24359 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address:' S—1 3 +��� s+ f - 24359
one: A
K�-I,IGLK-�7
14L4&—zsqqCITY OF CUPERTINO-BUILDING DIVISION
can nar.Nam Lie.No: APPLICATION I PERMIT 1 2
O D Ia OMLDINGELECTRICAIPLUMBINGMECHANICAL CATEGORY CONTROLM
Arehkect/Engineer. Lk:.Nm
�� QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Addrear o eft 2 PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
]hereby af(kmehatlam lkoeed under prwtpons olChapter9(convnrn APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Ingwlthse on7000)of DlvWon3ofthe Buen sand PmfnponsCode,andmy
lienee le in full or¢and effeet. p PANELS
Llarae Lie# ��
Date ® Contractorp n/'a{ R/rim
ARCHITECT'S DECLARATION ,.J 201-1000 AMPS ��•
oZ f understand ery plane shall be used m public records. OVERIOWAMPS SQ.FT.FLOORAREA S/SQ.FT.
❑O
�(/ Llmnsed Professional SIGNS ELECTRICAL
Q GL'�S OWNER-BUILDER DECLARATION SPECIALCIRCU1T/MMC
Iherebya((Irm that am exemptfromthe Contractor's License Law for the
f my greason.(Senior70Xto Business and Professions Code:Anymy it
TEMP.METIER OR]'OLE MST. '
P v,3 ayalm lmpn toaperame alunqu, .theapU=tfrsuah,orrepto
any alruaurctatemelt Wu be e,alcensedrcstheat to the provisions
of lte POWER DEVICES
r� (� file a signed statement that M t licensed pursuant to the provtlons of the
Owl Contractors License Law(Chapter9(rommencingwkh Section 7000)of DWI. SWIMMING FOOL ELECTRIC
sWn3afthe BustessandPd.ess Cade)orthatheil.mmpttherefmmand VALUATION
•aa the basis for the alleged exemption, Any violation of Section 70'315 by any O[TILE7SSWITCHESFlXrURFS
ya G; applicant for a permit subjects the applicant to a civil penalty of net rrorc than 4000,, QO
five hundred dol lar(A0). NEW RESIDENTIAL ELECTR
�j ❑I,as owner of the property,or my employees with wages as their sole `SQ'ET' STORIES TYPE CONSTRUCTION
e compensation,will do the work and the structure b not intended or offend for
Osale(Sea 7064,Business and PMadcaru Code:The Conhanore License Law
$ don not apply to an owner of property who builds or Improve,IhereoM and OCC.GROUP RFS.UNITS
who does such work himself orthmugh hisown employees,provided that such
improvements are not intended oroffered forsale.If,lummver,thebuilding or TOTAL:
hoprovement bwld within oreyearo(compleftm the owner-bullderwill have
diLtliurden of proving that he did not bund or Improve for purpose ofsale.). QTY. PLUMBING IT
Lf L as owner of the property,am exclusively mnlraning with licensed FLOOD ZONE APN
contnctme to construct the project(Sec.7001,Business and Profeapons Cade: PERMIT ISSUANCE
The Contractors License Law dm nn apply to an owner of property who ALTER-DRAIN&VENT-WATER(EN
holds or improve thereon, and who contracts for such ptojens with a FEE SUMMARY
.c raganurW licensed pursuant to the Contractors License Law. BACK FLOW PROTECT.DEVICE
LJ I am exempt under See. B k P C for this reason
DRAINS.FLOOR ROOF,ARECOND. / SANITARY Y N
M, FEES
A,
Owner -Date RECEIPT M
WORKMAN COMPENSATION DECLARATION
F]%IVRF.S PER TRAP OOL TAX Y N
❑1 hereby affirm that I have o Insurance
of consent to copy
thereo ora RFLEB'T M
certklate of Worken'Compeneatlonlmunnce oraartifkd mpy thereof(Sec. - GAS EA.SYSTEM-1 INCA OUTLETS PARKFEE V N
Pall. 'b CJ .I RELENT#
'Policy# - �P — T
iaM
BUILDING DIVISION FEE
/ laGAS EA.SYSTEM-OVER
S
herebyte cid. GREASE/INDUSIRL WASTE INTERCE'NR PLANCHECK FEE
�lertNed copy t(led withh the city Inspection division.
