24350 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL'POINT PEN ONLY
Building Project Identification PERMIT NQ, 4 3 5 0
Building Address:
a'd 10- cede T e-
ere ams: one:
0t 11 .,(?-i C"4GL� CITY OF CUPERTINO-BUILDING DIVISION /
Common's Name: Lie.No: APPLICATION /PERMIT �b
BUILDINGELECTRICAI.PLUMBINGMFCH LAICAL CATFCARY CONTROL#
Architect/Engimer. Lia No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE �tJ Ate/ El El
CONTRACTOR'S DECLARATION ❑ V1
I hereby affirm that l am licensed under provisions of Chapter 9(commene APP11ANCES-RESIDENTIAL ' JOB DFSCRII-TION -
IngwlthSedion7OOmof Divlsim3ofthe Buslnemand ProfesdonsCode,and m //
license I.in full farm and effect. PANELS
License Clam ir-#
Date Cormuoar
ARCHITECTS DECLARATION 201-IMO AMPS -
qtaZ I understand my plainshall be used as public recorEA ds. OVER 1000 AMPS SQ.FT.FLOOR ARS/SQ.FT.
q��uu OC
Fe 5(s Licensed Professional SIGNS ELECTRICAL
I IPX+ OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MLSC
Zf., IherebyafRrmthatlam exempt(romlhe Contras<or's Lkenae Law forthe
o lo0awing reason.(Section 70315,Business and Professions Code:Any city or
IX
FyF� TEMP.METER OR POLE INST.
� cauntywhkh requires,pemdtrocomtruc[,alter,improve,demolish,orrepalr
S a nystmmmpriortoitsb amesalsorequtmtheapp4mntfol..d p.rmitt. )OWER DEVICES
P file a signed statement that he Is licensed pursuant to the provisions of the
G67 Oµ Contractor's License Law(Chapter 9(commencing with Section 7000)a(DIW- SWIMMING POOL ELECTRIC
SOS VALUATION
slon3ofthe Bb
usluessand ProfesemCode)orthat he is exempt thamfrumand
6 the basic for the alleged exemption. Any violation of Section 70315 by any OUTI.ETSSWITCHESFIXTURES
applicant for a permit subjects the applicant to a civil penalty of not rtnrc than
five hundred dollars(AM.
I,as owner of the property, NEW RESIDENTIAL ELECTR SQYF. STORIES TYPECONSTRUCTION
CTION
�n ❑ p party,or my employes with wages r their dole
compemaHon,wllldolhew andthestratchne is The C Intended or offered for
qsale(Sea apply Bu siness owner
of property
Code:The Contractors Lt...Law
�$ does not
ssuchloan owner otprough who nemporlmpmwes ovidedreoRand OCC.GROUP RFS UNITS
EE whodoeaents arm khimself nded oroughedhis owne.If,huenuu,thebuildbuch
Improvementis raid lntenomyearofcmorsalmtheoneer,theerwilI have TOTAL: (,
Improvementlssoldwithinomyearofcamplelion,theowner-bu0derwill have
tF"prden of proving that he dM not build or Improve for purpose of sale.). QTY. PLUMBING PERMIT FEE
j L as owner of the property,am exclusively contracting with licensed FLOOD ZONE APN
L
contractors to construct the project(Sm.70K Business and Professions Code: PERMITISSUANCE
The Contractor.License Law does not apply to an owner of property who
Wilds or improves thereon,and who contracts for such p(o)ses with a ALTFR'DRAIN&VFM•WATER(EA)
owllicensed pursuant to the Con omficus License Law. FEE SUMMARY
� l am oempt under yea B&,P C Zr tis reason BACKFLOW PROTECT.DEVICE OUTSIDE EES
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N - „
• Owner Date RECEIPT-
WOR AN CO PFNSATION DECLARA ON pgpg PER TRAP SCHOOL TAX Y N
❑1 here afllrm that I have•certificate of consent to sect-Insure,or RECEIPT#
certificate of Worken'Compematlonlmurance or acerti(kd copy thereof(S...380(iGAS EA.SYSTEMS WC.40UILEIS PARK FEE Y N
Polic y M lab C.)' — RECEIPT N
PolicGAS F.A.SYSTEMAVRR 4 IEA) BUILDING DIVISION FEES
Co�mpa ray
1 I Certified copy ts hereby turNshed. GREASE/WDUSTRL WASTE IN'I'Q4CET"NR PLANCHECK FEE
lr�J-•CerUtied copy b(Red with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WOR KERS' GREASE7RAP PAID
COMPENSATION INSURANCES13WER•SANITARY-STORM FA pBFf Date Recei t#
(This section need not be completed lithe permit is forom hundred dollars
($lam miss.) WATER HEATER W/VENT/ELFCTR ENERGY FEE Y_ N_
I certify that In the performance of thework forwhlch this permit Is Weed, -
I shall not employ any person In any manner so as to become subject to the WATER SYSTEM/TREATING
Workem'Compensallon Laws of California.Date PAID
0Z Applicant NEW RESIDENTIAL PLMB.—SQ .
Date Recei t#
Z O NOTICE TO APPLICANT:If,after ma king this Certificate of Exemption,you
should become sub)ect to the Workers'Compematlon provisions of the Labor. TOTAL:
CC N Code,you must forthwith comply with such provisions or this permit shall be BUILDING FEE
W > deemed revoked.
CL c CONSTRUCTION LENDING AGENCY SEISMIC FEE
I herebyaflhat there Is a construction lendingagency for the perform TOTAL: ELECTRIC FEE /
7 Z anmoftheworkfor whkhthtspemdtistsmed(Sec.3097,CIv.C.)
() O Lenders Name PLUMBING FEE
LL F Lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW iscomIcadlfythatl)uvereadthinapplirmion and statethattheabove Information
a ct.I agree to complywilh act cilyand county ordinances and state laws PERMIT ISSUANCE FEES PAID.
�. relating tobullding construction,and hereby authorize representativn ofthb
F N city to enter upon the abovcmentioned property for inspection purposes. ALTFRORADDTOMECH.
? (We)agree to save,indemnify an a keep harmless the City of Cupertino Date Recei t#
V against llabNtks,judgments,costsand expenses which may In any wayaccue AIR[CANDLING UMT(TO 10,0DO CFM) - SUBTOTAL:
against said City In consequence of the granting of this permit.
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signature of Applicant/Contractor Date FXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfuture building occupant store or handle hazardous HEATING UNIT(TO 100,00001[)) Date Recei t#
material as defimd by the Cupertino Municipal Cade,Chapter 9.1$and the
HEATING UMT(OVER 100,000 BTU)
Health and Satcty cod Section 75532(x)7 TOTAL:
❑Yes No
Wllltheapplkntor444uwmbulldingo pantumequlpmentordeWces VEMILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air r� A
Quality MamgemcnI ID
t trict7 800.ER-COMPOW'OR IOO,IXD BTU) Ir i"a
4 Yes o
have mad the haza ossa materials requirements under Cha pier 6.95 of BOILER-CDMP(OVER 100,0(10 BTU) ,. ,a q ��a�akryaea
the California Health&Safety Code,Sedlom 25505,75533 and 15534. 1 OCT lb "992
understand that if the budding does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. - SQ.FT
msapomlbflty to notify the occupant of the requirements which must be met GTl tIIYU
prior to bans (a Cenmoteof Panry. ,1 /,� !`I I'Uj"u Ut'
U lr V
er or authorized agent I Doti
TOTAL: ISSUEDB
OFFICE COPY