24148 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT"'24148
4 1 4 8
Building Address: �G7
tv
v 23 0 ! W /Ivr
e aces/: —1- 11h.eu,: APPLICATION SUBMI I I AL DA IlE
CITY OF CUPFR77N0-BUILDING DIVISION
C nidor.Name: _ t' LI.No: APPLICATION I PERMIT
r 7 BUILDINGELECnUCAI PLUMBING-MECHAMCAL CATEGORY CONTROL N
Architect/Engineer. Lic No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: GD , 'G!(/ PERMITISSUANCE ❑ ❑ _- �1
LICENSE CONTRACTOR'SDECLARATION TJ f
I herebyifftrm that l am licensed under provedonsof Chapter 9(commenc APPHANCF RESIDENRTAL ]OB DESCRIPTION
ingwith I.full7000)o(it effeon3ofthe Busineseand Prolnslom Code,and my FtX a yrty� �. S /
license is in full!ores and dfect. PANES �'Vl�s X11?�7's�'i�
License Class C ]D Lk.N y& 7641
Datej'�1� —contneor 281-1000A AMES '" r
Tv
ARCHITECSDECLARATION OVER100DAMPS SQ.FT.FLOOR AREA S/SQ.FT.
7p
7�HI understand my piaw shall be used as public rcconls.e Licensed Professional SIGNSELECTRICAL
<QOWNER-BUILDER DECLARATION SPECIALCIRCN7/MLSC IN
Ihercbyafflrm that lam exempt from the Contractor+License Law for the
F9~4 9 counfollowing reason(Sectlon 7031Z,Business and Professions Code:Any city or 7EMCMETEROR POLEINST.
tywhichrequlresaper tmrommeg
td,Otimpmv den lWh,orrepair
g anystrucum,pdorto its tuuance,also requires theappllant forsuch permit to POWER DEVICES
6�` file a signed statement that he ls licensed pursuant to the provisions of the
H3Ou, mractorb License Law(Chapter 9(commencing with Section 7000)of Divi. SWNIWNGPOOL FIECTRC TION
C0� sion3oftheBusinnsandProfessiomCode)orthatheisexem therefeemand — DATE 11 4L
�2 S the basis for the alleged exemption. Any violation of Section 7131.5 by any OUTLETSSWITCHFSFIXTURZS VA
pa applicant for a permit subjects the applicant to a civil penalty of not morethan
P. o five 1,a. .oro! hepr(SM. NEW RESIDENTIAL ELECTR SQ.FF. STORIES IYPECONSTRIICTION
C 7 6 ❑1,as owner of the property,or my employees with wages r thele sole
role Ckc.t0K Business
the wale and lhes Cadurch not intended or offered for
5 O sale(Sec.apply
Business and f property
rope ty who
Wild.Contractors License law
$ wh.dot apply loan ow lfr t .gh hiw. .ilplyor i sp 1dh thryand OCC.GROUP RES.UNITS
5 whodoe:vnts a ork him Bodoroff ndisawnemp,heave
er,the uilding or
improvementsarenot Intended earofco pleioe.ILh ner-g deer ilI have TOTAL:
improvement rdenof keold eling that he did ottruildoron,theowner-builderwNhave
m,s.baben of of the preerty,a build orlmprovefacting with borne QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
L1 4 as owner t the Property,am exclusively Buttress
and
with Ilcensed PERMIT ISSUANCE
Tho
contractors to romiruct thew doe(Sec.70Kapply
to nem and Pf prop ert Code:
Wil s or Imper License law don not apply tct an owner I property who ALTER-DRAIN&VENT-WATER(EA)
Wilds or Improve thereon,and who centrads !or each pRojem with a
cy ador(s)licensed pursuant to the Contractor'sns
License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LII am exempt under Sec B& P C for this reasonOUTSIDEFEES
DRAINS FLOOR RODF,AREA,COND. SANITARY Y N
Owner Date RECEIPT N
WORKMAN COMPENSATIONDECLARATION FO(IlIRFS ISR TRAPSCHOOL TAX Y_ N_
I hereby affirm that I have a arti0cate of consent to self-insure,or a RECEIPT N
Irate o(Worken Comperealion Imuran¢ora certified copy thereoS F.A.(Sec. GAYSTEM-1 WG60UTLE1'S PARK FEE Y N
00,Lab C.) RECEIPT M
Pulley N Cu ff -y GAS EA.SYS TNI-OVER 6(EA) BUILDING DIVISION FEES
Certified copy Is hereby furnished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Codified copy Is filed with the city inspection division.
