24337 APPLICANT TO FILL IN INFORMATION WITHIN-'RED LINES — USE BALL POINT PEN ONLY
Building Project Identification - PERMITNO33
i, - 7
Building Addreas: - •/ A 1
L{ — �tl1JDlPL4 a G 41
where 11.hhxw CIIMINC, CITY OF CUPERTINOQBUILDING DIVISION
bntradors Nama: Lr.N. APPLICATION I PERMIT
CO,12� , 'Li 39gIb BUILDINGELECTRICALPLUMBING-MECHAMCAL CATEGORY CONTROL
A hitect/Engineer. Llc.No -
CI '"' BUILDING�PEhMITdNFO "r i'
- �aI , . QTv. - 1 t E�.ECTRIC PERNYIT tis$ .t
Address: �u;.aI
69. L Nl L.,l4F,Zl PERhRTISSUANCE - `_ LJ ❑
LICENSED CONTRACTOR'S DECLARATION I
Ihembya(fbmtlallam Bcensedunderprovielonaof Chapter9(mmmena APPLIANCESRFADENTIAL )Oil DESCRR'TION
.. ingwithSe on7")of Dlvtsion3ofthe Busimwand PmfelsmsCode,and my � s
Ilcense Is in fullf ire and effect, PANELS
License lam Lick 34Q tb3 ,
Date Centimeter 7,,,e q–' UP TO 200ANTS
ARCHITECTS DECLARATION MI-1000AMPS
OZIundemtandmyplamshzllbeuwda.pubhcmmrds. - OVERI000AMPS 0 $Q IT.ODR AREA $/SQ.FC.
qqq O II -PF�fjj`����
5
Licensed Professional I- SIGNS ELECTRICAL
Z F�.� N '
Z Fo¢' Y OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MIST "�"°� 111 J �`) �, R
iv:( Ihereb afflrmthat l am exemptfromthe Contractor's Lineae Law frnthe
O following reason(Section 7031.5,Business and Professions Code:Any city or
P Zt't9 county which requires a permit to construct,alter,bnprove,demolish,or repair TEMP.METER ORPOLH INST.
g� '� anyaerocture prior to its lsse.em,alsorequires theappllcaot for such permit to
k5�w file a signed statement that he Is licensed pursuant to the provisions POWER DEVICES
of the _
31"I. Contractors License Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC _ VALUATIO.
F�O:•1 slon3oflheBuslneseand Profemlom Code)orthae helsemmpttherefromand
•77 the basis for the alleged exemption. Any violation of Section 7031.5 by any UTLE•S-SN7.CCFIESFI%7lJRE5 F'7
applicant for a permit subjectstheapplicantto a civil penalty of not mere than - '�1 .2.q� �•
live hundreddollarshepro - NEW RESIDENTIAL ELECTR STORIES TYPE CONSTRUCTION
❑I,as owner ll the property,or my employees with wages r[herr sole �'�'
compensation,B.A.d lhework,endtons;Cohe Codeure:The
Contractor or Law
O d for
sale(Sec. pply 70K Bu sinessandf property Code:The Contractors Llreme Law
3$ . whododoes tapply torn unser ofpropertyhisonemporimprovnprovided that such
- OCC.GROUP RES.UNITS
whodoementsas such notinte dedoroughed own�.If,
ho en however,
dehatsg or
' improvehmmis renotintendneyear fcomoreale.th owner-g deer ill have -
improvementismldwilhlnoneyearo(completion,the owner-bullderwlll have 1 "
thi*rdon of proving that he did not build or improve for Purpose of sale) QTy.t;�.,= ,'(? umiINGPEiig1,Ftttr'_' .`;FE$:I FLOOD TONE APN
u 4 as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construe the project(Sec.7044,Business and Professions Code:
The Contractor's License taw does net apply to an owner of property who ALTER-DRAIN&VENT WATER(EA)
builds or Improves thereon,and who contracts -for such pW*u with a - i•;tit a
,fit.[actor(#licensed pursuant to the Contractor's Lice..Law. BACK FLOW PROTECT.DEVICE i " FEE;SUMMARY•`
LII am exempt.under Sec. H&P C for this reason
mer Data
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_
WORKMAN COMPENSATION DECLARATION RHCER'T p
❑I hereby affirm that I have a certificate of consent d self-insure,(Sec. fr PER TRAP ., SCHOOL;TAX Y_ N
