24263/ APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —'USE BALL POINT PEN ONLY
Building Project ideml(latlon PERMIT N24263
Building Address: .. ,
.:2.? � �P�.
neveName: one:
--_XPFMMM79M=AL DATE
S'" . '3 CITY OF CUPERTINC-BUILDING DIVISION �� ^
centraete sN.na: . L'Ie.`No- APPLICATION I PERMIT [—
L ���"NJ BUILDINGELDCTRICAL-PLUMBINC-MECHANICAL CATEGORY - CONTROL
Architect/Engineer. Lk,No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PFRbtITISSUANCE ❑ ❑ -
LICENSED CONTRACTOR'S DECLARATION
I hereby afflrmthat l am licensed under provisions of Chapter9(commmc APPLI NCMFLESTUENTIAL JOB DFSC ON
Inon f Dlvthe Busiwand ProlnsionsCode,and
license 1.1.full force and dlect.
PANELS
Llrenw Cl.m Lit.N
Datc Cmd.cmr
ARCHITECTS DECLARATION 201-1000 AMPS
ntOZ lundentand my,pians shall be used npubucrccorda OVERIWDAMFS SQ.FL F(-OOft ARIA $M-FT.
p O
Licensed Professional - ,. SIGNS ELECTRICAL -
a' OWNER-BUILDER DECLARATION SPFGIALCIRCUIT/MISC
I hereby affirm that l am exempt from the Contractors License Law for the
O /ollowing reason.(Section 70)15,Busineu and Pmfenbne Code:Any dty or
Issuance, TEMP.MEOR
POLE]NST.
counrywMch regWreapeuNttocerImpmvsuch,or
nyatacturcabnrequiesch ntfor such witto POWER DEVICES
ALE D_
0 N/11e a signed statement that he Is Ilocesedi pursuanttotheprevisions of the
3c Contra=?&License Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING IDOL ELECTRIC
OC' don 3 ofthe Buslnenand ProfessionsCode)orthat heis exempttherefromand IVI
the basis for the alleged exemption. Any violation of Section 70315 by any OUTLETSSWITCHESFTXTURES 104
appuantforap.rs t.bjecbtheappBcmttoadvilpenaltyofnot=mthan
red
ve hunddollan(5.00). NEW RESIDENTIAL ELECTR ECO SlRUCTION
li
�n ❑I, downer of the pmperty,or my employees with wages as their sole
compensation,will do the workand the structure isnot intended or offered for
Cx O sale(Sec.70K Business and Professions Code:The Contactors License Law ,
FK�Fi; does nut apply to an owrar of property who build.or improves thereon and OCC.GROUP RES.UNRS
EE who doessuchworkMmself orthrough Nsownemployeea,provided thatach
Improvements are not Intended oroffered for sale.If,however,lhebulldingor . TOTAL:
Improvementsddwithlnomyearoftompldloo,thee et-buuderwulhave
trden of proving that he did not build or improve for purpose of sele.). QTY. PLUMBING PERMIT FEE FLOOD7DNE APN
as owner of the property,am exclusively contracting with licensed I- PERMIT ISSUANCE
-
contractors to construct the project(Sec.7054,Business and Professions Code: ,
The Contredor's License Lw don not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)`
builds or Improves thereon,and who mrdrsct for such pipiects with a FEE SUMMARY
ay6t�+ctor(s)harmed pursuant to the Contadors License Law. BACK FLOW PROTECT.DEVICE
[J I am exempt under Sec B&P C for this reason '
Virg
DRAINS FLOOR ROOF,ARERECE A,COND. SANITARY Y T -
' - N
Owner Date
'1yrt WORKMAN COMPENSATION DECLARATION FINTURFS PER TRAP SCHOOL TAX Y_ N
I hereby.(firm that 1 have a mnifleste of consent to sell-ing c,or a RECEIPT N
ce'niTimeo(Workers'Compem"minsummn am"if d copythermf(Sec. GAS EA.SYSIEM-I INCAOUILETS PARK FEE Y_ N_