CERTIFICATE OF EXEMPFTON FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.2(K)FT. Date Remi t#
(This section need realIm completed if the permit is forces hundred dollar
($100)nrless.) WATER HEATER W/VENT/ELECTR ENERGYFEE Y_ N_
I certify that In the performance of the work for which this permit Ia issued,
I ahall out employ any person In any manner so as to become subject to the WATER SYSTEM/TREATING
Workers Compensation laws of California.Date TIPAID
O Z Applicant NEW RESIDENTIAL PLMB, SQ.T. Date Remi t#
Z O NOTICE TO APPLICANT:➢,akar making this Certificate of Exemption,you
should became subject to the Worker'Compensation provisions mf the Labor TOTAL:
H N Code,you muastforthwith comply with such provision orthis permit shall be BUILDING FE
> deemed mucked.
W — CONSTRUCTION LENDING AGENCY SEISMIC FEE
d eof3 I ebythe work for
rwhichat thiis s
perp tis don Issued
agency 7,Civ. .) perform- ELEC'T'RIC FEE
7 Z ancc of the workfor whkhthls permit blawe0(see 3097,Civ.C.) TOTAL
() O Lender'+Name PLUMBING FEE
Iy F Lender's Address TY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW IcertifythatlhavereadeMsapplcatmnandpatethatlheabovelnfamution
!L lsrorrcd.lagreemcomply with all city and county on nate laws PERMIT ISSUANCE �� FEES PAID.
N relating to building construction,and hereby authorize representatives of this
F Z city to enter upon the above-mcntiomd property for inspection pu rpeses. ALTORADDIOMECH.
(We)agree to save,Indemnify an d keep harmiess the City of Cupertino Date Receipt#
V
against 11ab11itln,judgrrcn0, a pdexpenus which may in anywayacctue AIR I IANDLING UNIT(TO 10,000 CFM) �� SUBTOTAL:
aga Wt said try in roils ce of the gr Ing of this pernit.
p- AIR HANDLING➢INIT(OVER 10,000CFM) CONSTRUCTIONTAX
n tvreof Applicant/ tractor Date ` EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will theapplicant or future building occupantstomorhandle haurdous I HEATING UNIT(TO 100,008 BTU) Date RecelI#
material as defined by ted Cupertino Municipal Code,Chapter 9.12,and the
I lealthand Safety Code Section25532(a)? BEATING UNIT(OVER 100,000 BTU) TOTA
❑ Y. In No
Will the applicant or future building occupant use equipment or devices VENHLATION FAN(SINGLE RESID) ISSUANCE DATE
which emit haurdous alr mnlamimnls as defined by the Bay Area Air
Quality Management District? BOILER-COMP OHP OR 100,000 BTU)
YesNo
have read the hazer cus materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) R] p
the California Health&Safety Code,Sections 25505,25533 and 2:534.1 I� M
understand that if the building does not currently have a tenant,that it is my NEWRESIDENTIAL MECH. SQ.ET
responsibility,to notify the acxu pant of the requirements which must be met AUG (�
PAto immnce of a Cenifioteof Ompanry. A � 9 199;
1
Owner or authorized agent Date .TO I�IDBY..'
OFFICE COPY