24236 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NQ, 4 23 6
Building Address:
Z
w ase:
q IA3%L* r 1I Ctq. g CITYOFCUPERTINO-BUILDING DIVISION G� A
C&IST&i $ +��►�r gle.Ne: APPLICATIONIPERMIT 1�I�� Z
Architen/Engineer. BUILDING-ELF CTRICAI.PLUMBINGMFLHAMCAL CATEGORY CONTROL M
S QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add.. PFRMITISSUANCE •"� ❑
LICENSED CONTRACTOR'S DECLARATION
I herebyde7000atf M.1.3.fth. erprovblonsof Chapter9de,and y APPLIANCES-RESIDENTIAL J BDFSCRBxfION
Itonse1in fonforecadeffeon3oftheBusinesandlaro(nslonsCode,ands ♦�..tt �
limns.b In toll farce and steer. PANELS
License Chs. Llap 1
Date Contnctsr UP TO 2DOAMPS
ARCHITECT`S DECLARATION 201"1000 AMPS
q�q�uu reOX I understand my plans shallbe used as publlcremtds. OVERIOJOAMPS SQ.FC.FLOOR AREA S/SQ.FT.
Licensed Prateslonal SIGNS ELECTRICAL
I<n< FEEFBd�v OWNER-BUILDER DECLARATION 7ALCIRCUIT/MLSC i
7l" a Iherebyaffmm
irthatlaem.pt fromthe Geturmorb Llmnselawforthe
p following reason.(Settle.7031.5,Business and Proteslons Code:Any city or
Iy county which requires a permit to construct,alter,Improve,demalbh,or repair TFMP.METER ORPOLE!NSC.
any strutture prior to Its issuance,also requires the a ppBmnt for such permit to
3 file n signed statement that he is Bmnsei pursuant to the provision,of the POWER DEVICES
w Commoner'.License Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC
O sion3o(the Busnms dProf.sW Code)orthahebexemptthamfromand VALUATION
y.'S the bash for the alleged exemption. Any violation of Section 70315 by any
« applicant fora permit subjects the applicant to a civil penalty of net mare than OUTLETSSW(TCFESEXTURFS 4L,11J� IVa F-"
five hundred dollars(5500). Ld
�n ❑1,as owner of the property, NEW RESIDENTIAL ELECTRSQFF. STORIES TYPE CONSTRUCTION
p perry,oe my employees with wags as thele door
r6, compensation,Buldothe work,and
mai.m trotture is henet CoIntendeddee or offeredTaw
O sa doe nota ply to an Business property
Code:Wid,or Improve;Llreron law
3$ does notapplyloan owner of throng hiswho
nemorlmproovidedthat and OCC.GROUP RIS.UNITS
whodom much work himself edoroughhisow ice If,employees,provided that such
improvementsarcnet Intended earofred(plane.!(,however, older ldl have IL
Improvement bnldwithlnoneycaro(complellon,theowner-bullderwlll have
tile Iferden of proving that he did net build or Improve for purpose of male.). QTY. PLUMBING PERMIT FEE FIOODZONE APN
I,as owner of the property,em exclusively coneraning with Ilmneed PERMIT ISSUANCE
contreaces to carstruct the project(Sec.7041,Be.ines and Pref egions Code:
The Contmetor's License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
builds or Improves thereon,and who contracts for such ptojects with a
c9a4ader(s)licemed pursuant to the Contradde.Limnme Law. BACKWI'ROTECr.DEVICE FEE SUMMARY
LJ I am exempt under Sec B&P C for this reasonOUTSIDE ITES
Owner Date DRAIN
-RROOF,A ND,7 A RY Y_ N N
WORKMAN COMPENSATION DECLARATION RECEPT_
❑1 hereby affirm that I have a mniHcam of consent in.elf-Insure,ora TRAP i ^ I i L TAX
mn--N
mficdmofWorken'Compwsgawlnsuranm ora certlfkd copy thereof Gat. GAS SYSTEM-j INC tl A Y N
3800,Lb CJ
Policy RECEB'fM
GAS .SYSTEa�Ne¢6 )
Com any BUILDING DIVISION FEES
�CenlBed copy bhereby luml.hed. CREASE/INDUSIRL WASTE INTERCEPTOR - .P-LA CHECK FEE
❑Certified copy b filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY STORM EA 200FT Date Re i t#
Qhb senlon need not he completed!(the permit b(Drone hundred dollen
($100)mWATER HEATER W/VENT/E.ECTR ENERGY FEE Y N
Imrtify fyth that In the pedomanm o(thework(or which RNs pernithbeucd,
I shall not employ any person In any manner n as to become subjen to the WATER SYSTEM/TREATING
Worken'Compenntionlawsof G.lifomla.Date PAID
0 Z Applicant Date Recei t#
Z 0 NOTICETO APPLICANT.If,after making this Certificate of Exemption,you NEWRESIDENUALPLMB. SFr.
should become subjed to the Workers'Comperuatlon proodors of the Labor TOTAL:
CC N Code,you=at forthwith comply with such prev4bns orthis permit a hall be BU
> deemed revoked.
W CONSTRUCTION LENDING AGENCY SEISMIC FEE
(l I hereby affirm that them Is a construction lending agency for the perform ELECTRIC FEE
7 ZO
...of the work for which this permit b issued C.3097,CIv.C.) TOTAL:
V Iendels Name PLUMBING FEE
LL H U.dce.Addredm - QTY. MECHANICAL PERMIT FEE MECHANICAL FEE r"
OW Imrtlfythat]havercad this application end Wale thatthe above information �^.
S is correct.l agree to comply with all city and county ordinances and state laws PERMITISSUANCE [ FEES PAID:
). W relating tobuliding couttroction,and herebyauthodze repremetativs of this
I Z cityto enter upon the above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,Indemnify an d keep harmlessthe City of Cupertino Date Receipt#
V against Rbilities,judgment.,coebandexpenss which may In anywayaccue AIR HANDLING UNIT CFO 10,"CFM) SUBTOTAL:
against said City in consequence of the granting of this permit.
AIR HANDLING UNIT(OVER lO,OW CFM) CONSTRUCTION TAX
Signature of Applicant/Contractor Date EXHAUST HOOD(W/DICT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or furore building occupant store or handle hanrdoes HEATING UNIT(TO 100,ODO BTU) Date RL ei t
matedalasdefl dbytMC.pertlno Muddp.ICode,Ch.pter9.IZ,a dthc
I lealth and Safety Code Seniom25S32(x)7 HEATING UNIT(OVER IWM BTU) TOTA �
1� Yes M No
Illtheapplimnt orfuture building occupant use equipment ordevims VENTILATION FAN(SINGLE ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management District? BOILER-COMP 01 IV OR 100,000 BTU)
171 Y's
�No
Ihave
nusm
aledalsrequirements under Cha pter6.95of EOR,ER-COMP(OVER 100,000BTU)
the California Health&Safety Code,Sections 25505,25533 and 25534.I ppyy
understand that if the building does not currently have a tenant,that it b my NEW RESIDENTIAL MECH. S'Q.4T P A '
responsibility Issuance
ratifytheiate of oftherequlremenn which must be met
prior tsisuance day the Certificate of
req -
SEP
Owner or authorized agent Date 7�
SSUED BY:
- -ter n7uvv
OFFICE COPY