350D,Isb C.)/a •'J' y RECEIPT
C.IIryN .7 �S CAS EA.SYSTEM-0VER 4(FA)
Com an (L t �((J�N BUILDING DI VISION Fr.ES
Ccrifeacoy ereyfur sh CAEASE/INDUSTICL WASEINTFRCEPTOR PLANCHGCK FEE
CmBiled copy La filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'. CREASETRAP PAID
COMPENSATION INSURANCE, SEWER-SANITARY-STORM EA 2001171' Date Recei til
(This eedn.need not b,completed If the permit Is fgom hundred dollars
(E100)mless.) WATER H[ATFR W/VENT/ELECTR ENERGY FEE Y— N_
I artifythat In the pedorrmnocof the work for which this permit Is Issued,
I shall not employ any person In any manner w n to became abject to the WATER SYSTEM/TREATING Workers Compensation Laws of California.Date PAID
O Z Applicant NEW RESIDENTIAL PLMB. SQFT. Date Recei t#7
Z NOTICETO APPLICANT:ILafter making this Certificate of Exemption,you
should become subject to the Worker.'Compenatlon provblonsof the Labor TOTAL:
QN Code,you must forthwith comply with such provisions orthis permit a hall be _ NG FEE
W > deemed revoked. SEISMIC FEE
CONSTRUCTION LENDING AGENCY
a Z ]herebyaf(Ik W,hhere Laammit Is on lendingageocy
c.309,Civ. the pedorrry TOTAL: ELECTRIC FEE
7 arm Leade thesNwork(erwNch this permit Is blued(Sec.3097,Clv.CJ PLUMBING FEE
(.) 0
� O �ender¢Naos
U. I— Lendces Address QTY. MECHANICAL PERMIT FEE MECHANICALFEE
O W Icertifythatl have readthis applicatlonand statethatthe above information FEES PAID:
1 tcorrect.I agreeto comply with all city and county ordinances and nate laws . PERMIT ISSUANCE
} N miatingtobulldtgmmtmdlm,and) mbyautho mpresenUtivmofth4 �.�OR ADD IO MECH.
F Z dtytoenter upon the above-mentlomd property for Wpectlon purposes. Date Recei tM
(We)agree to save,Indemnify an d keep harmless the City of Cupertino
V against liabilities,judgments,mets and expenseswhlch maAIR HANDLING UNIT(f0 W,ODO CFM)ayln anywayacue SUBTOTAL:
.)dg.tnfd City In nee Grace of the granting of this permit - CONSTRUCTION TAX "
AIRHAFIDONG UNIT(OVER iQODOCFM)
mture of Applicant/Contndor Date EXHAUST HOOD(w/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT GO 100,000 BTU)
Will the a ppliant or future Wildleg omapant store or hand le hecardou. Date R
material as defined by the Cupertino M.Mdpal Code,Chapter 91 Z,and the -
Health and Safay Cade Section 25532(a)7 HEATING UNIT(OVER 100,DD0 BTU) TO
RYes No
illthe applicant or�ture building occupant use equipment ordevims VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE.
Mich emit hzrardm.air contamRunts as deRaed by the Bay Area Air
ality,Management District? BOILER-COMP DHPDR 100,000 BTU)
�i�J Yes n❑No LLI'
shave read the harardous materials requirement under CFapter 6.95 of BOILFR,COMP(OVQt 100,000 BTU) - O"�
the Caluomia Health&Safety Code,Sections 25505,25533 and 25534.I 24 19
understand that if the building does not currently have a tenant,that it Lamy NEW RESIDENTIAL MECN. SQ17 A�
responsibility to notify the occupant of the requirement which moat be met _ C�IY(�� � 9
prior to Issuance of a Certificate of Occupa cry. - (p-
- �hlllyy
a 7wncrorawhodsedageet Date TOTAL ISSUED BY,
OFFICE COPY