24037 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project identification PFR.WTN24037
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Building Address: 2 4 0 3 7
I05-7S Merr( mAk,
o e: A A A
Ikn M• Te rb/GD 37/J CITY OF CUPERTINO-BUILDING DIVISION
Contract :Name: uo.Na: APPLICATION /PERMIT
BUILDING-ELECTRICALPLUMBING-MECILAMCAL CATEGORY CONTROL#76
Archlt�}/G Lk.No:
G--0. (� _SIGN 'Z7 QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
FLUMB MUCH
Al '" Alfinelk S-.h-r Ja3F I PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter 9(commenc- APPLIANCESRFSIDENTIAL JOB DFSCRpTION
'ngwith Section 7000)ol Dlvisnon3ofthe Busbussand ProfesslonsCode,and my
Banns b in tali forte and dfcct PANELS y T �
LicenseChi Lletl eQO
Dale Gr At-1000
, —
ARCHITECHITECTS DECLARATION OVER1 1 I 5Q,FT.FLOORAREA S/SQ.I.-r.00 l understand my phi shag W used n public records,
O
Licensed Profembwl SIGNS EL "�D C st��
,Q OWNERAUILDER DECLARATION IALCIVJa')(/rISCfol if
7t„ Iherebyaffirmthat l am exempt frumthe Contrador:License Law for the
pp following remon.(Sedlon 7031.5,Business and Professions Code:Any city or
OZ�pppp OR POLE INSfmir . (�''���,�(((( (1y •
countywhlchre toiaperMteaLsorquimtheaprovntforsbh,er tto Jv� Lp Vtl
any atmdampaler tent shat he u,also sed pursuant to the fowWoreseofte POWER DEVICES
a� /
rvE file a algned statement that he b licensed pursuant it the provbbns o! the
�j ion 3 of thaLkenseLaw(Cha 9(comnoncin with exempt
and w
Pt`r B SWIMMING POOL ELECTRIC VALUATION tl
O slon3 of the Bottoms and ProfesebnsCede)orthat hebexempt therefromand
the bests for the alleged exemption. Any violation of Section 7031.5 by any 7
applicant
QO pensOUTLEISSWITCF3FSFI%,'UAES ant for a permit subjects the applicant to a civil penalty of more than
five F11,ashundred
wnerof the property,
NEW RESIDENTIAL ELECTR SQX7. STORIES TYPE CONSTRUCTION'
k76 ❑I,asownerll tedproperty,ormyempbyenwith wage as their sole
compenaat0K Business
work and thertmdure b not blended or offend for
vie(Sec.apply
to alnowand Professions Code:The or improves
License Law a
$
does not applytork ownerofproperty who Wilds loimprovesthereon,and OCCGROW RFS.UNITS
whodoeZrAsaorkhimselfedorough hbowne.11,ho eprovided that such
improvementsaredm Intended earofcomplroffered io It,h mer-gthebuiilln ve TOTAL:
proverrcnt b sold within oneyearofcompletion,the owner-W 0derw111 have
rdenolpmvbgthat he did not baud orlmpmv"'or purpose of vin). QTY. PLUMBING PERMIT FEE FLOOD LANE APN
L as owner of the property,am exclusively contracting with Ikensed PERMIT ISSUANCE �A
C
it ton to construct the project(Sec.7654,Business and Professloro Code: I .0
e Comrador's License Law does net apply to an owner of property who
Wilds or improves thereon, and who contracts for so& pippets with a ALTER-DRAIN VENT.WATER(EA)
mdmr(il licensed pursuant to the Contractor:License Law. FEE SUMMARY
6am exempt under Sec. B k P C for this rcaron BACK FLOW PROTECT.DEVICE
OUTSIDE FELS
DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y N
Owner Date RECEIPT tl
WORKMAN COMPENSATION DECLARATION I'6('IIJRES PER TRAP SCHOOL TAX Y N
❑I hereby affirm that I have a certificate of consent to sell-Insure,ora RECE1178