40RECEIPT a "
1 certificate of Workers'Comperu(a�tloanelnsuranre rnaartifled copythereef(Sec: GAS FA.SYSTEM-1 INCAOUI1,M PARK FEE Y N_
Fol ry a�e,?Gt7'd I 1 DZ� - - AECER?p
GAS.F.A.SYSTEM-OVER 4(HA)
COm an
�] BUILDING DIVISION FEES
Certifichilled copy is hercbyth the city " i _ GREASE/INDUSTRL WASTE INTERCEPTOR •PLANCHECKFEE �^
Certified copy b here with the city Inspection division, 9 \J
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
E
I
COMPENSATIONNSURANC
(Thlaseelen need CnetO be completedtithe permit fairer one hundred dollars SEWER-SANRARY-SCORMEA.2DIFI' Date Remi t#
($11D)orlessJ ' - WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
I cent empthatloy
oy an person in annce mannerhe work w as to
this eermlt h bo the
I shall not employ any person in any manner ro u to become subject to the
Worken'Compensatlon Lawaof Callfornla.Dare WATER SYSTEM/,TREATING PAID '
Z Z Applicant
NEW RESIDENTIAL PLMB. Ff. Date - Recei f#
Z O NOTICE TO APPLICANT:ILafter making this Certificate of Exemption you
should become subjce t to the Worken'Compensatlon provisions of the Labor TOTAL:
CC N Code,you at fort hwilh comply with such provisions or this permit shall be - ^�
deemed revoked. L ING FEE
CL C CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL I hereby affirm that there lea construction lending agency forthe perform ELECTRIC FEE
Z anceofthe work for whitbthls permit b Issued(Sec.3097,Civ.G TOTAL
O O Lender.Namen�/pe PLUMBING FEE
LL F Lender.Addres. / a QTY ,`;; =MHCkANICA4•P4IRMIT1 ?"i.,'•,�'EE•,i MECHANICAL FEE
OW Icertifythatl havereadthts applicationand statethattheabovelreformatlnn
G ecorrect.I agree to comply with all city and county ordinances and Rate laws PERMIT ISSUANCE �— TEES-PAID:
} relating to building constroction,and hereby authorize representatives ofthls I '
H Z city to enter upon the above-mentioned property for inspection purposes. ALTfRORADDTOMF:CH. Date Recei f# '
z (We)agree to save,'IndemNty an d keep harmless the City of Cupertino P
against BabilltMa,pdg nro,metered expenses which may In anywayaccme AIR HANDLING UMT(TO 10,fIW CFM) SUB AL;
gal q aid Ciu In co . uence o(the granting o(thb permit
/9 C_ AIR HANDLING UNIT(OVHR10,000CEM) CONSTRUCTION,TAX
Sigratureof Applicent/ .ntractrn Data EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HA DOUSMATERIALS DISCLOSURE
Will the applicant or future building ompant store or handle hazardous - HEATING UNIT(TO 100,W0 BTU) Date.
material as defined by the Cupertino Municipal Code,Chapter 9.1 RfCej t# .`
Y P P M 7,and the - V
Health and Safety C ion 2553$.)7 HEATING UNIT(OVER 700,000 BTU) TOTA
❑Yee No
which
erme applicant r rebuilding as defined
ndby tequipmant he Bay Area devices VEN'HLATION PAN(SINGLE RESID) ISSUANCE,DATE
whlcheManaemente air contaminants as de(Ined by the Bay Area Air p 1!
silty Management Dist ct7 BOILER-COMP(3I-R'OR 100,0(D BTU) H
❑Yes Ne
Ihave read thebaz materials iequirementsunderChapter6.95o( BOILER-COMP(OVER IW,OW BTU)
the California Health&Safety Code,Sections 75505,25533 and 25534. I OCT 3
understand that lithe building does not currently have a tenant,that It is my - NEIN RESIDENTIAL MECH. SQ.F
C C
responsibility tonotifytheoc pant of the requirements which most be met 1
pilo ssuance fa Ce Tec no Oavpancy.; Cl`�Y UI• Ct1F
1
O,vmrm..th.n.d age. Dae ' -
' T I ISSUED BY:
OFFICE COPY