24243 APPLICANT TO FILL IN INFORMATION WITHIN, RED LINES — USE BALL POINT PEN ONLY
Building Proed Identification PERMIT NO.24243
Buuding Address:
I Lv N.
mors one. -
ams rS a e_ � .. P CITY OF CUPERTINO-BUILDING DIVISION �r�^11
nmoAPPLICATION SUBMI I I AL UA 11,
doe.Namn: LIB.No: APPLICATION /PERMIT I��,
v � BUILDINGE.ECTMCALPLUMBING-MECHANICAL CATEGORY CONTROL M
it /Fn nese Lk.No:
Q ELECTRICPERMIT FEE ate-BUILDING PERMIT INFO '
Addms: 10 PERMITISSUANCE. �y 0 D
LICENSED CONTRACTOR'S DECLARATION �u
I hereby affb hat l amllcensed under provisions o(Chapter9(commeno- APPLIANCES-RESIDENTIALJOB DESCRIPTION
Ing with Section7000)of Divislon3ofthe Buslnessand ProfeulonsCode,and my OV;T`��. 1
It came is In fuB fa and dS deflect. PANE {/r
Date Comractor ta/7`ARCHITECT'S DECLARATION 201-1000AMP5
qWZ Iunderstand my plen,ehall be used u public records. OVERIOOOAMPS SQ.FT.FLOOR AREA 5/SQ.FT.
CO
W�nud Professional I SIGNS ELECTRICAL
cid lb'll OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC
T hereby affirmthzt l am exempt fromthe CoMrador's License law for the
p a following reason.(Section 7031.5,Business and Professions Code:Any dry or TEMP.METER ORPOLE INST.
r rountywhich requbu a permit to constmro,alter,improve,demolish,orcepair
anyslrodom priormlts issuance,also requimithe applicant for such permit to POWER DEVICES
H
S�
t,5 file a signed statement that he is licensed pursuant to the provision,of the
OAF, Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC
ParrottVALUATIOr^
30 eon 3 ofthe Business and Pmf..W.CW.)or that he I.exempt therefrom and V fry/
the basis for the alleged exemption. Any violation of Section 7011.5 by any OUTLETS-SWITCHES-FIXTURES /1 O�
appilcant fora Parrott subjeatstheapplicant to a civil perahy d mre no othan V
O five hundred dollars($500).
'4..' [:]I,as owner of the property,or my employees with wages as their sole NEW RESIDENTIAL ELECTR_�.Ff. STORIES TYPE CONSTRUCTION
compensation,will do the work and the structure is cart Intended or offered for
0 sola 5ec.7066,Business and Profession,Code:The Contractors License Law
$ docsnotapplyto an owner of property who builds or improve therein,and OCC.GROITP RFS.UNITS
es
who dosuch work himself orthmogh his own employees,provided that such
Improvements are=intended oroffered ferule.If,however,lhebuilding or TOTAL:
improvement h sold within aneyearof completion,the owner-bullderwRi have
tl1Rturden of proving that he did not build or improve for purpose ofule.). QTY, PLUM BING PERMIT FEE FLD— DIANE APN
"L as owner of the property,am exclusively contracting with licensed PERMIT
ISSUANCE
contractors to mutmd the proje'et(Sec.7061,Business and Prefesskn,Cade:
The Contractor's License Lw does nor apply to an owner of property who ALM-DRAIN Is VENT•WATER TWWilda or Improves thereon,and who contracts for such pSojects with• FEE SUMMARY
gB(I�oor(.)licensed pureuant to the Cortisone.License Law. BACK FLAW PROTECT.DEVICE
Lf I am exempt under Sec. B&P C for this reason -
DRAINS-FLOORROOF,AREA,COND. SANITARY Y N
Owner Dale RECEE7 N
WORKMAN COMPENSATION DECLARATION FIXTURF_S PER TRAP SCHOOLTAX Y_ N
❑I hereby affl.that I have a certificate of consent to self-Insurs,or a RECEIPT N
