24055 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO
BuiOw ing AddresJmms 2 .-rte I , 24055
ru rYlt-y\I'`'Vs alai---.17 e: A A A
('E1V !-57 CITY OF CUPERTINO,BUILDING DIVISION
C aam<: — APPLICATION / PERMIT LZ'«Z
BLnDINGE ECTRICAL-PLUMBING-MEC NTCAL CATEGORY CONTROL#
Architect/En neer. Llc.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMITINFO
Address: PERMTISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I herebySectjglrmthatla iskm sed 3 oftkeerprovbrd Fro Chapter9do,and c PANELAPTLINCFSRESIDEN7IAL JOB DESCRIIxI'ION
Ingwllh Sectio 1100)ol Divlslon3olt eBusln and ro(yslonsCmde,and my
limns b In B fect. /� PANELSLip TO 2DO AML!S
Limns Gla -(,�('�_Licp�w V� 1-�#,�I'+`+►�r
nate_! ( Contractor
nn shaTECPs DECGRc me OVER I0 DO FIS
AM
µppµ!!�O 1 understand my plan shag W used v public rerords OVER 1000 AMPS �.Ff.FLOOR AREA S/SQ.Ff.
Fi Z� Licensed Pmmsslonal SIGNSELECTRICAL
<<�?to OWNER-BUILDER DECLARATION SPECIALCIACUIT/MTSC
7 s,l2� Thereby a!@m that l am exemptfrom the Contractor's Llrense Law for the
following reason.(Section 7031.5,Business and Professions Code:Any city or
FF'� countywhich requim a permit to conswq alter,Improve,demoLLsh,or repair TEMP.METER OR POLE INST.
any structure prior to Its Issuance,aism mqules the applicant for such permit o
y'c file a shed statement that he Is licensed pursuant to the provisions of the TOWER DEVICES
O a Contractor's License law(Chapter 9(commencing with Section 7000)of Divi-
t,w05 SWLMMIM1GTOOL ELECTRIC
sion3 of the Business and Pro(eorob
bCode)or that he exempt therefrom and VALUATION
the basis for the alleged exemption. Any violation of Section 7031.5 by any
��• applIcant for a permit subjects the applicant to a civil penalty of not more than OUTLETSSWITCHES
live hundred dollars%S00). NEW RESIDENTIAL ELI .FT.
�n
F-1 1,as owner of the property,or my employees with wages as their sole sTO TYPE CONSTRUCTION
compensation,w111 dothe work and thestruttue b net intended or offered for ( - TER O sale(5oc.7044,Business and Professions Code:The Contractors Lt..law l 9Y 11-L
j$ docs not apply to an owner of property who Wilds or imprwesthereort and
whodoes suchworkhimselforthrough hlsownemployees,provided that such UC CROUP RE'S.UNITS
improvements arc not IntendN oroffered for sale.1f however thebuilding or T
improvern<nt bsold wlthlnoneyearofcompletiorttheowner-W Bderwill have
th rden of proving that he did not build or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD LO APN
1,as owner of the property,am exclusively contracdng with L PERMIT ISSUANCE .
contractors to construct the project(Sec.70K Business ami Professions Code:
The Contractor's Limns law don net apply to an owner of property who ALTFRARAIN&VENT-WATER(EA)
Wilda or improves thereon,and who contracts for such projects with a
co,nn.t..[[ador(s)Bmnaed pursuant to the Contractor's Limas Law. FEE SUMMARY
LJ I am exempt under Sen B&P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE FEFS
Owner Date
DRAINS ND.FLOOR,ROOF,AREA,COSANITARY Y N
WORK MAN COMP FNSATION DECLARATION RECEIPT p
FD(TURE&PER TRAIT S iQUL TAX Y N_
ereby affirm that 1 have o lmu ate of consent to pythn re,ora RECE17F p
c Late of Wmrken'Compensatlonlnsuranre oraQmnifled copythereo((Sec. GAS G.SYSTEM-1 INC OUTLETS PARK FEE Y_ N
y Tall SII y�p�u CV
Policy M �/ Iay��//r GAS G.SYSTEM-OVER<(G) RECE0vF X
00,Lab Cam any Y70acby'�i y�g BUILDING DIVISION PERS
[�Ccrtde copy filed
the city GRGSEANDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
Bled ropy u tiled with the city inspection divblon.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWERSANiTARYSIORM EA 200FT Date Remi t#
(Thiseectbn need rad W completed i(the permit b(prone hundred dollars
(Bt Oo)oifyth) WATER HEATER.W/VENT/EL,.ECTR ENERGYFEE Y N
Illnot that In the person nmofthe workfor s towhich bthis permit cblued,
1 shall not employ any person f any manner ro n to become subject to the WATER SYSTEM/TREATING
workers'Compensation Laws of California.Date PAID
O Z Applicant NEW RESIDENTIAL PLMB. SQ.Fr. Date Remi t#
Z U NOTICE TO MPLICANT:If,aker making three CertltlLate of Exemption,you
Fshould became subject to the Workers'Compensation provislomof the Labor TOTAL:
W Code,you most forthwith comply with such provisions or this permit shall be BUI TNG FEE
Uj j deemed revoked.
CONSTRUCTION LENDING AGENCY
W O SEISMIC FEE
d Iof ebythe orkfoffirm whiclat retsaermit i tionIssued
leadlegagency 97,Civorthe perform ELECTRIC FEE
0 IMir' Name for whichthis permit blasued(sec 3097,C1v.C.) TOTAL: PLUMBING FEE
(� I<nder's Name U. 1<nders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
U Icenify Natlhavemadthis appllatbnand statothattheabovelnformation
O a bmrect.l agree to comply with all etyand county ordinances andstatelawa PERMIT ISSUANCE FEES PAID:
} re- tobuilding mnswction,ast herebyamhodz<repreacntativesofthb
F Z city e t on the above-nrntloned property for inspection Purposes. ALTEIiOR ADD TO MECH.
- e) ce to save,indemnify an d keep harmless the City I Cupertino Date Receipt#
ago rot iBtl dgments,causandexpenssawhichmaylna way roue AIR HANDLING UMT(TO 10,000 CIM) SUBTOTAL:
ago iso Ci 1 o m o t e rating of this t -
AIRHANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
Slgvtum o(A plHAZARDOUSor HAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant the future Municipantstoreoapter le hazardous HEATING UNIT(TO tOJ,000 BN) Date Recei t#
materialasdefinedbythe Cupertino2(a)?Municipal Cod,Chapter 9.12,and the -
i Icalth and SafetyCade Seniors 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
Yes r]No
Willemut hamnantorfuture
ont building onupantuse the Bayequipmenta devices VENTILATION FAN(SINGLE RESIU) ISSUANCE DATE
which eManaementsal rict? ants as definM by the Bay Area Air LL1, pp
Qu Illy Management Distdct7 BOILEA-COMP(3hI'OR 100,OW BTU) W 0
Ycs FF��No DEChave read the h.Q.us materials mqulremente under Chapter 6.95 of BOILER.COMP(OVER 100,000 BTU) `
the California Health&Safety CW ,Sections Z5S05,25533 and 25534. 1 ` 9�as�
understand that if the building does not currently have a tenant,that It is my NEW RESIDENTIAL MECH. J
SQ.FT I
responsibility to notify the occupant of the requirurrents which at W metC(�•Ir VF
prior to Issuance of a Certificate of Occupancy. - VUrtlTJJN/�
Owner or authorimd agent Date IOTA L: ISSUPD BY
OFFICE COPY