anifialc ofWorkesi CompensaHwlNVanaaraartlFled copy themof(Sec. GAS EA.SYSTEM-1 WCA OUIILETS PARKF'EEE Y N
3800,Lab C.) N_
Policy tl RECEITT N
Com any GAS F.A.SYSITM-OVER4(EA) BUILDING DIVISION FEES
cc
copy Is hereby furnished. GREASE/WDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy b filed with the city inspection division. 77T 13
CERTIFICATE OF EXEMPTION MOM WORKERS' GREASE IRA? PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200Ff. Date Recei t#
(Thiasedlon need na be completed if the permit b forom hundred dollar
($100)orless.) WATER FIEA1TIt w/VEM/ELECTR ENERGYFEE Y_ N_ �4 a
I rectify that in the performance of the work forwhkh this pemnit is forced, `/r
I shall not employ any person In any manner n as to become subjectto the WATER SYSTEM/TREATING
_62 Sit
Workers Compensation Laws of California.Date PAID ]-�YZ
O Z Applicant NONRESIDENTIAL PLMB. SQ.PT. Date Remi t#
Z 0 NOTICE TO APPLICANT:If,after making this CenBiateof Exemption,you
should become subject to the Workers'Comperaation provbions of the Labor (� �•�s TOTA 10VV.(
F U) Code, oumost forthwith cons 1 with such provisions permit D .0
W j deem a m oked. P r Pm� P` BUILDING FEE
W _ CONSTRUCTION LENDING AGENCY SEISMIC FEE X
a Ihereby affirm that there b a construction lending agency for the perform- - ELECTRICFEE
D Z ares.fth.workfo hIchthb ematbbet (§ec.3097,Civ.�j) TOTAL'
() O
Lenders Name v�'Y'�t AD n=3 A{, fyri'yl l_ PLUMBING l6.
LL 1= Lenderb Address QTY. MECHANICAL PERMIT FEE MECH444M rEE
U ladlfy thatl have read thbappliatlonand datethattheaWve information
0 W bcorrect.Iagreeto comply with all cityand countyordlnanasanelstat,laws ' PERMIT ISSUANCE e400 FEE A
IV
} a relating to building construction,and hereby authome representativs of this
I. Z city to enter upon the aWvs-mentioned property for inspection purposes. ALTERORADDTOMECH. Date RCGCiPt#
(We)agree to save,Indemnify an d keep harmless the City of Cupertino
V
against+liabilities,Hdgments,cestsand expenseswhlch mayln anywayaame AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
aglof
d i In con f the granting of this permit.
,� �� �' er t. AIR HANDLING UNIT 10,000CFM) CONSTRUCTI TAX
Sigw re fAppliant/Coactor Date EXHAUST HOOD(W/DU1CT) CONSTRUCTIO TAX PAID:
HA2AR OUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle havrdous HEATING UNIT(TO 100,000 BIU) Date eeoi t
material as defined by the Cupertino Municipal Cade,Chapter 9.1;and the
Healthand Safety Cade Section25532(a)2 HEATING UNIT(OVER 1W,000 LIM T TA
❑ Yes M No
Will the applicant or future Wilding occupant use equipment ordevices VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
which emit harardous air conmminanta as defined by the Bay Area Air
Quality Management Dbtrid7 BOILER-COMP OHP OR 100,0IX)BTU)
IlYes No
lavereadthebarart`Iousmaterial3mquime ntsundcrChapter6.95of B011,1111-COMP(OVER10gONBTU)
the California Health k Safety Code,Sections 25505,25533 and 2:530.1 Q I
u M crsta nd that if the building does not co raently have a tena nq that it is my NEW RESIDENTIAL MECH. SQ.FT ID
responsibility to notify the occupant of the requirements which most be and 0 s 80prior to Issuance of a Certificate of Occupancy.
Owner or authoreda ens Date b/r
1//-
g TOTAL: ISSUED BV:
.ta rV
OFFICE COPY