f certlfted.ofWorkam Compensation i insurance on a mdlfled ropy thereof(Sec. GAS-PA.SYSn M-11NCA OUTLETS PARKFEE Y N
3800,Lab C.) RECEIPT p
Policy N GAS EA.SYSTEM-OVER/(EA) BUILDING DIVISION FEES
rem Ceany —
rti(iedcopyisherebyfumished. CREASE/IND L�V.' I IN HECK FEE
F-1 Certified copy b Bled with the city Inspection division. — IRIS4
( b
CERTIFICATE OF O(EM PTION FROM WORKERS'
GREASE THAIs r. TAID
or t
COMPENSATION INSURANCE Sh.WgR-gpNff "Bp B'1 Date Recef led
(Chia section need nhe completed If the permitb for one hundred dollars
($100)orless.) WATER HEATER VJWAWELFCTR If ENERC YFEE Y_ N_
I certify that In the performance of thework forwldch this permit Is Weed,
I shall not employ any person in9 1 any ma er so u su ro the µATTR /TREATING — PAI
Workicart, n�ss 1Re�Laws of Gllfo b Date Y
O Z A Beam - 1 Date Recei tq
Z NOTICE TO APPLICANT.If,after ma Ing this Certificate of Exemption,you NEW RESIDENTIAL PLMB. SQFT.
O should become subject to the Workers'Compensation provisions of Labor TOTAL:
(p Code,you meal forthwith comply with such provisions or this permit shall be BUILDING .
W > dramed revoked. SEISMIC FEE
CONSTRUCTION LENDING AGENCY
0. •1herebyaffirmthat there bamnslruolon lendingagency forlhe perform- TOTAL: ELECTRIC FEE-
7 Z anceofthe work forwhkhthis permit is laded(Sec.3097,CIv.C.) PLUMBING FEE
(� O Lendee.Name
LL I— Lendcr.Address QTY. MECHANICAL PERMIT FEE MECHANICALFEE
O U s Imftlfythatl MvemadthbappBrationandpate Natthnaboveinforrutian FEES PAID
bccrsed.l agree to complywith all city and county ordinances and state laws PERMIT ISSUANCE
IL relating to building construction,and hereby authorize representatives of this
I—V U) m
city to enter upon the above- enlioced property for Inspection purpoeea. ALTER OR ADD TO MECH. Date Receipt#_ (We)agree to save,Indemnify an it keep harmless the City of Cu Fenian T TO 0,000 CFM[
against llabillties,pdgments,moAIR HANDLING UM ( 1
sand expenses which may In anywayamme SUBTOTAL:
against said City In consequence of the gra rating of this permit. CONSTRUCTION TAX
AIR HANDLING UNCI(OVER 10,000 CFM)
SI lureApplicant/Centra or Date
EXHAUST HDDD(W/Dl1CA CONSTRUCTION too
TAX PA
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or hand Is hazardous HEATING UNIT(TO 100,000 BTUI Date RCC" t#
nuumal as dented by 1M Cupertino Municipal Code,Chapter 9.12,and the
I Iralth and Safety Cody Section 25532(a)T HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑ ll mit _ N No VENTILATION FAN(SINGLE RESID) ISSUANCE,DATE
Will the applicant or( lum bu
ailding occupantse upanl uequipment er devices I I J
which et harardous air contaminants as defined by the Bay Area Air ROMER-CAMP OHP OR IDQIXD BTU) P
Quality Management Mind?
❑Yrs 11��11 No
[have read the hazardous materials requirements underChapter&95 of BOILER-COMP(OVER 100,000 BTU) SEP 18 1992
the GIifomW Health&Safety Code,Sections 25505,25533 and 2SS36.I
understand that if the building does not cummtly have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.I•T
i I
responsibility to notify the occupant of the requirements which moat be met Cf(Y Ur VUr Cn I[IVU
prior to uxuanco of a Certificate of Occupancy.
Owner or authodaed agent Date ISSUEDBY:
TOTAL:
OFFICE COPY