24266 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE SALL POINT PEN ONLY
Building Project Identification PERMIT NQ
Nullding Address:- � _ ?,4e Z4266
era me ma:
A
.115.2- 1671 CITY OF CUPERTINO-BUILDING DIVISION �1— �y
° '"Pod; Lie.No APPLICATION /PERMIT 1—1,q
7J BUILOING-ELECTRICAL-PLUMBING.MECHANICAL CATEGORY CONTROL N
Architect/Engineer. 01 Lk.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
naarem: ❑ ❑ PLUMB MrCri
� [IPERM TISSUANCE
LICENSED CONTRDECLARATION
thereby affirmehat lam lcmunder aed under provisions o(Cha... d.,.edn APPWANCESRESIDENTUL JOB DESCHI'RON
ingwbh Sectlon70m)of Dlvlaan3o(Ihegualnemand Profesdona Cd.,.ed my
licence le In full f rce and effect. -, PANELSLiccIQ
// -¢
Date Ckm (P 36 Lk.#actor xa IQ 4 P W _ /.�
Date /)_.w '' Contractor /J i A /' W (W-
ARCHITECTSDECLARATIONOOAMPS
02 !understand my plain shall be used as public records. OVEROVER1000 AMPS SQ.FI.FLOOR AREA S/SQ.FT.
CO
�() Licensed Professional SIGNS ELECTRICAL
to OWNER-BUILDER DECLARATION Spp-CIALCIIiCU1T/MIST
e, Iherebyaffirm from the l am exempt frothe Contractor's License law for the
Z following reason.(Section 70315,Business and Professions Code:An cityor
rEll county which requires a permit to construct,alter,improve,demolish,or reair TEMP.METER OR POLE INST.
5 anystructure prlorte,its Lssuance,also requirestheapp0ant forsuch permit to IN A,
c file a signed statement that he Is licensed pursuant to the provide.of the POWER DEVICES 'V
3w� Contractors License Law(Chapter 9(commencing with Section 7000)of DWI- SWIMMING IDOL ELECTRIC
LO
sI,nl,lthe Budoessand PmfemiomCede)mthat hekexempt therefromand -owION
6 the basis for the alleged exemption. Any violation of Section 7015 by any OUTLETS-SWITCHES-FIXTURES
applicant for a persalt subjects the applicant to a civil penalty of no morethen110-1 1
flue hundred dollars(SSDO). NEW RESIDENTIAL ELECTR SQ Fr. ECONSTRUCTION
[-11,as owner of the property,or my employees with wages as their sale
7acomps -it w0ldo the work and the structure 4 not Intended or offered for
0 saleZ.7304,Buainessand Prefrookm Code:The Cmoractors Liceme Law
$$ does not apply to an owner a property who builds or Improves thereon,and
who doessuch work himself or through his awn employees,provided that such OCC.GROUP RES.UNIT'S
improvementsare not Intended oroffered forsale.If,howevegthebullding or TOTAL:
Improvement bsaM withlnomyearofcomp]Mtb theowner-buMerwlll have
filLIturden of proving that he did not build or improve for purpose ofsakJ. QTY. PLUMBING PERMIT FEE FLOODZONE APN
LJ{as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec.7094,Business and Professions Code:
The Co leader's License law does not apply to an owner of property who ALTE4DRAINh VEM-WATER(F A)
Wild.or improves therm.,and who moment fee such p,)<s with a
cgR3pctor(s)licensed pursuant to the Conhadoe'a License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
L_I am exempt under See. B k P C for this reason
EES
Owner DRAINS FLOOR ROOF,AREA,COND. SANITARY Y NOUTSID� �
• Date RECEIPT N
I� WORKMAN COMPENSATION DECLARATION PIXTURFS PER TRAP SCHOOLTAX Y N
,1 hereby affirm that I have o lmumne of concent to pythe re,ora RECEIPT N
N—
A, ateo(Workers'Campewtlonlmursnce araarti(led copy thereof t5ac.
3800lab C.) GAS FA.SYSTEM-1 INC4 OUTLETS PARKFEE Y— N—
,
Polley p — RECEIPT N
Com env _ a GAS G.SYSITM-OVER4(EA)
7_ BUILDING DIVISION FE ES
�CertRkBto yetnl 9 GREASE/[NDU5IRL WASTE INTERCEPTOR PLANCHEGIC FEE
�Certlfled ropy k ftkd with the eRy InapFatlon dlvlslon.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
G.Wcorn ATIONhapmutNGE SEWER-SMBTARYSR7RM EA 200F1. Date Recei t#
(fhtsxctlonneed intoe completedNI SURAVforonce hundred dollars
(Slm)orlem.) WATER HEATER W/VENT/E.ECTR ENERGY FEE Y N
(certify emai in y he try person
in any man.rk forwhkh this permit I.Issued, —
I shall not employ any person In any manner m m to become eubfect to the WATER SYSTEM/TREAUNG
Workn
e 'Companaation Laws of California. Date PAID
-
zZ Applicant NEW RESIDENTIAL PLMB. SD.FT. Date RL'CCt t#
Z O NOTICETO APPLICANT:I{aNer ma king this Cortlflate cf Exemption,you
should become subject to the Workers'Compensation provlsione of she Labor TOTAL:
CCN Code,you at forthwith complywithauch provisions amble permit shall N
W > deemed revoked.
L
W
C CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that them Ise construction lending agency for the perform-
Z ante ofthe work%r which thlepermit k ksued(Sec.3097,Civ.C.) TOTAL: ELECTRIC FEE
02 L°nder'.Name PLUMBING FEE �.
LL H Le.der.Addrcss QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O LU I certitythet I havereadthlsappllatlonand date thatthe above information
Is con t.l agree to comply with all city and county ordinances and date laws PERMITISSUANCE FEES PAID:
0. relating to building construction,and hereby authorize representatives ofthls
to F Z city to enter upon the above-mentioned property for Wpectlon purposes. ALTERORADDTOMECH.
V _ (We)agree to save,Indemnify and keep harmless the City of Cupertino Date Receipt#
against llabilllee,judgment,cadsand expenses which may In anywayanmue AIR HANDLING UNIT(TO 10,000CFM) $ AL•
alnst old City In n ence of the granting of this persalt
a AIR HA LADLING UNIT(OVER 1 fi,m0 CFM) CONSTR
ignsmra of Appian/Contractor Date EXHAUST HOOD(W/DUCT) CONSTR CTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applies or orfuture building occupant store or ha nd le ha,cardous HEATING UNIT(10 100,000 BTU)
mateda l as defined by the Cupertino Municipal Code,Chapter 9.12,and the _ Date Reeei
I Iealth and Safety Code Section 25532(.)7 HEATING UNIT(OVER 100,000 BTU) TOTA
❑Yes No
Will thezppllantor lure building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
. Quality Management District? BOILER-COMP DHP OR Im,OGT BTU)
IR4 Yes I No
read the hazar`1i"au.n.terials requirements underChapter 6.95 of BOILER-COMP(OVFR 100,000 BTU)
the Califemia I Iealth k Safety Code,Sections 25505,25533 and 25534.1 NO
-D
and erstand that if the building doss nes currently have a ten.nh that it is my NEW RESIDENTIAL METH. SQ.IR. y� 1/ •]�
responsibility to notify the occupant of the requirements wh lch must be mit V 1 �n(]a�
prior to Issuance of a Certificate of Occupancy. 79
Gll r [)-
)-
Ownerorauthmbcdagent Date ISSUED BY: J
TOTAL
OFFICE COPY