24344 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMITN24344
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BuOd1 Address 01 V aS 2 4 3 4 4
w rAPPLICATION SUBMITTDA M
A
—�� CITY OF CUPERTIN0.8UILDlNG DIVISION _
° °na Lk.No: A 2
APPLICATION %PERMIT �0"
BIDLDlNr—ELECTWCA PLUMBINGMFCliANICAL CATEGORY CONTROL#
Arc ect/Englaer. U I LIc.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address PERMITISSUANCE El El ElLICENSED CONTRACTOR'S DECLARATION
It
Ihereby affirm that l am licensed under provistons of Chapter 9(commerx, APPLIANCFS-RESIDENTIAL JOB DESCRIPTION
Ingwith Sectio )of Divlaion3P(jhell Ia a drm(esalon.Code,and my �r.N
iicenae ie In ( a ic.. LIT 7/,_� PANELS
License Cla Cochranton
Date I7YI ,�CHITEtar
ARCHITECT' . RATION 201-1 OOO AN`PS
pa OVER 1000 AMPS FL Ifl $/SQ.FT.
p��++O C0 I understand my platy shall be used ae public rcmrtle. � `•�•
tt (I Licensed Professional SIGNSELECTRICAL
G� 61 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC
7F, 4 I herebyaffirrothat l am exempt from the Contractor',License Law for the
rodfollowing reason.(Section 70315,Business and Professions Code:An cl r
countywhlchrequiresapemtromnatmdalter,Impmve,demollah,orrepair TEMP.METER OR POLE INST. DA E
8anystmcture prior to its issuance,alsorequlreatheappliramforsuch permit to foe a signed statement that he is licensed pursuant to the provisions of the POWER DEVICES �1
w Contractor's License Law(Chapter 9(Commencing with Section 7000)ofDivi-
'CO El slon 3 of the Business and Profesloa Code)orthat he is exempt therefromand SWIMMING POOL ELECTRIC VALUATION
Qthe basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLEISSWITCIiES1gX['URES
O applicant for a permit subjectathe applicant to a civil penalty of not more than
five hundred dollar,hepr. NEW RESIDENTIAL ELECTR SQ.FT.
�j ❑I,a,owner of the property,or my employees with wages their Cole STORIES TYPE CONSTRUCTION
tion,
and
C som(Sec.70K will do the Business and kefe.i. structureItContractor or License
d for
Law
5 O sale(Sec. pply to alnowandfpreerty, Code:The or
License Law
does not apply loan owner afp rough who
nempor imp themes,and
that such
OCC.GROUP RFS.UMTS
0.0. improv sauce am not mself or ended orwgh his owne.If,however,protheedthatavch
improvements arenotintended earofc fordale.If, er- Hder flingve TOTAL:
improvementbsoldwithin oaycarofcoinplelioo,theowner-bu8derw0l Five
drJurden of proving that he did not build or Improve for purpose ofsale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
LJ I,as owner of the property,am exclusively Contracting with licensed PERMIT ISSUANCE
Contractors to ronstruct the project(Sec.7014,Business and Professions Code:
The Cont etor4 License Law does not apply to an owner of property who ALTER-DRAIN kVENT-WATER[FA)
Wilds or Improves thereon, and who mantis for such p.ojern with a FEE SUMMARY
cg0_tfactor(eexempted pursuant to the Contractor's theme,P Law. BACK FLOW PROTECT.DEVICE
u I am exempt under Bee B &P C for the reason
SANITARY Y_ N_
Owner - Date DRAINS FLOOR ROOF,AREA,GOND. RECEIPT N
WORK MAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOL TAX Y_ N_
hereby orken that I have o linsu ate of consent to self-Ihersof ora RECEIPT#
< cabC.)is rkemi Compeaatlonlauranceora certified Copythereo((Sec. GAS EA.SYSTEM-I INCA OUTLETS PARKFEE , Y N_
38110,lab C.I,N'1P1iUW) of/C�z�._0
Policy p ('J4 �T�LI O>�'/ C./ RECEIPT a
C,,o��mppanv '47 GAS G.SYSTEM-OVER4(EA) BUILDING DIVISION FEES
I J6mfwd Is he the crd. CREASE/INDUST'RL WASTE INTERCEPTOR PLANCHECICFEE
erti(ied copy R filed with the tlty Inspection division.
CERTIFICATE OF EXEM PTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SENVER-SAMTARY-S'PDRM EA 200F1• Date Recel t#
(Ihlssetlbn need not be completed If the permit V(Drone hundred dollars
($100)orles.) WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
(certify that in the perent in nofthe ymwork(ors to whichthispermit1.clamed,
I shall not employ any person In any manner so u to become subject to the WATER SYSTEM/•I•RFAT.ING
Workcra'Campensation laws of California.Date PAID
O Z Applicant NEW RESIDENTIAL PIMB. SQFT. Date Recei t#
Z o NOTICETO APPLICANT:If,after raking this Certificate of Exemption,you
should Wourre subject to the Workers'Compensation provisions of the Labor TOTAL:
~ M Code,you must forthwith comply with such provisions orthis permit shall be
LU 9 deemed revoked. UNG FEE
CL CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirmthat there Is a Construction lendingagency for the perform- ELECTRIC FEE
:3 Z ance of the work for which this permit It thood(Sec.3097,Civ.C.) TOTAL:
00 lender's Name PLUMBING FEE
LL F Lendeen Address QTY. MECHANICAL PERMIT FEE MECHANICA
O 111
Icedlfythatl have readthls appllmtWnand atatethatthe above inforation
0. Is correct.l agree to comply with all city,and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
} N relating tobulldln construction,and hereby authodas repraentativesafthb
F_ Z city to enterupo t above-rrentload property for inspection purposes. ALTER OR ADD TO MECH. Dat Rece] t#
— (We)agree t ea e,Indemnify an d keep harm:Ca9[he Clty t C'Pe no
agabat Babllitle,H g ts,"send expenses which may In ways a AIR HANDLING[IMT(TO 10,000 CFM) SUBTOTAL'
against said Ci in ,"sen ening w this pe
HANDLING UNIT(OVER 10,000 CFM) CONSTRUICVION TAX
SlgatureofAIf t tractor Date IXHAUST HOOD(W/DUCI) CONSTRUCTION TAX PAID:
ZARDOUS MATERIALS DISCLOSURE
Will the applicant orfuture building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTI))
Date Recei t#
material as dented by the Cupertino Municipal Cade,Chapter 9.17,and the
7 Lealt ye. Safety CodWe Se 37(x)7 HEATING UNIT(OVER 100,000 BTU) TOT °"'�
Yea o
WIIlhot ha=ils orftmu Illding oavpandby tequipment he Bay Area devices VENRLA770N FAN(SINGLE RESID) ISSUANCE DATE
whichhemit lacca ou,air coma eta as defined by the Bay Area Air
bty Mawgemcnt D.
BOILER-COMP(3FI°OR 100,000 BTU) PAID B
�i J Yea No P A
Th ave read the bozo ou°mate rials requlnernents under Chapter 6.95 of BOILER-COMP(OVER 100,0008#(
the California Healthk sty Code,Be tlons 75505.25533 and 25534. I OCT ��
understand that if the b n donsnotmrrentlyhave ithoant,that it l9 my NEW RESIDENTIAL MECH. SQ.FT. 1992
reaponsibilityton, y a nt of the requlremnts which m at be t /x 942%
prior to issuance o(a III t (Occupancy. Gl1Y Ur
VUrcnr�la
Owner or authorized a ate a_"`�
" TOTAL: ISSUEDBY:
OFFICE COPY