24303 APPLICANT TO FILL IN INFORMATION WITHIN REDLINES — USE BALL POINT PEN ONLY
Building Prom Identification . PB- TNO
Building Addmss: - ' 24303
ooln ern ��\� L �ti„ � n o '
neve acre: oneal.
izexxie-:1 pa Cts Fj(p� \ (p - CITY OF CUPERTINO-BUILDING DIVISI /e_� r�
Conrad°''°Mane° L19.Mao APPLICATION /PW
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—g- M Fit- b 3 BUILDING-E.ECtMCAL-PLUMBINC-M NICAL CATEGORY
1'.mhltM/Engineer. Lle No:
QTY ELECTRIC PER FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE ❑ _ ❑
LICF.NSEDCONACTOR'S DECLARATION
I hereby affirm that lams du er provisions of Chapter 9(commnc. APPLIANCES JOB DESCRIPTION
In wllh Section 7000).f Divlsl off uslnemand PmfmsionsCodeandm
Ilcgcnx Is In full force and d( y PA
LlcenxClsm Llc.# - �.
Date_Contractor T
ARCHITECTS DECLARATION 201"1000
µ❑!mO p I undenta cad my Pict shag be'used u pubic recortls. OVER 1000 [5
SQ. FLOOR AREA f/SQ.FI'.
E� Llccnxd Professioml - SIGNSELECTRICAL
< OWNER-BUILDER DECLARATION
SPECIAL CIRCNT/MESE
Z f' G owing affirm(Sthat l am exempt I.5,Bu from the d Professions
Lirenm Law for the
oo followingicon.(Benson Illi LS,ummuctand Profembn Cade:Any dty or
ir
F Z F� TIIdP.METER OR POLE INS!.
countywhkh rcqulma pentyl toconinct,alter,Improve,tlemollsh,orrepalr
a'� anystructure pdorto its Issuance,also requtresthe applimntfor ouch permit to POWER DEVICES '
L5 file a signed statement that he In Ilansed pursuant to the provisions of the
G51 3 Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC
Bion 3 oflhe Buslnessend Profemiome)ob
Codrthat he exemptiberefromanci VALUATION
Q.•�77 the bash for the alleged exemption. Any violatlon of Sedlon 7all.5 by any OUTLETSSWITCHESflXTN2F5
applicant lora permit subjects the applicant to a civil penalty of not more than
$ five hundred dollars($500). NEW RESIDENTIAL ELECTRSQ.FT. STORIES TYPE CONSTRUCTION
n m owner of the property,or my employees with wages as their sok
. PQ wm, sallon,wllda the wor"nd lhesltucture ls not intended or offered for
O ole(Sec 7014,Business ami professions Code:The Contractors License Law
$ does notipply to an owner of propertywho bolldsor improvnthereoq and OCC.GROUP RFS.UNITS
whodoessuchwork himxltorthm igh hisownemployees,provided Ihalsuch
Improvements are not intended oroff rad fmsale.If,however,thebuilding or TOTAL:
I improvement bsold wlthmoneyearbfmmpidion,the owner-bullderwlli have
tIatfa rden of proving that he did not build or improve for purpose of ole.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
LJ L as owner of the property,am exclusively contracting with licensed
contractors to comlruct the project(Sec 70K Business and Profession Code: PERMIT ISSUANCE / O O
The Conlmdoes Limnos Law don not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
' Wilda or impro mi thereon,and who contracts for such p(ojeds with a
co➢!(+ctorp)Bmnaedpurauanl to the Carmadura License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec. B&P C for this reasonQUTSI
DRAINS FLOOR RODF,AREA,GOND. SANITARY Y N�
FEES
Owner Date RECEIPT# '
S WORKMAN COMPENSATION DECLARATIONpp(TURpS.pER.IRAIP" SCI1O0L TA% Y N
❑I hereby affirm that I have a certificate of consent to self-Insure,ora I co RECEIPT
M00,Lab C.I M
mniflmteofWorken'Compematlonln mnceorawalfiedmpythemof Tvc. .J GAS PA.SYSTEMINO4OUTLEfS PARK FEE Y N
Policy# GAS EA.SYSTEM-OVER 4 TEA) RECiII'1'#
' any BUILDING DIVISION FEES
Cam
Certfied copy In hereby tehid. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy Is filed withh the City inspection division.
CERTIFICATE OF EKEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANfTARY-51ORM EA.200Ef. Date Recei t#
((hlsscdlon need cad be completed tithe permit ls forom hundred dollars
(5100)mlemJ WATER HEATER W/VFM/D.CCTR ENERGY FEE Y N
I mrtify that In the performance of thework forwhlch this permit le Bound,
I shall not employ any person In any runner so m to become subject m the WATER SYSTEM/IRGi7NG
Workers'Compensation Laws of California.Date - PAID
O Z Applicant NEW RESIDENTIAL PLMB. :O,Ff. Date Remi t#
Z O NOTICE TO APPLICANT:If,after making thin Certificate of Exemption,you -
should become subject to the Workers'Compenat Fix provision of the Labor TOTAL:
N Code,you must forthwith comply with such provisions orthia permit shall be GFEE
W j deemed revoked. ' .1311-IL�1�
CONSTRUCTION LENDING AGENCY Ot SEISMIC FEE
0. I hereby affirmthat there is a construction finding agency for the perform- ELECTRIC FEE
M Z aoco ofthe work for which this permit ls lswed(Sec.3097,Civ.C.) TOTAL:
02 Iendee.Name PLUMBING FEE t
LL F Lender's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEB
O W Roundfythatlhavercadthlsapp11n11ona MMalelhattheaboveinformation
S Incorrect.I agree to complywith all city and county ordinances and slate laws PERMITISSUANCE FEES PAID:
'} relating tobullding construction,and herebyauthoricereprexntativesofthis '
Zcity to enter upon the above-mentioned property for inspection purposes. ALTERORADDTOMECH. Date R.CCI t# `
(We)agr a to ova,Indemnify an d keep harmiem the City of Cupertino -
against
Il ties,Judgments,cmteand eapenxs which may in anywayaccrue AIR HANDLING UNIT(ED 10,ODO CFM) SUBTOTAL:
agai City incon ence of the W.Jrg of this permit.
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
S cant/Contractor Date EXTIAU9fITOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
WIII applicant orfuture budding occupant store or handle hazardous HEITINGUNIT(TO100,0000TJ) Dat. ReOpl t#
material as defined by the Cupertino M.Ncipzl Code,Chapter 9.1Z,and the -
Health and Safdy Code Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU) T
❑ Yes No
Will the applicant or Lure building occupant use equipment or devices VENTILATION PAN(SINGLE RFSID) ISSUANCE DATE
which emit hacandous air contaminants as defined by the Bay Area Air
( ality Management cti BOILER-COMP(311POR 100,00(i BTU)
Yes No
s' have read the hit r ousnotedaB requirements under Chapter 6.95 of BOILER4roMP(OVER 100,000 M) p
the California Health&Safety Code,Section PAID
25505,25533 and 25534. I i D
understand that if the building don not currently have a tenant,that It is my NEW RESIDENTIAL MECH. SQ.rr OCT
rnponibslity to notify the occupant of the requirements which must be caret y '
prior to usuanceOf a Certificate of Occupancy. (/
Owner or authorized agent Date S� f / •_
TOTAL: .ISSUE BY:a
OFFICE COPY