24227 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building 24227
nets ame: A A A
CITY OF CUPERTING'-BUILDING DIVISION
Rcontr et°r Name: L . APPLICATION I PERMIT (6 2
BUILDING-ELFCTRICAL.PLUMBINGMECHANICAL, CAT-GORY CONTROL#
A tett/Engineer. s L .N .
�f QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BIL� ELLCF PLUME, IV=
Ad PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATIO
I hereby af(Irm that lam licensed under provisions of Chap" - AlaIaLIANCESAE5IDENTIAl JOB DESCRIPTION
'ng with Section 7000)of Division 3 ofthe Business and Professions Code,and my 11
lire..is in folljorre and dlect. a PANELS . \)����
Limn la _ Lic.p
Date Con eUP TO 2DOAMPS
ARC", ECLA I ION 201-1000 AMPS
O ZO I understand my plan shall cap comords. OVER 1000 AMPS SQ.FI'.Id.00R AREA S/SQ.Fr.
E Z. Licensed Professional SIGNS ELECTRICAL
GG Q ro OWNER-BUILDER DECLARATION
rn 7 371„v� Ihereby afRrtnllutlamexempt fromthe Contractor's License law fee the SPECIAL CIRCUIT/MLSC '
following reason.(SMI°.70315,Businessand Professions Code:Any city or
TEMP.METER OR POLE ANSI.
county which requinesa permit to mtrod,alter,Improve,demelish,or repair
ns '
a nystm=mpriortolb( ame,aLsorequU theappBcantforsuchpermitto
POWER DEVICES
file a signed statement he a licensed pursuant to the provisions of
3f` Contractor's License Law(Chapter9(commencing with Section 7000)otDlvi-
rn SWIMMING POOL ELECTRIC
�1� he bolt for
Code)iolatihelaexemptliallZromand VALUATION
< the baab for the permit
alleged exemption. Any ,violation of SMIon not room
by any OUTLETSSWIICHFSFIXTURES
��5 applicant fora permit subjectalhe applicant toa civil penalty of morethan
QQ five hundred dollars($5W).
m.0 NEW RESIDENTIAL ELECTR Fr.
I,as owner of the property, _SQ.Fr. TYPE CONSTRUCTION
compen. �n ❑ p perry,or my employees in with wage as thele door
d for
C .1,(Se 7044,wBldothework,andthes Code:The
Contot ctor'nded o License
Law
$a O sae(Sec apply to an ow and Professions Code:The C impmoves LImnsn law
HQ
don notapplysuch loan owner of throng his onempW(Ids orimprovnthereoRand
whodonsuchwarkhlm.Borlhrwgh hisownemployees,provided that such OCC.GROIJP RFS.IINI'f5
improvements are not intended cautioned for sale.If lorweveq thebuildleg or TOTAL:
improvement Wold within oneyearofcomplMlon,the owner-bis Oder will have
thg.�iirdenof proving that he did notbuildorimproveforpurposeofoe.). QTy, PLUMBING PERMIT FEE FLOOD ZONE APN
u 1,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
mianctors to cons54,construct the project(Sec.70Business and Professions Code:
The Contractor's License Law does act apply to an owner of property who ALTER-DRAIN&VENT-WA
Wilds or Improves thereon, and who contracts for such p(ojecb with a FEE SUMMARY '
c,.I aetor(s)licensed pursuant to the Contractor's License Law. N3. i
LJ 1 am exempt under Sec. B& P C for th m n o f BACK}T.OW PRO1FpT_9 C
OUTSIDE FEES
Owner mDate Ir
•, I,' DRAIN&FLOOR ROOF'' SANITARY RECEIPT
WORKMAN COMP 5 ON DECLARATION 1 A l` pyX:I.URFS1'ER SCHOOLTAX Y N
❑I hereby affirm that I have a cenlfimte of eon.nt m selfdn.e,or RECEBT N
certifimteofWorken'Compensatlonl nm mnifkd eopytheieof(Sm.
3800,Lab C.) 9 GAS F.A. II PARK FEE Y_ N_
cY I.<. II / Rff=- N
Pdl N GAS FA.SYST�M-OVERd(FA)
Co,�my_a�'nY/� n hL ami Qt�� � -l—:. BUILDING DIVISION PEES
��,LLLLL,���������JJJJJffff'''��_�������e i copy hereby ed. 9'' GREASEANDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
nified copy b filed with the city Inspection division.
CERTIFICATEOFF EMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWTIRSANFTARY-STORM EA.200FT. Date Remi t#
(this section need not 4 completed tithe permit la(°rune hundred dollars
(SIM)°`less.) WATER HEATER W/VENT/ELFCTR ENERGY FEE Y N
I certify that In the performance of the work forwhlch this permit is Lswmd,
1 shall not employ any person in any manner m as to become subject to the WATER SYSTEM/TREATING
Workers'Compensatlog Lgsofrr liffomla.Date PAID
O Applicant A ,- Date Remi t#
Z'Z NOTICE TO�NTi7.r,aX king this Certificate of Exemption,you NEW�E9DENTfAL PLMB. SQ IT.
0 should become avbjeR to the Workers mns
'Coprauon provuionsuf the Labor .TOTAL:
N Coda you most forthwith comply with such provisions or this permitshall be BUILDING FEB
W
> deemed revoked. .
CONSTRUCTION LENDING AGENCY SEISMIC FEE
a Z Ihereby affirm that there is a mmtruction lending agency for the perform TOTAL ELECTRIC FEE
O
7 Z anceofthe work forwhichthla permit 6 097
'.s,ed(Sec.3 ,Civ.C.)
U ,.du .N.. 731aPLUMBING FEE
IL V Lr.dcr',iAddren QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW Icesifythatltuvemadthb pplcetlonandatateth ttheaboveinformation
1 lacorrect.l agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
>_ 11. to building construction,and hereby authorlu repre.ntatives ofthis
F N city to enter upon theaBove-mentioned property for lnaposlon purposes. ALTER OR ADD TO MECH.
Z (We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Receipt#
O against liabilities,ydgmenta,costsand expenses which may In anywayaccroe AIR HANDLING UNTO 10,000 CFM) SUBTOTAL:
against said City in consequence of the grant Ing d this permit.
AIR HANDLING UNIT(OVER I Q000 CFM) CONSTRUCTION TAX
Sign,iure of Applicant/Contractor Data EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT GO 100,ODO BTU) Date Reeej t#
material as defined by the Cupertino Murddpal Code,Chapter 9.IZ and the
Hrabha.d Safety C, e n25532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL:
Yes No
W111 the appilont or tore building occupant use equipment or devices VFNIILATION PAN(SINGLE RFSIU) ISSUANCE,DATE
which emit tueardous air contamirants as defined by the Bay Area Air P
Quality Management Dista 7 BOILER-COMP OFR'OR 100,0(0 BTU)
4Yes o
haYe read the haves nutedala requircrrcntn under Chapter 6.95 of BOILER-COMP(OVER100,000 BTU) OCT 7 1992
the Califomb Health& fety Code,Sections 75505,25533 and 25539.1
understand that lithe building does not currently have a tenant,that it k my NEWRESIDEMTALMECH. SQ.FT ,
responsibility to notify the occupant of the requirements which must be met T111IV V
prior to issuance ofa Certi(iwto Fancy. CITy fj�r UUrCIM0
err or out ent Date ISSUEDBY: "�`�A
TOTAL:
OFFICE COPY