24300 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project Identification PERMIT N24300 4 3 0 0
Building Addreu: '
t o �czA gwo • Cu��n-r ln�oCA
k_eVert came, one: - A
(�t.._%A41_f__ CITY OF CUPERTINOLBUILDING DNIS
CmtraciaraNam: LIC No: APPLICATION / PER T
BUILDING-ELECTRICAI.PLUMBI CAL CATEGORY
n h tact/ ser. ��I /1 1 ,r LJp No:
r�p� (�.� ' .�,�E3��w ,gn/J.,,(/b', QTY ELECTRIC PER FEE BUILDING PERMIT INFO
ro TPERMITISBUAN
LICENSED CONTRACTOR'S DECLARATION
Ihereby of@m thin l am licensed under provisions of Chapter 9(rommme- APPLIANCES L OB DFSC ON
dngwith Section 7DOO)of Division 3 ofthe Beat reassert ProfessionsCode,and my
Bance lChiss (ora and effect P �� �1i' -to
License Class Lkec 4A/
Date Contractor 11000
ARCHITECT'S DECLARATION
072 I understand my plane shall be used as public records. OVERT SQ.FT.FLOOR $/SQ.Fr.
SIGNS EL AL
z�1 Licensed Professional v
<<�6 OWNER-BUILDER DECLARATION B IAL IRCUI 15C /a I
L., a Iherebyaffi.that l ern exempt from the Contractors Lie Uwlsthe43
o Q following
a.(Section 70715,Business and Professions Code:Any city or
�g rountywhlchrequimsapermittoromtmd,alter,lmprove,demolish,orrepalr TEMP.M ORPOLEINST.
a any stmcture prior to it.Issuance,also requdms the applicant for suchpermlt to m
U file a signed statement that he is licensed pursuant to the provWam of the
3wIn Contractor's License Law(Chapter 9(rommenclng with Section 7008)of Divi- NG POOL ELECTRIC VALUATION
�Og Mon3 of the Business and Profeuloni,Code)orthat he is exempt therefrom and
6 S the basis for the alleged exemption. Any violation of Section 70715 by any OUTLETSSWITCHESFIX'NRFS 'l D O OD
applicant fora permit subjeem the applicant to a civil penalty of net more than O/--
five.hundred dollars($SM. - NEW RESIDENTIAL ELECTR
�n
[j 1,as owner of the property,or my employees with wage as their sok - �' STORIESTYI'G CONSTRUCTION
compensation,will do the work and the structure is nal Intended or offered for
0 nae(Sec 7074,Studies,and Profeniom Code:The Contractors License law
2 does not apply to an owner of property who builds or improve*themes,and OCC.GROUP RES.UNITS
who doessuch work himself or through his own employees,provided that such
Improvements arc not Intended or offered for sale.If,however,the building or T
Improvement issold within oneyearofcompletion,the owner-bullderwlll have
tlt,tIurden of proving that he did notbuildorimproveforpurpouofuk.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
LJ 4 as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
rontracton to construct the protect(Sec.7040 Business and Warsslans Code: %
The Contractor's Ldmme Law does net apply to an owner of p rty ^
Wor Improve thereon, and who contracts for such pi je s w hno 1IN - LA
gR�aea(q emneed pursuantec rothe Contractors Llanx Law. FEE SUMMARY
c
LJ I am exempt under SB k P C for this m n - BACKD ICE
Owner Date DRAINS R SANITARY Y N_
RECEIPTM
WOR KMAN COMPENSATION DECO RATION aa0o _� SCHOOL TAX Y_ N
❑I hereby affirm that I haw a certificate of cmseat to uB-In a RECEIPT 8
,y certificate of Workers'Compevatlonlruurana ora anl(led ropythd rc((Sea _ GAS EA.SYSIT144 INCAOUTLMS re PARKFEE Y N
3800,Lb C.) - RECEIVE
Policy M
ore Ry GAS F.A.SYSTEMAVFR4(EA) BUILDING DIVISION FEES
rtifled copy is hereby furnished. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCI-IECK FEE
Certified copy is filed with the city Inspection dlvlalon. -t `� 1 V•7
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID'-Z0'T Z •O b'4 • t/-T .l
COMPENSATION INSURANCE SEWER-SANITARY-sroRM EA 700FI. Date Recti t#
(Thisse tlon need net be completed lithe permit is fororm hundred dollars
($100)or len.) WATER HEATER W/VENT/ELECTR ENERGYFEE Y_ N_
I certify that In the performance of the work for which this permit is Weed, [ f 21(tt
I shall not employ any person In any manner so as to become subject to The WATER SYSIFM/TREATING PAID '� [`,4Oq�((�
Worker'Compensation Laws of California. Date
C) Z Applicant NEW RESIDENTIAL PLMB. SQ.FT. Date Rece1 t#
Z O NOTICETO APPLICANT.ILafter making this Certificate of Example.,you
Hshould become subject to the Workers'Compereatlon provisions ofthe Labor TOTAL: 2-1.42
(n Cod,,you mot comply with such provisions orthis permit shall be BUILDING
Wj deemed revoked.CONSTRUCTION LENDING AGENCYSEISMIC FEE
a Iherebyamf that there is a construction lending agency forthe perform- I ELECTRIC FEE 4
M Z once ofthe workfor which this permit is iwed(Sec.3097,Civ.C3
O O Larder*Nae PLUMBING FEE
LL F Lender's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
U IartifythatlhavereadthheppButlona odstatethattheaboveleformaHm `
O W iscormct l agree to comply with all cityand countyordinanasand state laws ` PERMITISSUANCE S FEES miu.
1 relating to buildingaretructlon,and hembyaulhorinreprewntativesofthb
(— 2 yA(We) g,c pon the above-rrentioned property for Inspection purposes. ALTERORADD7OMECH. Date Receipt#
to ave,Inde p harmless the City o!Cupertinoagatka, udgmen ,castes ran which may In anyway acme AIR HANDLING UNIT(TO 10,000 CFM) Fz SUBTOTAL:
aity In mnarqu the gr ng of this permlt' CONSTRUCTION TAX
3` 91
AIR HANDLING UNIT(OVER 10,000CFM)
nor c ppliont/Contacts Da EXHAUST HOOD(W/DUCT) �—. CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE.
WI the pplicant orfutere building occupant store or handle hazardous, HEATING UNIT(TO IOWO, BTU) / Date - Re
nate las efined by the Cupertino Municipal Code,Chapter 9.1Z and the
Health n fety Code,r._SS,ection25531(a)7 HEATING UNIT(OVER 1(X),000 BTU) T T 1
[�_ LJ No
Ills aapplicant sT sirs,building occupant use equipment or devices VENILATION PAN(SINGLE RESID) RI�SSUANCE DATE
which emit havrdous air cootamimots as defined by the Bay Area Air - r
ality Management District? BOILER-COMP DIE'OR 100,IX0 BTU)
Ye* ❑1 No
've read the bazardsus materials requirements under Cha pier 6.95 of ROME R-COMP(OVER 100,000 BTU) DEC3 1 gOe
the California Health k Safety Code,Sections 75505,75533 and 75534. I b C✓! P.,J2
1 41 understand that dflhe building don not cinently have a tenant,that it E;my NEW RESIDENTIAL MECH. SQ.FT.
responsibility to notify the omupant of the requirements width muss bemM /. tJrto 1114V�
prior to Issuance of a CertificateofOccupancy. Cllr OF V
Owner or authorized agent Data T ; ISSUED B
OFFICE COPY