CERTIFICATEOF EXEMPTION FROM WORKERS' GREASE9RAP PAID
COMPENSATION INSURANCE EA.200Fr. Date
(This,ection need nn be completed lithe permit t forom hundred dollars SEWER.SANITARY-STORM Recei [71
($100)mIcks.) WATER HEATER W/VENT'/ELECTR ENERGYFEE Y N_
I cedifythat tnthe perfomanmof the work forwMch this permit is Weed,
I shall not employ any person In any manner an as to became subject to the WATER SYSTEM/TREATING
Workers'Compensation Laws of California.O Z Applicant NEW RESIDENTIAL"B. SQFI'. Date Recei I#
Z O N'OTICETO APPLICANT:It,after making this Certificate of Exemption,you
should became subject to the Workers'Compensation provislonsof the Labor TOTAL:
(A Code,you carat forthwith comply with such provisions orthis perodt shall be BUILDING W j deemed revoked.
1CONSTRUCTION LENDING AGENCY SEISMIC FEE
IhembyafBhat them is a construction lending agency for the perform TOTAL: ELECTRIC FEE
0 arm o(the work(or which lhh percale bblued(5ee3097,CN.C.)
Larder's Name PLUMBING FEE
LL H Iznder's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW Ioertiythatlhavemadthisappllationand stalelhattheaboveinfomalion
fi scorroct.I agree tocomplywith all city and county ordinances and pate law, PERMIT ISSUANCE FEES PAID:
>. relatingtobuildingamstmctlogand herebyauthoixampresemMivnoflhis
I'- N citywenterupoothe abovementioned property for inspection purposes. ALTERORADDTOMECH.
? (We)agree to save,indemnify and keep harmlessthe City of Cupedlna Date Recei tlf
V agaWtltbWtlea,Judgment,ropsand expense which may In anyway.come ATR HANDLING UMI CIO 10,000 CFM) SUBTOTAL:
agalmt aald Rlyl on ems 1 granlingoft ie permit. AIR HANDLING I1NTf(OVER]0,000CFM) CONSTRUCTION TAX
Signature AppHant/Cant D.4 EXHAUST HOOD(W/DI1Cp CONSTRUCTION TAX PAID:
HAZAROO115oMATERIALS DISCLOSURE
WilltheappItant orfuturebuldingomvpommme or handle luvrdous HEATING UNIT(TO 100,OW BTU) Date R - f
material as defined by the Cupertino Municipal Code,Chapter 9.1 2,and the -
Ifealth and Safety Cader.-S�ection25532(a)7 HEATING UNIT(OVER IOg0008TU) TO
u '
❑ Yes No
Willtheapplieanl or future building occvpantose equipment ardevices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hamolous air contaminants as defined by the Bay Area Mr
Quality Management District? BOILER-COMP OHP OR 100,000 BTU)
sn Yes ❑No � ' Ps
Bove read the haxammus materials mqulmment under Chapter 6,95 of BOILER-COMP(OVER 100,0(0 BM D
the California Health A Safety Code,Sections 25505,25533 and 25534.I
understand that lithe building don not currently have a tram;that it Is my NEW RESIDENTIAL MECH. SQ.FT
responsibility to notify the occupant of the requirements which must be met JAN 7 1 - ,
prior to Issuance of a Certificate of Occupancy. \1
ytl
Owner or authorlaed agent Dat ISSUED BY:
V lJl✓iT1 LnI Ile,
TOTAL:
OFFICE COPY
c