24335 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification 7 PEtMITNO 4 3 3 5
Building Address: L OSM S KIIF54��l
one. q p p
P)lam. CITY OF CUPERTINO-BUILDING DIVISION
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Cnntr/ ` . a xa e1 Lk. e, APPLICATION / PERMIT
1 � Y � NS—L6Y BULDINC-ELECTRICAL-PLUMBING-MDUMMCAL CATEGORY CONTROLp
Architect/Engfnner. C Lie.Na
�J BUILDING PERMIT INFO
QTY ELECTRIC PERMIT FEE
Address: PERMITISSUANCE �s ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby af(irmthxt l ambeens.M under provlalonsof Chapter9(commenc- APPLIANCES-RESIDENTIAL JOB DESCRIPTION
ingw5thenseIIn force anUvfect. oftheBuslassand Pro(essionsCode,and my
❑celiac b Section tun 7000)and effect. PANELS 'lY aYn'�IVr1_i\s
License Clam Lk.#
Date Contractor
ARCHITECT'S DECLARATION W140DOAMP5
pZ I understand my plarns)un be used as public records. OVER 1000 AMPS SQ.FT.FLOOR AREA E/SQ.FT.
{pp++ O
Licensed Professional SIGNSELECTRICAL
<L
Q OWNER-BUILDER DECLARATION
jn SPECIAL CiRCUT/MISC
1p., 7 Ihemby affirm that am exempt from the Contractor's License Law for the
ZOZt-'� following maors.(SMion 7031 S,Buslncss a lid Professions Code:Any city or TEMP METLR OR POLE❑NST.
5 u9 county which requimsa pemtittoco swct,alter,improve,demolbh,orrepair
anyatm=mpdortultslsasancealsorequtrestheappbmntfowchpermitto ]OWER DEVICES
file a signed statement that he is licensed Pursuant to the pmNalom of the
3t` Contractor'sLicense Law(Chapter 9(commencing with Section 70W)olDivi-
Orn sion 3 ofthe Bustnessand ProfessionsCods)orthat he b exam therefromand SWIMMING POOL ELECTRIC tr j1Cr TA
X the basis for the alleged exemption. Any violation of Section T 70)15 by any
applicant for a permit subjects the appllcantto a civil penalty of nus ore than OUTLETSSWITCHESFlXTURFS
a five hundred dollars($50B. NEW RESIDENTIAL ELDCTRFT.
j 0 I,as owner of the property,or my employees with wages as their sole TYPE C SIRIJCTION
compensation,will do the work and the structure is not intended or offered for
Osale(Sec 7094,Businessand Professions Code:The Conteacto's License law
5$ docs not apply to an owner of property who Wilds or improves theme,and OCC.GROUP RES.UNITS
3. whodoaasuchwurk hicaenorth4wgh Id3own employees,provided thatesch
improveroxe s arenot intended oroffered foruk.IL however,thebuildingor �—
Improvement bsoldwithin oneyenrofcompidlmgthe owner-W ilderwill love
t119„lurden of proving that he did not bund or improve for purpose oftede.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
Lj L as owner of the property,am exclusively=trading with licensed PERMIT ISSUANCE
contractors to construct the project(Sec.70K Business and Professions Code:
The Contnctoes Limms,Law does not apply to an owner of property who ALTER-DRAIN&VEM-WATER(EA)Wilds or imprvvn thereon, and who contracts for such ptojects with a FEE SUMMARY
,,ppjjfTactor(.)hcens3d pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
eLl I am exempt under Sec. B h P C for this reasonOUTSI DE
DRAINS FLOOR AOOF,ARFA,COND. SANITARY Y_ N :
Owner Date IEC— p_
WORKMAN COMPENSATION DECLARATION FIX'NRF.S PER TRAY SCHOOLTAX Y_ N_
❑I hereby affirm that I have•certNcate of consent to self-Insure,or a RECEIPT N
certificate ofWorkeri CompensationInsurance ce a certified copythereof(Sec. GASEA.SYSTEM-1 INCAOUTLETS PARK FEE Y N
M00,Lab C.I
RECFIFT p
any S F.A. M
GA .SYST -OVER4(EA) BUILDING DIVISI ON FE ES
CoCom
ffCeetiBed copy b hereby furnished. GRFASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy b filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GRFASETRAP PAID
COMPENSATION INSURANCE SEWER-SpM.1.pRY-SCORN FA XpFT Date Recci t#
(fhlssection need nor be comted pleIf the permit b formic hundmd dollars
($100)orless) WATER HFATEt W/VENT/ELECTR ENERGYFEE Y_ N_
I certify that In the performanre of the work forwhich this permit is issued,
I shall not employ any person in any manner an as to become subject to the WATER SYSTEM/TREATING
Workers Compensation Laws of California.Date PAID
O Z Applicant NEW RESIDENTIAL PLMB. SQ.FT. Date Reeei t#
NOTICETO APPLICANT.H,aRer making this Certieeateof Exemption,you
Z O
should becorre subject to the Workers'Cmmpersation provisions of the Labor TOTAL:
CC W Code,you must forthwith comply with such provisions orthis permit shall be BUILDING
W > de3mcd revoked. -
25 CONSTRUMON LENDING AGENCY SEISMIC FEE
CL Ihereby affirm that there b a construction lending agency for the perform- ELECTRIC FEE
Zarm, f1he work for which thin permit b ivsued(Sec.3097,Civ.C.) TOTAL:
UO Lender.Name PLUMBING FEE
LL I— Lender'.Addes. QTY. MECHANICAL PERMIT FEE
O U I certifythat l have read thisappllcatlonand gate that theabove Information MECHANICAL FEE
C (scorned.l agree to complywith all cityand county ordinances and state laws PERMIT ISSUANCE FEES PAID:
>• relating to Wilding construction,and hereby authores authorise representativofthis
F y city to enter upon the above-mentioned property for hopedlem purposes. ALTERORADDTOMECH.
? (We)agree to save,indemnify an d keep harmless the City of Cupertino Date Receipt#
V against liabilities,judgments,mereand expenses which may in anyway aceree AIR HANDLING UNIT CIO 10,000 CFM) SUBTOTAL:
aga ity in consequ re of the granting of this permit
.o .
AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
SiBIDMIV&Applf lit/C ntractor ate E)(HAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle harardous HEATING UNIT(TO 100,000 BN) Date Reeei t#
material as defined by the Cupertino Municipal Code,Chapter 9.13,and the
Health and Safety Cade Section 25532(a)? HEATING UNIT(OVER I00,000 BTN TOTAL:
❑Y. M Nm
Wllllhe applicant or fumm building occupant use equipment urdevices VENTILATION FAN(SINGLE REBID) ISSUANCE DATE
which cent hav mdous air contambu nts as defined by the Bay Arca Air
Quallty Management District? BOILER-COMP DILP OR 100,000 BTU) d�
•� n Ycs ❑F�No C
a hBfercad teeth Safet modelab tions 2m3nb5533 and &534.1 of BOILIiR.COMP(OVIR 100,000 BTU) 0 r
the understand
t health A Safety Cods Se¢loa 25505,vest and 25534.1 ^
respontandytohat lithe the.egdoes concurrently onlidneravea ,hich thath boy NEW RESIDENTIAL MECF[. $QFT ls,,r� t7 ' 4?
responsibilityto nmlify tM1e occupant o(the mqulmrrcnb which.,the met b J
primrto Issuance mf a Certificat3 of Occupancy. h GUI
-1-Cres
Owner or autherimd agent Data ISSUED RYW404'
TOTAL:
OFFICE COPY