24434 APPLICANT TO FILL IN INFORMATION WITHIN REDLINES — USE BALLPOINT PEN ONLY
Building project Identification PERMITN24434
Z 4 4 3 4
Bu Add ^ .. - .• Z
where one A
L � 42!SY OF CUPERTINO-BUILDING DIVISION
cant" ° Lle•Na: ''APPLICATION I PERMIT
BUILDINGC- CATEGORY CONTROL#
Arcbltect/Enginem Lk.Na:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Addreu: PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l con licensed under provisions of Chapter9(commen APPLIANCESRESIDENTIAL JOB UfSCKJJ-1 ION
Ingwlth 1.fon force
ofthegudnessand Proles.lons Code,and my I v _ _(]
Lteerslslass force and c# PANELS \Y
Licence Cba LIc.N
Date Contractor
ARCHITECTS DECLARATION M-1000 AMTS
�rqqv�W, lundentandmyptamaluilbeuwdaepubecrecorda OVER 1000 AMPS SQ.FT.FLOOR AREA S/9Q.Fr.
6 E Licensed Professional . SIGNS ELECTRICAL se r, •� ® B
«<; LN to
DECLARATION SI'EC[AL CIRCUIT/MISC 11— 0L�T1B N6�
ZO� following reason.
B fromthe Contraatio Llmne:AnyLaw cit or E^1R U TER
qqq�y county whic
h
ire aper permit to
and Professions Code:Any city or V�
K�~3 countywhich requlmaperrNt tocoruwa,alter,improve,demolish,or repair
TEMP.METER OR POLE INST.
7 any strudure prior to its issuance,also requires the applicant for uch permit to
POWERDEVICES.
01e a signed statement that he V licensed pursuant to the provisions o! the
Contractors License Law(Chapter 9(commencing with Section 7000)of Dlvl-
s1..3ofthe Business and Pra(emto.Code)arthat hebexempHherefromaed SWPIMING]Y30LELECTRIC '
the basis for the alleged exemption. Any violation of Section 7031S by any
pS applicant lots permit subjects the applicant to a civil perultyofnamarethan OUTLETSSWUCHES-FIXITIRFS
five hundred dollars%5f)(1), NEW RESIDENTIAL ELECTRSQ.I7,
�a ❑1,as owner of the property,or my employees with wages as their sole STORIES TYPE CONSTRUCTION
compensation,will do the work,and the structure le not intended or offered for
sale(Sec.7014,Business and Pro(emlow Code:The Contractors License Law
r3$ does not apply to an owner of property who builds or improves thereon,and OCC.GROUT' RES.UMTS
who does such work himself or through his own employees,provided that such
Improvements are not Intended or offered for sale.If,however,the building or
Improvement is sold within oneyearofcomplellon,the owner-builder will have w
t1liLtEurdeno(pmving that he did not build or Improve for purpose of sale.). QTY. PLUMBINGPERMIT' E' LOOD
F70NE APN
I;as owner of the property,em exclusively contracting with licensed PERMIT ISSUANCE !
contractors to corutruct the project(Seo 7014 Business and Profession Code:
The Cmarector's Licence Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(FA)
Wild.or improve.thereon,and who comas for such pt.*ss with e
co,yIlttffactor(s)licensed pursuant to the Contraciors License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec. B&P C for this reason -
DRAINSFLOORROOF,AREA,COND. SAMTARY Y N
Owner Date RECFRT N
WORKMAN COMPENSATION DECLARATION FDCTURIE,PER TRAP SCHOOLTAX Y_ N_
❑I hereby elOrm that I have• In tRate of consent m copy
thereof
or - RECEIPr N
3800,
certiateofWorken'Comperuatlonlmurana aracertlfled copythereo(ism. GAS PA.SYSTEM-1 ING40UTLETS PARK FEF. , Y N
Policy
lab C.)
aliq# GAS EA.SYSIFAI-0VER4(EA) RECEIPT# .
r� ry BUILDING DI VISION FEES
ertNed ropyIs he d with the cit. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
crtlRed copy V filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER- STORM-STORM EA 2001x' Date Rem IN
(rhlecectbn need na be camplaed If the perMt V lar one hundred dollen _
(f1 W)or.rieless.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
[cethat U the pedornunce of the work larwhlcn Ihls permit is lowed,
I shall not employ any person In any manner w a to Wcome subject to the WATER SYSTEM/TREATING
Workers Compensation Laws of California. Date PAID
PP
A licant
Z � NOTICE TO APPLICANT:If,after making this Certificate RESIDENTIAL PLMB.
le o(Faemptbn,you SQ17. Date Recei til
should become subject to the Workers provisions of Labor TOTAL:
Code,N deem,revokedr�hwith comply with such provisions mtM3 permit shall be BUILDING FEE
W SEISMIC FEE
CL CONSTRUCTION LENDING AGENCY s..,
I hercbyarlirmrwhicrebacomtmalon lending 097,Ciforthe pedorm- ELECTRIC FEE jP�rA'
� Z once olthe work for whlehthb permit bhwed(Sec.3097,CIv.CJ � TOTAL: V
V O Leaders Name PLUMBING FEE
IL h Iendee.Addeon QTY.1, MECHANICAL PERMIT FEE MECHANICAL FTE
OW Icertlfythm l have read thlsapplicatWnend Yatethattheabovc Informal]..
IL Iscorred.l agree to comply with ell city and munty ordinances and state laws PERMIT ISSUANCE, FEES PAID:
} relating to building corutrodlon,and henbyauthoriaenpresentativesa(this
Zcity to enter upon the above-mentioned property for Inspection purposes, ALTERORADDTOMECH.
(We)agree to save,Indemnify an d keep harmless the City of Cupertino _ Date ReCeiPt#
V'
against liabilities,jud mems,malaand eJ penseawhich may lnanywa ammc AIR HANDLING UNIT(TO ID,000 CFM) SUBTOTAL:
-
againstsaidCityln nae encs of f orating of thls pertni _
�/ AIR HA LADLING UNIT(OVER i ITWO CIM) CONSTRUCTION TAX
-` 4z
Signature of Applicant/Ca 'tor le EYHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZ.A Rffbus MATERIALS DI SCIASUR E -
Willtheapplicantorfuturebuildingmcupantstoreorhandlchazardous HEATING UNIT(TO 100,000 BTU) Date RCCeJ tN
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the
I ealth and Safety Cade Section 75532(a)7 HEATING UNIT(OVER 100,000 BTU) TO
M Ye. M No
Will the appllant or future building occupant use equipment or devices VEMDLATION FAN(SINGLE RESID) ISSUANCE DATE a
which emit haeardens air cents anneals as defined by the Bay Area Air _
-� Quality Management Diatrla7 BOILER-COMP(3HP OR 100,000 BTU) (� p /
n Yea f—I No a`7
`1 have read the Masa U.0.1cdabi requ Imments u adcr Cha pier 6.95 of BOILER-COMP(OVER 100,000 BTU) nIo
the Califomla Health&Safety Code,SMIore25505,75S33and25534. I I{f (/
understand thati(thebuildingdoanotcumentlyhavc a tenant,that It rtmy NEW RESIDENTIAL MECH. SQ.FT v as
responsibility to notify the moupant of the requirements which must W met
priortolssuanceofaCenlBateof Ocoupancy. - Or�'uhCut-
Owner or authorized agent Date - - TOTAL: ISSUEDBY:
OFFICE COPY