24306 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PFRMIT NQ, 4 3 0 6
Building Address: Z
nen a / t APPLICAITONSUBMIIIALDATE-
CITY OF CUPERTINO-BUILDING DIVISION
c.n APPLICATION /PERMIT
K BUILDING-ELECTMCAL-PLUMBING-MECHANICAL CATEGORY
A
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Ad PERMITISSUANCE
EN CONTRACTOR'S DECLARATION
Ihembyaffirm t l am lkemed under provisions of Chapte,9(comme APPLIANCES-RESIDENTIM, BDFSCRI''HON
OIN
ingwith Section )o(III v is ion 3ofthe Businsand no ssimsCed,s
liunselslnfill and Wfs27 / PANELS _
Date ac Cla O'
Date Contractor -
ARCHF=S 12019i"\.
reO ZpC I understand my plans shall be u public recoNa. OV 1000 AMPS.. n SQ.FT.FLOOR AREA S/SQ.FT.
U Licensed Professi.ml SIG I LECTRICAI. l
QF75 OWNER-B UILDER DECLARATION
t- IhWebyarmthat l am exempt fromthe Contractor's License law for the SPECIA /M
OOZFq fRfollowing reason.(Section 70315,Business and Professions Cade:Any city or Q;QAP.METER OR POLE INST.
S;P , countywhlchrtquiresaper ttoromtmd,Oter,tmpmvgdennlbh,orrepalr
.a any structs re prior to its issuance,also requires the applicant for such permit to
F
Fu file a signed statement that he V licensed pursuant to the provisions of the POWER DEVICES
3 4 t, Contramm
rs Lice.law(Chapter 9(commencing with Section 7000)of Diet.
e,Gy.'S sion3ofthe Bus nand ProfessiomCWe)orthatheisexemptthemlmmand SWIMMING POOL ELECTRIC VALUATIQU
the basis for the alleged exemption. Any violation of Section 70315 by any
��0� DITILETSSWIICHFSFIXIURES
applicant fora permit subjects the applicant to a civil penalty of not more than
w c, five hundred dollars f$SM.
NEW RESIDENTIAL ELECTR _51 FEES TYPE CONSTRUCTION
7 I,as owner of the property,or my employees with wages r 'Mir sok �'FT
C 6 samp(Sec.
70K Business
ess Wed work and ima,Cede:
Th n IntenContractors
.,offered for
��p rile(Sec.7004,Busimss and Pro(esslom Code:The ConlraRofs License law
does not a pply to an owner of property who Wilds or improves thereon,and OCC.GROUP RES.UNITS
whodomauchwurkhimself.,through hisownemployees,provided that such
improvements arc not Intended oroffered forsals.If,however,thebullding or T
improvementasold within oneyearofrompletion,the owner-budderwill have
t ,den of proving that he did not bund or improve for purpose of sale.). Qly, PLUMBING PERMIT FEE 17LOUDZONE nPN
L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE /
contractors to combuct the project(Sec.7004,Busine
The Contrare and Ih.lessiom Code:
ctor's License Law does not apply to an owner x pmpery who ALTER-DRAIN&VENT-WATER(EA)
Wilds or Improves thereon,and who contracts for such pAojecs with a FEE SUMMARY
ro,IWBTTactor(s)ifenssd pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
t_J
,am
exempt under Sec on
B&P C for this reason
Owner -rte DRAINS. ROOF,AREGOND. SANITARY Y_ N
• WORKMAN COMPENSATION DS FLOOR, A,DECLARATION RECEIPTN
❑I hereby affirm that I have a certificate of consent to self.insurs,or a FITDTRFS PER TRAP SCHOOL TAX Y_ N
o ei0cateof Workers CompersatlonImuranoramd[fled ropythereof(Sec. RECEIPT N
S
380,Lab C.) GAEA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
Policy N RFCDIPI'N
Com any GAS EA.SYSfEMOVERd(FA) BUILDING DIVI51 NFEES
Certified copy is hereby th the city
❑Certified copy bfiled with the dtyimpection division. CREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK F��
CC l N 4�to
CERTIFICATEMPE SATIO I N FROM WORKERS' GREASE TRAP PATQ7
COMPENSATION INSURANCE E foro
(This sectiSEWER-SAN TEARY STORM EA 200FT Date Re
on need na W compicted if the permit m hundred dollars
($1 W)or less.)
Irortify that In the perfermance.fthe work forwhlch this permit is issued, WATER HEATER W/VENT/ELECTR ENERGY FEE N_
1 shall not employ any person In any manner so as to become subject to the
O Worker Compensation L,wsof California. Date WATERSYSTEM/TREATING PAID
Applicant
Z 0 NOTICEIOAPPLICANT:If,aker making this Certificate of Exempllon,you NEWRESIDENTIALPLMB. SQFT. Date RC N �.
HAmid become subject to the Worked Compensation provisions ofthe Labor TOTAL:
W Code,you moat forthwith compiywith such proom
vislorthis permit shall be
LU > deemed revokad. BUILDING FEE ^N
d p CONSTRUCTION LENDING AGENCY SEISMIC FEE _
I hereby affirm that there V m a construction lending agency for the perform,Z anceofthework forwhichthb permit is iawed(Sec.3097,Civ.C.) To ELECTRIC FEE
U O Lender's Name PLUMBING FEE /
U. U Lender'stAthatI QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Icertlfythatl have read this appBcationandsatethattheabove Nformation
IL ucomect lagree to comply with a B city and county ordinances and sate laws PERMIT ISSUANCE FEES PAID:
r W relating tobuliding comWctlon,and hereby ulhorize reprcxntaevm otthis
Z citytoenterupon theabove-a 'It"dp rty for Wpe<to purposes ALTER ORADDTO MECH.
(We)agree to save,Inde f4,and harMem me city.,a no Date Receipt#
against) ;iadgme sand n whlchruyina AIR HANDLING UNIT CFO 10,000 CFM) SUBTOTAL:
aga' id ny I. ..it ant' gofthispermil.
AIR HANDLING UNET(OVER 10,000CFM) CONSTRUCTION TAX
5 re C e
EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
A US MAT CLO RE
Ill the applicant or future building occupant sto rhan e� o HEATING UNIT(TO 100,00 BTU)
terial as defined by the Cupertino Municipal C ,Chapter9 andthe _ Date Reset t#
Ith and Safety Cade Section 25532(a)? HEATING UNIT(OVER 100,000BTU) TOTAL:
❑ Yea No
Wlllthe appllra nt.,(score buildingoceupantusecqulpmentordevices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air rontanne.,us as defined by the Bay Area Air
Quality Management District? BOILER-COMP 011POR 100,000 BTUI
o Yes 11'�No ^
'have read the haz,rQiousmaterlak requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU)
be California Flealth&Safety Code,Settlors 75505,75533 and 25534.1
understand that if the building does not currently have a tenant,that it iseny NEW RESIDENTIAL MECH. I1
mspomibSQ.F7iiitytonctifythenecvpant ofthe requirsermtswhich must be end PPC 31
priortoissuanofa CcnifinmofOvdpancy /y
. Clly - 994?
Owner or authonud agent Date I 'Ul,
TOTAL ISSUED BY:
OFFICE COPY