24309APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identlflatlon- ,f �+'/ �,
BuildingAddress: -/✓y/•. /_�/jam
Z74
PERMIT N 24309
O
s e.
amAPPLICATION
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
-MIAMCAL
suasti ii AL EA iL;
CT Zca
10`
i
CATEGORY CONTROL M
Architect/ ginner. Lie N
QTY ELECTRICPERMIT FEE
BUILDING PERMITINFO
Addrchs:
PERFRTISSUANCE
LICENSED CONTRACTOR'S DECLAMT
I hereby affirm that l am Bcanaedunderprovbloneo apter 9(mmmenc
Ingwlth Sed1an70DD)of Divldon3 ofthe Budnessan fesdonsC„odgand my
licenseislnfullformandeffed.
APPLIANCES -RESIDENTIAL
_ JOB DESORPTION
/-
KI t ��L �10��—IA
PANELS -
Luumu Clam LIc/
ARCHITECTS DECLARATION
I understand my plana shall be used As public records
,.L. �/1,1
-`r e\� -
Zp1-1000 I
1 Ia5
SQ. FT. FLOOR AREA
5/SQ. FT.
VSELECTR M,
Licensed Professional
ji
SPECIAL C E /
OWNER-BLDER DECLARATION
UI
I hereby a(flrmthat I am exempt from the Contractor', License Law
TEMP. LE INST.
following reason.(Section 70315, Business and Profcssime Code: Any city or
county which reqs Ise a permit to construct, alter, impmve, d ennlbh, or repair
anystacture prior to is Wuance, oleo nequirestheappBont for such permit to
Ole a signed statement that he Is licensed pursuant to the provinces of the
Contadoes License Law (Cha Enter 9(mmmendng with Section 7000) of Divi -
Aim
,m 3 o(the Business and PfemimoCcde) or that he b exempt therefrom and
the bolo for the alleged exemption. Any violation of Section MIS by any
dtaubjects the applicant to a civil penalty of net ore than
applicant fora pemm
POWER DEVICES
'
SWIMMING IDOL ELECTRIC
OUTLETSSWIT'CIiFSFTKTURFS �-
VALUATION
`n /s O
1 � V //
Ove hundred dollars (5500).
nI, as owner of the property, or my employees with wages as their sole
NEW RESIDENTIAL ELECTR SQFT.
STORIES
TYPE CONSTRUCTION
compensation, will do the work and the structure is not Intended or offered for
sale (Sec 7046, Business and Profexsloro Code: The Contradoes License Law
0
does net apply to an owner of property who builds or improve, thence, and
whodoes o
such work himself or through hlswn employees, provided that such
OCC.GROUP
FSM
RUTS
m
Improveents are not Intended orolfered formic. If, however, lhebuilding or
TOTAL:
69
Impmvementbwldwlthlnomyearolcompleion,the cwner-bullderwlll have
ttiLturden of proving that he did not build or improve for purpose ofeale.).
L,J L as owner of the property, am exclusively =trading with licensed
contractor, to construct the project (Sec 7061, Business and Professions Code:
QTY, I PLUMBING PERMIT FEE
FLOOD ZONE
APN
PERMIT ISSUANCE
—00
The Contradois License Law does not apply to an owner of property who
builds or Improve thereoh and who emtraats e for such ptcjewith a
cgOl(+dor(a) licensed pursuant to the Commerce'. License Law.
LJ I am exempt under Sec B k P C for this reason
ALTER -DRAIN &VENT-WATER(EA)
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
OUTSIDE Fr[.,.q
DRAINS FLOOR ROOF, AREA, GOND.
SANITARY Y_ N
RECEIPT If
Avner Date
WORKMAN COMPENSATION DECLARATION
( -]I hereby affirm that 1 have a certificate of consent to ad!-Nwrc, or
380DceHirILab COWorknn'Comperuationlrouran¢oracertltkd mpythereof(Sm.
