24379 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Pm en identification PERMIT NO. '
Building Address: 24379
2z1 LL e s� z'
ners ante. one: APPLICATION
FI LA L-E Z�'I•ST95' CITY OF CUPERTINO-BUILDING DIVISION
Contnctois Name: LIc.No: APPLICATION / PERMIT L V
Li L IN ETCK— .L0µ , C�j 501LI-L$ BUILDINGELECTRICALPLUMBINr—MDCI1AMCAL CATEGORY
Archlt=/Engineer. Lic No BUILDING PERMIT INFO
sw� QTY ELECTRICPERMIT FEE
Address 50(� �, (�, yau(�, 6I- T PERMITISSUANCE (;jl ❑
LICENSED CONTRACTOR'S DECLARATIONLPThereby afilrm lhaLlam llcrneed underprovWons o(Chapler9(tommrnc- APPLIANCESFRE9qEhrrIAL A JOB D^ESCRQ�IPT"IION
tngwllh is I fn 70W)of Dlvfun f and fect" flheautlnenandProtesslonsCode,and my ��, Ia/�/�w/Y
L=C Llcg SO L Z
Date �'L Contractor j
1000
A..h fl a mad a public ION OVER SQ.FT.FLOOR AREA $/SQ.FT.
�2O I understand my phis shall be used u public records
Fi 1 E Licensed Professional SIC TRI
t; OWNER-BUILDER DECLARATION a R{CUIT/MISC
I herebyaffirrnthm lamexempt(romthe Contractor's License Law for the
zz oo following manors.Genion 7031.5,Business and Professions Code:My sty or
FZ P.MEfIX OR1aOLE INSf.
cwntmetim requlme peroutta cowtru udecathea prov,demRlbh,or ech ir
to
S any stmnedsuturtoltehaa he
also occlsed putheat to the rovicihpermlt POWER DEVICES
6 file a actors statement that h< t r 9(tom pursuant it the pro 700D) of the
fi❑3u,� Contractor's License lawrofmiom Cod)orthgwith eiseS lon70mof Divi�mand gWyp{hgNGIWLELECTRICdon3oftheVALUATIO
H OS thebublo Buslneeged Professiws Any violation
of Seempt therefrom and
<, the brio for the alleged exemption. Any violation o(.Ity 70315 by any OUTLETSSWITCHEST XTURESILI
O$Z appBantfora perout subfede the npplfcanlloo dull perulty o(not morethan J
R Cr` 15
Be Imndreddollan($500). NEW RESIDENTIAL ELECTR SQ.FT. STORIES TYPECONSTRUCTION
�i u I,as owant of the property,or my employees with wages as their sale
compensation,will do the work and lhentructom isnot Intended or offered for
Osa1eCSec.7044,Business and Professions Code:The cmusetoe.License Law
$ does not apply to an owner of property who Wilds or improves thereon,and OCC.CROUP RES.UNITS
whodoessuchworkhlmsel(wthrough hisownemployees,provided that such
improvements are not Intended Reoffered for sale.If,however,the Wilding or T
improvement beold wlthinoneyearofcomplel Ntheowner-WIlderw111 have
tl)RJZurden of proving that he did not Wild or Improve lw purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
LJ L as owner of the property,am exclusively contracting with licensed ppZM)T ISSUANCE
contractors ec to construct the project(S 7061,Business and Professors Code: �
The Contractor's Liceise Lw don nae apply to an owner of property who
Wilds or improves thereon,and who contracts for such pnpjects with a ALTER-DRAIN&VENT-WATER 2U
tgw.dor(s)Licensed pursuant to the Contractor's License Law. FEE SUMMARY
L I am exempt under See. B&P C for thin mown BACKFLOW PROTECT.DEVICE
Owner Dee DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
RIECFTPT X
WORKMAN COMPENSATION DECLARATION FWRJRES.I'ER TRAIa � SCHODLTAK Y_ N
QI hereby affirm that I have a eardficate of consent to self-Iwrs,w a B C=R
cenlRcate o(Worken'Compensatlonlmunnce or a certified copy thereof(Sec. GAS FA.SYSTEM-1 INCAOUILEIS PARKFEE Y N
3800,lab C.) RECEIPT N
Polity M
CGAS EA.SYSTEM-OVER 4(EA) BUILDING DTVI SION FEES
omoanv � OMC M R '
1 I Certified copy b hereby furnished. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
{ESyI CerWled copy is filed with the city Inspection division. )
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEVER-SANUARY-STORM F.A.2(ppI Date R I tll
Uhusectim need not be completed if the perrat b foroor hundred dollars
(y100)mlen') WATER HEAT ER W/VENT/ELECTR ENERGYFEE Y �s
I certify that In the performance of the work for which this permit is Issued, np
I shall not employ any person In any manner an as to beacons subject to the WATER SYSTEM/TREATING
Workers'Compensatlon Laws of California.Date PAID
O Z Applicant NEW RESIDENTIAL PLMB. SQFr. cel IN
Z O NOTICETO APPLICANT:If,after making this Certifica of Exemption,you
should become subject Lathe Workers'Compensation pmvislare of the Labor To
fA Cod,you at forthwith comply with such provisions orthis permit shall be
> deemed revoked.
W
W c CONSTRUCTION LENDING AGENCY EIS'
FEE
Iherebyaf(Irtn that there be construction Lending agency for the perform E RIC FE- g
0 ante ofthe worktor which this permit b baued(Sm 3M,Civ.CO
Iand.e.Name LU BINGE E - qA
LL t- Lenders Addrem QTY. MECHANICAL PERMIT FEE MECHANI L FEE
OW bcorImdlfythatl have readthbapplicationard mon statethattheabovelnforati
1 ect.I agmetocomply with all city and county ordinances and pate laws PERMIT ISSUANCE FEES PAID:
>. y relating to building construction,and hereby authorize representatives of this
H Z city to enter a Eonthe above-mentioned property for inspection purposes. ALTER OR ADDTO MECH. Date Recei to
(We)agree to save,indemhi(y an d keep harmless the City of Cupertino
V against ZtibWtiea,judgments,mets and expenses which may ingPy wayaame AIR HANDUNG UNIT CTO I O,ODO CFM) SUBTOTAL:
.gal ty in consequence of the gra this perms -1 ft HANDLING UNIT(OVER 10,000 CFM) CONSTR ON TAX
o p rant ntndor Date FXHAUSTHOODCW/DUCT) CONSTR TION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfutam Wilding occupant atom or handle hazardous HEATING UNIT(TO 100,000 BTU) Date ReCei tic
material as defined by the Cupertino Municipal Code,Chapter9.IZ and the _
Health and Safety Code Section 75532(.)? HEATING UNIT(OVER 100,000 BTU) IOTA
❑Yen MN.
Will the applicant or future Wilding occupant use equipment ordevices VENTILATION FAN(SINGLE RFSID) ISSUA CE DATE
which rout hazardous air contaninann an deo Red by the Bay Arca Air
Qua lily Management District? BOILER-COMP DHP OR 100,000 BTU)
Yes ❑No
have read the hazardous materials Requirements under Chapter 6.95 of BDILERCOMNOVER100,000BTU)
the Ca verals I lealth&Safety Code,Sections 25505,25S33 and 75534. 1 D
understand that lithe building does not currently have a tenant,that It is my NEIN RESIDENTIAL MECH. SQFr P
responsibdity to notify the occupant of the requirements which moat be mel
prior to Issas are of a Certificate of Occupancy. Q
Owner or authorized agent Data TSSUEDB
TOTAL: —
bt
OFFICE COPY