOB DESCRIfT10N "
IngwhhSectWnhomeandvl;Ape2.jMe8uBinem`antl i'm,wmon'ni,',ae,and my
lirnnseis in(uB fora wDW14¢t. PANELS
.Liana Cbm C.ra
Date Contractor.,'. UP TO 200ANVS
ARCHITECTS DECLARATION 201-1000 AMPS
2C: 1 understand my plana shall he used u public records. OVER 1000 AMPS SQ.Ff.IT.00R AREA 5/SQ.FT.
U Limnsed Profemtorul .. SIGNSELECTRICAL
OWNER-BUILDER DECLARATION SPECIAL CII2C[BT/MISC
I hembyafflrmthat l am exempt from the Contractors Ltmnw Law for the
following reason.(Section 7031.5,Business and Profession Code:Any city or TEMP.MEI7iR OR POLE 7NST.
county which mqulmsa permit tommtroct,alter,Improve,demollsh,orrepalr
< anystr Mmpri°rtolts Lswance,elwmquirestheapplianiforsuchpermttm POWER DEVICES+
V file a signed statement that he Is limned pursuant to the provlslom of the
F Contractor's Licewe Uw(Chapter 9(mmmencing with Section 7000)Of DIA- SWIMMING TOOL ELECTRIC
.J7 elon30f 1he0u Blnessand Profemlom Code)orthat he Ls exnmpttM1ere(romand VALUATIQN.
the basis for the alleged exemption. Any violation Of Section 7031.5 by any
appllact
ntfora permit eubjesthc appllanttaativll penalty of net rtnrethan OUTLCTSSNOTCFIFSFIXTURFS
five hundred dollars(5500), . a
�n ❑I,as owner of the property,or my employees with wages as their sole NEW REMDFN77AL ELECTR SQ.FT, l 670W[S 7Y1'E—CONSTRUCTION
compensation,will do the work and the Btmctum is not Intended or offered for
O sale(Sec.70K Hinimns and Proteadra Code:The Contutlols License law
$ don not apply to an Owner of property who Wilds or Improves thereon,and -
who donsuchwork himself orthrough his own employees,provided that such OCC.GROUPRES.UNITS
Improvements are not Intended oroffered forsale.If,howevegthe building or TOTAL:
improvement6s ldwlthinoney¢arofcompletion.theowner-bu0derwillh.ve
ttElkurden of proving that he didrwt build or Improve for purpose Of sale.). Cry. - PLUMBING PERMIT °t FEE -, FLOOD ZONE. APN
Lj L as owner of the property,am exclusively contracting with licensed p fT LSSUMrCC•
co tractors 10 construct the project(Sec.7044,B.d cls incl Profeniou Code:
the Contractor's Liana Law does not apply to an owner of property who ALTQt-DRAIN&VENT•WATER(FA)
Wilds Or improve ill--,and who contracts for such ptt
�.jes with a
cgp4ryaorts)licensed pursuant in the Contractor's Liana Law. '' 'FEE SUMMARY
elf"I am exempt under Sec mass
ion&P C for this ren BACK FLOW PROTECT.DEVICE
' Owner. - DRAINS FLOOR ROW;AREA,GOND. SANITARY Y. N_'
Date RECEIPT g
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOLTAX Y— N_
❑I hereby affirm that I have a l n ne of concent to.styself-insum,Ora RECEIPT N
ccrtlffubc.) orke,e'Comperuatlonlruuranceon certilled copy thereof(Sec. GAS FA.SYSTFAM INCA OUTLETS PARK FEE Y N
3800lab CJ :-
T N
Cff0C GAS EA.SYSTEM- DINCRECEDIV
Com any OVER6(EA) pUILDINC DIVISION PIiiiS' _
�CertNed copy Is hereby fumCREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
�Certlfled mpybfiled with.11m
e city city inspection division.
CERTIFICATE OF EXEMPTION PROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWF.R-SANHARY-STORM EA 200FT Date -Recei t# .
Qhbaction need ata he completed If the permit is forne ohundred dollars
(b100)nfyth In WATER HEATER W/VFM/ELECTR ENERGY FEE Y N
tarot thatoy oy. anumIaofthework for to hich
pesubjcrmit Is blued, —
I shall not employ tion Lrs.n In any manner w as t.berome subject to the WATERSYSTTM/TREATING
Workeri Compensation Laws o(Glifomla.Date - PAID
Applicant NEW RESIDENTIAL PIMB, Date Recel tN
NOTICETO a subp t to the,after making perhis athu,pro of Exemption,you —�'hT'
Code,shoulbecome forth to the Workers'CompemasonproWiOmrmit of Labor be , TOTAL:
Code,you trust forthwith comply with such provisions or this permitBhallbe BU ING
deemed revoked. SEISMIC FEE
CONSTRUCTION LENDING AGENCY
'[hereby affirm
work
aermiti Issutioned
lending ,Civ.ncy C.) perform, TOTAL: ELECTRIC FEE
once of the work for which this permit la Lowed(Sec.3097,Civ.C.)
Lander'.Name PLUMBING FEE
Lend.e.Addreu QTY. ''MECF7ANICAI:PERMIT° r FEE i MECHANICAL FEB
I certifythat I have read this application and statethattheabow information
Is correct.I agreeto comply with all city and county ordinances and state laws PERMIT ISSUANCE FEESBPAID:
relating to building construction,and hereby authorize representatives°lthts
city to enter upon the above-mentioned property for inspection purpose, ALTTMORADDTOMECH. - -
(We)agree to ave,Indemnify an d keep harmless the City Of Cupertino Date Receipt# '-
agatest llabillika,pdgmenta,cold oe whichmayinany sea ecrue - AIR HANDLING UNIT 8010,000 CFM) !TAX
AL'
agalrrat sal n conseyu f the Ba i g of t emnit.
B AIR HANDLING UNIT(OVER 1QOOo CFM) !CONSTRUCTIONr reof Applicant/Contract. DatE(HAUS'r HOOD M/DUCT) - STRUCTIOHAZARDOUS MATERIALS DISCLOSU E Will the applicant orfuture building occupant store.,handle hazardous HEATING UNIT(TO 100,000 BTU)
material..defined by the Cuperti n.Municipal Code,Chapter 9.1$and the Date tN
I ealth and Safety Code Sedion25532(a)P t- HEATING UNIT(OVER 100000 BTU) - TOTAG �
r-1Yes �No
Will the applicant or future building occupant use equipment ordevices VWIILATIONpAN(SINGLERESID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air '
Quality Management District? BOILER-COMPOHPOR100,of0BTU)
qYea t1 NO - - pp p
have read the hav .NumWrLfl.requlrementsunder Chapterii.95of BOILER-COMP(OVER 100,000 BTU) r N
the California Health&SafetyCode,Seciton,25505,25533 and 25534. I ���
understand that If nottlyhe occupant note wrmntly have that It be mot
NEW RESIDFN77AI.MECH. SQ.IT. 2
responsibility to Isla ce of a Cthe occupant 0l the requlrcmenta which must be met
prior to Issuance o(a Certificate ofOttvpanry,,
_
CITY 4r ( I nip
VU
Own¢rorauthoriand agent- Date ISSUED BY
TOTAL:
OFFICE COPY