24026 APPLICANT TO FILL IM INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
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Building project act Identification - - PERMIT N24026
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Building Address:
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nere eros: one: ...
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Contnaor'BName:
o�t Leq I APPLICATION /PERMIT CATEGORY ` coNRo1«
Architect/Engineer. _ Lit No: BUILDWGELECTRICALPLUMBINc-m CH NicAL
Q ELHCTRIC PERMIT FEE BUILDING PERMIT INFO'
AadRBa: a O Y Q� �� ` 1l _
rFR%IrlssuANCE -
LICENSED CONTRACTOR'SDECUAKA ION
Ihewhy aRirmtlut l am licensed under pnwalons of Chapter9(common APPLIANCES RESIDENTIAL ]OB DESCRIPTIONingwBh Swffi 7 00)ofDlviaion3 ofthe Business and ProfeselonsCocie,and my -
Ilcenee is In fuR f nex and effect. PANELS
Llanse Class �'s.
,
Date ConCo,tractor
ARCHITECTS DECLARATION 2014000 AMPS
OZ (understand lane shall be used a,t public OVERIWu AMPS - - - g/SQ,FT.
rn3'P P � `�.FT.FLOOR AREA
Licensed Professional SIGNSELFLTRICAL ,
< OWNER-BUILDER DECLARATION SI'FGLAL CIiCUIT/M15C
zFp � I hereby afHrmum
that l n exempt frothe Contractors se LicenLaw for the
O2 following reason.(Section 703IS,Business and Professions Code:Any city or TFMP.MEfQt ORPOLE(NST.
F cmntywhi&mquresapermitumwtmd,alwr,impmve,de=lB hp
,orre air
anystructure prion.its Issuance,also requiresthe applicantfrn such permit to '
file a signed statement that he Is licensed pursuant to the provisions of the POWERDEVICES
k Contractor's License law(Chapter 9,(commencing with Section 7000)of Dlvi- '
SOS ei.n3.fthe Buatnessand Profemiom Code)orthat bele exempt therefromand SWIMMING POOL F7.EC77IICVALUATION
'•'1 the basis(or the alleged exemp[lon. Any vlolatlon of Section 70315 by any
applicant fora permit subiectatheapplicanttoe civil penalty of net rrnrelhan ''OUTLETSSWITCHESHKTURES -
fiv hundred dollars($50fB. NEW RESIDENT ALELECTR
�n I,as owner of the property,car my employees with wages ae their sole TRFL „STORIPS TYPE CONSTRUCTION
c mpencatlon,wWdothe wrnk andtheetmcture Snot intended or offered for
D sale(sec.7fK4,Buabusa and Profealoru Code:The Contractors Llce.a Law
does not apply to an owner o(property who Wilde or Improves thermq and I
hatwch .00C.CROUP RFS.UNITS
whodceaeuchworkhlmsel(wthrough hieownemployeea,provided t
impmvemente are notintended oro(fered tw vale.If,hmJevegthebuilding or TOTAL:
improvementlaaudwlthln oneyearofcompldlorytheowner-WRderwlllhave
t rden of proving that he did net build orimprove for purpose ofsale.). QTY„ PLUMBING PERMIT FEE FLODDZANE APN
• I,ae owner of the property,am exclusively contracting with Ilrensed PERMIT ISSUANCE
contractors to mriBtruct tM project(Sec.70td,Burmese and Isrofeseloria Code: '
'The Contractor's Llttnse Law does not apply la an owner of property who - ALTER-DRAW&VENT-WATER '
Wilds or Improves thereon,and who contracts(w aurh p(ojec[a with a (RN
�g0.t.[actax(s)licensed pursuant to the Contractors Llcenae Law. FEE SUMMARY
Lf I am exempt under Sec e&P C for this re awn BAIX FLAW PROTECT.DEVICE QUTSI DE FEES
Owner - Date DRAINS-FLOOR,ROOF,AREA,GOND. - SANITARY Y N_ ^
a� WORKMAN COMPENSATION DECLARATION - RECEIPT