Polley Y
FIXTURES PER 772AIP
U 0
SCHOOL TAX Y_ N—
RECEIVE 4
GAS EA. SY51"EM-1 INCA OUTLETS AT
PARK ITE Y N_ '
RECEIPT N
Com any
GAS EA. SYSTQ.i.OVER 4 (EA)
BUILDING DIVISION FEES
OCertlfled copy b hercbytumi city
�CertNed copy b flied with the city inspection division.
GREASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECKFEE
^
GREASE TRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
PAID
COMPENSATION INSURANCE
(Thlssedlon need notbe completed If the permit b forone hundred dollars
SEWERSSANITARY-STORM EA 200FT
Date Recei [N
WATER HEATER W/VENT/R TR
ENERGY FEE Y_ N_
(S10D)crf that
that the pedomunceny m week
I cartifyll
wMd this permit Is Ito
WATER SYSTEM/TREATING. 3^
sfor
not o
I shall not employ soy person In any manner at u to become subject to the
the
Warkcre'Compewtion laws of California. Date
PAID
ApplicaNOTICnt
NOTICETO APPLICANT: ttohe aftermakingcant Certificate pr of Exemption, oftheLabor
should become eub)eci to the Workers'Comperwllan provslom ollhe Labor
NEW RESIDENTIAL PLMB._SQFT.
Date Recef IN
TOTAL:
BUILDINGE •d
Code, you =at forthwith comply with such provisions miffs permit shall be
decmnd revoked.
CONSTRUCTION LENDING AGENCY
SEISMIC FEE
Iaerebyaffirm that then is a construction lending agency for the pedoren
anceofthework for which this permit is Issued(Sw. 3097, CIv.Q
1<Meia Name
Lenders Address
I certify that I have mad this application date that the above Information
smrreet.Iagree to comply with all city and county ordinance and nate laws
relating to building mrslnectlen, and hereby authorize representatives of this
city to enter upon the above-mentioned property for Inspection purposes. -
(We) agree to save, Indecently an d keep harmless the City of Cu pert Ino
Against liabilities, judgmens, coats nd expenses which may In any wayac¢ua
against old Cit n sen¢ gof
the this permit.
iowl�,Itthe
TOTAL:
- .�O
ELECTRIC FEE
PLUMBING FEE
QTY. MECHANICAL IT FEE
MECHANICAL FEE
PERMIT ISSUANCE
FEES_ PAII1
_�_��^ y 7J
Date .ReCel tp
P
'ALTER ORAOD 7O METH.
AIR HANDLING UNIT(TO 10,000 CFM)
SUBTOTAL: A
AIR HANDLING UNIT (OVER l0,000CFM)
IXIiAl15T HOOD (W/DUC'D s
CONSTRUCTION TAX
CONSTRUCTION TAX PAID:
re ofA pRa /Contractor Dale
HAZARDOUS MAT ALS DISCLOSURE
applicant¢(uNre buOdln pant stare or handle haaardous
material as dented by the Cupertino Municipal Code, Chapter 9.1 Z, and the
Health and SafetyCorin Section 75533(x)2
r7 Yes r] No
Date Recei to
HEATING UNIT (T0100p00 BTU) U
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
VENTILATION FAN(SINGLE RESID)
11 USV
ISSUANCE DATE
Will the applicant or future building occupant on equipment or device
which emit aarardous air conte Means as defined by the Bay Area Air
a llty, Management District?
Yea,0No
p�
trq �I] IV
1r
BOILER -COMP DEEP OR 100,000 BTU)
BOILER -COMP (OVER 100,ODO BT U)
nave read the hazariious materials mqulmmens urefer Cha pier 6.95 of
the California Health k Safety Code, Sections 25505, 25533 and 75534. I
understand that 11 the building does not co neatly have a tenant that It is my
��
OoTf
NEW RESIDENTIAL MECH. SQFT
resporslbility, to notify the occupant of the requirementswhich must be met
prlorto Issuance ofaCertificateo(Occupancy.
A,YUt�
ISSUEDB .
Owner or authorized agent DateD
TOTAL
OFFICE COPY