24275 APPLICANT TO FILL-IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Beadln Proed rdwalf mol.. PERMIT NO.
' BuRding Adde as: -
P , 24275,
I oo8'l
nerahone: KPPErCKT=Kmi7 VAI,DA 1h
a� CITY OFCUPERTINO-BUILDING DIVISION
c art a`•,p^y.f� N'►�(� `a: '
APPLICATION,/ PERMIT
—` L
^+v�� -- ` BUILDING-ELECTRICALPLUMBTNG-MWIiANICAL CATEGORY CONTROL#
ArchRed/Engineer. - Lie.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: r '
PERMITISSUANCE ❑ ❑ '❑
CONTRACTOR'SLICENSED DEC TION
I hereby a((Irm thetlam Bcenxd underunderprovisl o(Chapter9(rommac- APPLIANCESRESIDENTTAL
IngwitleSection 7000)of Divlslon3 ofthe Business dProfeasloreCode,and my
license Is In full farm and effect - PANELS
Licenm Cj Llcp , n Gs PF "/,
Date_ L.�%Llc,# Nor u(/� �r"r••� 1 Li
ARCHITECTS DECLARATION201-IOW AMP$
p�p�I"n auu MO O I understand my plana shall be used as public records. OVRR IOW AMPS SQ.FT.FLOOR AREA S/SQ.FT.
Ed Licensed Professional SIGNSELECTRICAL
<< OWNER-BUILDER DECLARATION
SPECIAL CIl2CUIT/M19C
uI
p,t" Thereby affirmm thatlaexempt from the Contractor'sLicense Lw(orthe -
pp following reason.(Sedbn 70315,Business and Professions Code:My dty or
O Z i.y9 TEMP. ER POLE INST.
P� countywhkh acquires permit tocorutmct,alter improve,demollah,orrepalr
an yatmmmpriortoittmanc"13omquireatheappRantforsuchpemrmitto POWERDEVICES
file a signed statement that he is licensed pursuant to the provisions of the -
3wContractor's Liceme Law(ChapterI(commencing with Section 7000)of Divi- VALUA'17(&N�. -
tin SWB.{h1MG POOL ELECTRIC C�7
�OS the 3 ofbasis
for he
Business and Profeexemption. Any orthrthela sxemptection 03LS by any -
Q the bxafor the alleged exemption. Any violation of penalty
c out re re any OUTLETSSWITCHESFI%TURES
applicantudfora permit subjects the applicant to a dull penalty of not morethan
five 1,..o demodollarthepr. NEW RESIDENTIAL ELECTR SQ.FT. STORIES TYPE CONSTRUCTION
�n ❑I,as owner of fist property,or my employees with wages r thele wk
compensation,wBldoth..dwork,Pa fess.. at odureh not intended or offered for
q sale(Sec.apply
to alnow ami f prop lora Code:The Contractors Llceme law
r3$ does nonsuch torn inc erofproperty who builds nemporimproovidedtheeon,and
that
OCC.GROUP RES.UNITS
who dcements a am t intended
rate dee orough his ownemployees,provided that g or
improvementarcnot Intendedprofferedfprsale.thhowever, deer ilI haw
TOTAL:
improvementtaoldwlthinoneyearo(completlorytheowner-bullderwlll Anus
tl)gkurden of proving that he did net build or Improve for purpose ofsak.). . QTY, PLUMBINGPERMITFEE FLOOD ZONE APN
u I,as owner of the Property,am exclusively contracting with hearted PERMIT contractors to construct the project(Sec.7044,Business and Professions Cade:
The Contractors License Law does not apply to an owner of property who
Wilds or Improves thereon,end who cmdrads for such plojeda with a ALTER-DRAIN&VENT-WATER(EA)
cgBt(adort)urxnxW pursuantno the Contractor.Lt...Law. FEE SUMMARY
LJ I am exempt under Sec. B&P C for this reason BACK FLOW PROTECT.DEVICE
I OUTSIDE FEES
DRAINS FLOOR ROOF,AREA,CONE. SANITARY Y_ N_
Owner Date BEC=#
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP - SCHOOL TAX Y_ N_
❑ affirm that hereby affirthat I have a artlflam of consent to self-insure,ora RECEE'f#
cediflmWO(Work m'Compematlonlaumnaoracertifiedmpythemcf(Sec. GAS F.A.SYSTEM-I INCA OUTLETS PARK FEE Y N
3800,Lab C.) RECENT#
Policy N GAS F.A.SYSCE WOVER 4(FA)
any BUILDING DIVISION FEES copy t herebyfurnished.the cid. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
F-1 Certified copy t filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWEjbSAMrARV-BIORM EA 2WFT Date Recei tN -
(Thlssedlon need not be completed If the permit t for one hundred dollars
($100)m leas.) WATER / rR EN RGY FEE Y_ N_
Icertifylhat In the performance ofthewak forwid thlspe itislssued,
I elull nM a ploy any pen
on In a neem t m the ,
orkers' mperyq#tlpnyya.werpf�a o�far Date WAS / PAID
O Z pplicant/ ( 's IJ J IATA NEW RESID LMB. Date Recei t#
Z NO TICETO APPLICANT:B,aRer ma ng(Tile Certificate of em Ion,you
should became subject to the Workers'Compensation provtlmu of the LaWr TOTAL:
(�) Code,you moat forthwith comply with such provtiona orthis permit shallbe DATE BIDING 'E �—
W deemedrevoked.-
UCONSTRUCrION LENDING AGENCY SEISMIC FEELeap
CL Ihembyaffirmthat there t a construction landing agency for the perform- TOTAL: ELECTRIC FEE
ce
D Z .onof the work fur which this permit t Issued(Sec.3097,Civ.C.) - '
U O _ Lenders Name - PLUMBING FEE
F .Lender's Address QTY. MECHANICAL PERMIT FEE
OW isroIadifythatlluvemadthtappBrationandrtatethattheaboveinformation MECHANICAL FEE _
a rred.l agreeto comply with all cityand cointyordinances and nate laws PERMIT ISSUANCE FEES PAID:
N relating to building construction,and hereby authorize representatives of this
F
city to enter upon the above-mentioned property for Inspection purposes. . ALTER OR ADD TO MFCH.
2 - Date Receipt#
{We)agree to save, encs,indemnify m an d keep es whitharmless the City of Cupertino
V against liabilities,judgments,coatsat expenses which cosy In enyweyaccme AIR HANDLING UMI'(I'010,000 CFM) SUBTOTAL:
against By in eras ott nisi of this perm . CONSTRUCTION TAX
AIR HANDLING UNIT(OVER 10,000 CFM)
Ignature of Applicant omrador Da EXHAUST HOOD(W/DUCT) ' CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will thea Ilan or future building occupant slam or handle hamodaua HEATING UNIT(TO 100,000 BTU) ,
PP B W Date Recei
material as defined by theCupertino Municipal Code,Chep[er9.1$.and the
Health and Safety Code Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU) � TOTA L
hJ
n Yea No
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DA'L'E
which emit havardousalr contaminants as defined by the Bay Area Alr
Quality Management District? BOILER-COMP 100,000 BTU) '
No .
Yea
4azarclahave read the hoo No
ae materials t requiremenunder CArpter 6.95 of BOILER-COMP(OVER 1W,000 BN)
the California Health&Safety Code,Sections 25505,25533 and 25534.I P A i D
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.Fr.
amponsibi ity to notify the occupant of the requirements which most be and
prior to issuance of Certificate of Occupancy. $ES
Owner or authorized agent Data ISSUED By'
, TOTAL:
OFFICECOPY