❑I hereby affirm that I have•certificate of consent to self-insure,ora FD(TUR2SPER TRAP = SCHOOL TAX Y_ N
N
certificate of Workers'Comperuatlonlruurana wa certified copythereof(Sec. RECEIPT p
3800,Labe GAS EA.SYSTEM-1 INC4 OUTLETS J PARK FEE Y— N_
Policy« - RECEIPT p
Com any GAS EA. EEM BUILDINGPTVISION FEES
�CerItfea copy b hereby furnished CRRASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE )
"�Ceriaied copy E,(Ikd with the city Irupectlon divitlon. ', � -
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP - PAID
COMPENSATION INSURANCE SEWER SANITARY
(Thiasectbnneed not becompleted lithe permit isforanehundred dollars �RM E^.2'T Date Rem t#
($1I certify that
WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
I artdy employ
an person
in ani the manner
so as to b co permit b Ito therd, _
I wk not employ any person In any manner at u to become subject to the
O Wplican Compensation Laws of Gldmnla:Date WATER SYSTEM/TREATING PAID f
Applicant
Z.0 NOTICE TO APPLICANT;If,after making this Certificate of Exemlrtlon,you NEW RESIDENTIAL PLMB. SQ.Fr 'Date Re i t#
Hshould become subject to the Workers Compensation provistom of the Labor TOTAL:
N
Code,you=at forthwith comply with such provisions or this permit shall be
LU > deemed revoked. BUILDING
d E3 CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there is a mmtmdion lending agency for the perfarm
Z ane of the work for which this permit E Issued(Sec.3097,Civ.O) ELECTRIC FEE
V O Lender's Name PLUMBING FEE
LL F Lender'sAddrese QTY. MECHANICAL PERMIT FEE. MECHANICAL FEE
O W dartlfythatl luveread thlsappRcetbnand&atethat thea—em(ormadon '
is coed.]afmwto complywith all cityand county ordinances and stare laws PERMIT ISSUANCE FEES PAID:
}SU) relating to building consourion,and hereby authorlaw representatives ofthis `
F Z city to enter upon the abovementmred property for inspection purposes. ALTERORADDTOMFCH.
(We)agree to save,indemnify an d keep harMeae the City of Cupertino - ' 'Date Remi t#
sgabist liabilities,judgments,mats and expenses which may In any way accrue AIR HANDLING UNIT(M 10,000 CFM).
against said City m conBtyuence of the gran got this permit SUBTOTAL:
^tea 7
Lr AIR HANDLING UNIT(OVER 10,"CFM) CONSTRUCTION TAX
siErraiure olYAppgant/Contractor 1Daate E)MIAUSTHOOD(W/DUCT) CONSTRUCT[ TAX PAID: '
HAZARDOUS MATERIALS DISCLOSURE -
Wllltheappllcantorfuure building occupant store or handle hazardoua HEATING UNIT CD 100,000 BTU)
material as defined by the Cupertino Municipal Code,Chapter 9.IZ and the to MRImIPM
Health andSafety Cade
❑ Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU)
ri No TOTAL:
Ym '
Will the applicant wuure building occupant use equipment or devicesMSQ-,Fr
ISWCLE REBID) ISSUANCE DATE
which coal harardous air cbntamimntaas defined by the Bay Area Air -
'4 silty Management District? 'OR IW,003 BTU)
Yee n❑No. PAID q D
ave read thehazalloua rtuterlaia requirements under Chapter 6.95 of BOILER-COMPER l00,"BTU( Ir M C N
the Cas forth Health&Safety Code,Sections 75505,25533 and 25534.1
understand that lithe building does not currently have atenanL that ltkmy MECH. SQ.FT � � 28responsibility to notify the occupant of the requirements which must be moaaprior to issuance of a Certificate of Occupancy. G V VV 1111IVISSUGD BY: �+ '�
TOTAL:
OFFICE COPY