24274 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pr.'ect Identification /' PERMIT N2427-4
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C94FP_ R/ittD�� JiY 17. 4'451)ftS CITY OF CUPERTINQBUILDINGDIVISION
Contractors Name: Lic.No: APPLICATION I PERMIT
• BUILDINGELECTRICALPLUMBINGMECHAMCAL CATEGORY CONTROL M
Architect/Engineer. Lle.Na
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: Aa Loo PERMITISSUANCE PLUMB MICH
LICENSED CONTRACTOR'S DECLARATION 0
I hereby af(irmthat l am beensed under provisions Of Chapter9(commenrr APPLIANCESRESIDENTIAL JOB DESCRIPTION
ing�tIt...I.I.full 7000)oad diedn3ofthe Budweand Pro/esdoneCode,and p
license b In full force and died. PANELS IL/` IA
License Clam Llca •lT
Date Contractor UP TO pl IOO2DOAM
ARCHITECTS DECLARATION
OaO Iundestand my pl rashall be used as public remrde. OVER10110AMPS F/SQ.FT.
1fiLicensed Professional SIGNBELECTRICAL
6 OWNER-BUILDER DECLARATION
SPECIALCItCULT/MLSC U T E R
tp, Iherebya/@m that am exempt fromthe Contractor's License Law for the
qqqqqq following mason.(Section 7R11S,Busines and Professions Code:Any city or
Fa'q c.untywhich requirma permit to mrutruct,alter,improve,dennlish,orrepair T__MP 'EFER OR]'OLEINDATI
as`'� 3 anI.
ystrucWm prior tons issuance,also requlreatheapp0ont fmauch permit to pOWpR DEhL'FS
(Ile a algned statement that he s licensed pursuant to the provisions of the
3µ Contractors License law(Chapter 9(commencing with Section 70M)of Divi- SWIMMING POOL ELECTRIC VALUATION
OJ slon3ofthe Busmees and ProfessionsCode)orthat he s exempltherefromami
Eb< the bass far the alleged exemption. Any violation of Section 7MIS by any OU7LETSSWITC}{E.FT]('TURFS O
applicant for.permit subjects the applicant to a civil penalty of me more than D Q s
fiyLbundred dolsn(SM. NEW RE4DENTIAL ELECTR SQkT. STO ES TYPE CONSTRUCTION
I I,as owner of the property,or my employees with wages as their ante
L.la compensation,willdothe work and Mestructure s not intended or offered for
p sale(Sec.70K Business and Pmfeanaro Code:The Contractors License law
does not apply to an owner of property who builds or Improves thereon,and OCC.GROUP, RFS.UNITS
whodom such work himself"through Ma own employees,provided that such
Improvements are not intended oroffered forsale.If,however,thebullding ce TOTAL:
improvement sold wlths one yearn comp letlor the owner-0u0derwWhave
tf urden of proving that he did nm build or Improve for purpose of sale.). QTy, PLUMBING PERMIT FEE FLOODTANE APN
u L as Owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
mntractos to construct the project(Sec.7044,Business and Professions Code:
Contractor'.License Law does not apply to an owner of property who
1 or im roves ereon,and who contra"for such p(oject.with a ALM-DRAIN VENT-WATER(IW
s cant to the Contract"s Imnse Law. FEE SUMMARY
I axe B&P C for this reason BACK FLAW PROTECT.DEVICE
OUTSIDEFFES
DRAINS.FLOOR ROOF,AREA,COND. SANITARY Y N
Date RECEIT N
WORKMANC MPENS TIONDECLARA ION FDGFURES PER TRAP SQi00L TAR Y N
a affirm that 1 have.certificate of consent to self-"sum,or a RECEIPT M
t ,Loxtoo.bCf pensatlonlmuranawaartifled wpytherm((&c.38MGASEA.SYSrEM-1 INCAOUTLM PARK FEE Y N
Polic # C.) RECEIPT0
Poiiry M GAS EA.SYSTEM-OVER 4(FA)
Com ray BUILDING DIVISION FEES
FCertlfied copy Is heed with the
city CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
�CertNed copy s filed with the dty inspection divitlon.
CERTIFICATE OF EX MPFION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANTTARY-STORM EA 200FT Date Recei t#
(This motion need not be completed 0the permit Is for one hundred dollars
($100)"lesd WATER HEATER W/VENT/Ef.ECTR ENERGY FEE Y_ N_
I certifythat in the performance of the work forwhich this permit Is Issued,
I shall not employ any person in any manner so as to become subject to the WATER SYSTEM/TREATING
Workers'Compensation Lam of CalifomIs
ZZ Applicant NEW RESIDENTIAL PCMB. SOFT. Date Recel t#
O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
should become subject to the Workers'Compensation provisions of the Labor TOTAL:
CC y Code,you must forthwith comply with such provisions or this permit shall be BUILDING _O
W > deemed revoked.
CONSTRUCTION LENDING ACFNCY SEISMIC FEE
Il I hereby affirm (Se
that there s a construction lendingagenry for the perform ELECTRIC FEE
M Z arm of the work(.,which this permit I.Issued&r.3097,Civ.C.) TOTAL:
U O I,andre.Name PLUMBING FEE
f Lenderres
Lender'.Adds QTY. MECHANICAL PERMIT FEE
LL U l mdllythatl have read thsapplicatlonand statethat theabove informationMECHANICAL FEE
O W scoreect.Iagreeto comply with all cityand county ordinances and dale laws PERMRISSUANCE FEES PAID:
>. fl. relating to building corutruction,and hereby authorise representatives Of the
N cit to enterupon the above-mentioned property f"W Ion ALTERORADDTOMECH.
2 yP pctY PM w�OBGti Date Receipt#
(1Ve)agree to ve,IndemNty an d keep es which
the City of Cu petition
a
net lsbllitles, ns,codsand expense which may In anywayacaue AIR HANDLING UNIT(TO IO,ODOCFM) SUBTOTAL: '
ag t said enm of the granting of this permit.
AIR HANDLING UNIT(OVER IO,000CFM) CONSTRUCTION TAX
fAppO .rat Ea(HAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
FIA2A OUS ATERIALSDISCLOSURE
W the applicant or tutu ding arvpant atom or handle harardous HEATING UNIT(TO 100,000 BTU) Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health and Safety CadSfaction 25532(a)2 HEATING UNIT(OVER IOO,OW BTU) TOTAL:
Yea No
Will the applicant !.lure building Omupanluseaquipn,mtordevm,, VENTILATION FAN(SINGLE RESID) ISSUANCE TE
which emit haraMous air contaminants as defined by the Bay Am Air 0y
Quality Management Dsl ct2 BOILER-COMP QHP OR 100,0(X)BTU)
Yea VJJN0
I have mad the hang us materials requftements underChapter6.95 of BOILER-COMP(OVER 100,000 BTU) 25 1992
the Califomia Health&SafetyCode,Sections2550.5,25533 and 25534.I SEP
understand that if the building does not currently have a tenant,that It s my NEW RESIDENTIAL MECH. SQ.FT.
me onst flitytonctiNthe.paot of the requlmm oto which must be man
no is it teof Occupancy. Z yr VUt'1-t�ttla�
CITY
naulho sed agent Dat ISSUEDB U
en
TOTAL:
OFFICE COPY