24378 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
building Proed Identification PERMIT NQ 4 3 7 8
Bullding Address: Z
/ 3
wasN aces: '--// Panne: p
a„��-/� CITY OF CUPERTINO-BUILDING DIVISION P�
a t -r. a e.Ne APPLICATION / PERMIT
�' BUILDING-ELECTRICAL.PLUMBINC-M CCHA L CATEGORY CO 01
Archlte /Englaer. Lk.No: 4
QTY ELECTRIC PERMIT FEE BUILDING PERMIT NFO
Address: PERMITISSUANCE
Thereby
LICENSED CONTRACTOR'S DECLARATION
affirm that l amlicensed under providonsaf Chapter9(commenc APPLIANCESRESIDENITAL JOB DESCRIPTION
Ingwlth Se ion700D)of DiNson3ofthe Busineasand PmfesstonaCode,and my
license le In(uu(or}'Y and effect. PANELS ... T/
LlcenseC C/ 'g L ICY J /�C YS (I/
Data Contractor Asdm
1011000 AM
ARCHITECTS DECLARATION
�p+mz l understand my plans shall be used as public mcords. OVER~ It SQ.FT.FLOOR AREA $/SQ.FT.
E� Licensed Professional SIGNS EC L
Gfn 6] OWNER-BUILDER DECLARATION SEE CIA /MISC
2 t'Tda Ihercbyatfirm that am exempt from the Contractor's License Law(orthe
qqqqqq following reason.(Sacci..70315,Business and Professions Code A y Hy or
W.
F t'cy cauntywhichrequbesaper ttommtmd,slter,lmpmwdemoibh,orrepair TEMP. l POLEI
E a anystructure priorto its Issuance,also requlresiheappBuntforsuch permit to
y'a Olc a signed statement that he b licensed pursuant to the provblom of the TOWER DEVICES
3µ Contnctors Ltmmte Law(Chapter9(commencing with Section 7000)of Divl-
H�OS slon3ofthe Buslneaand ProfmWmCode)orthathebeaempttherefmmand SWTMMINGIOOL C VALUATION
O the ba.b!or the alleged exemption. Any violation of Section 70315 by any OIITLETSSWITC E5 O O O
Eve
tlora permit subjects the applicant to a civil penalty of not more than D G
hundred dollars(S500).
NEW RESIDENTIAL kECIR SQ.FT. STORIES TYPECONSIRUCTION'
1,as owner of the properly,or my employees is with wages r thele sole
compensation,willdothe k,and iomC de:Tbnot Intended oralteredfor
O vie(Sec.7014 Bustnw end Prolesska Code:The Contradofa Lleense Law
$ does not apply to an owner of property who Wilds or improve thereon,and OCC.GROUP RFS.UNITS
who does suchwmichlmself orlhrwgh hisawnemployses,prwldedlhat such
m
improveents are not intended oroffered for sale.If,however,thebulWing or
Improvement beold Mthinoneyearofcomplet ,tMmnerbuBderwlll have
vu
thLmin of proving that he did not build or Improve for purpose of We.). QTY. PLUMBING PERMIT FEE
U L as owner of the property,am exclusively contracting with licensed HOOD ZONE APN
contractors to construct the project(Sec.7074 Business and Profealmu Code: PERMIT ISSUANCE
Tia C.Mctor's License Law does not apply to an owner of property who
Wilds or Improves thereon, and who contracts for such pipjects with a ALTER-DRAINk VENT-WAT[R(ETU
ombreetw(s)humsed pursuant to the Contractor's License Law. FEE SUMMARY
LJ I am exempt under Sec. B Yc P C for this reason BACKFLOW PROTECT.DEVICE
OIITqlnP F1 IN
DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y N
Owner Date RECEIPT X
WORK MAN I havea VSATION DECLARATION F.IX.�ES PER TRAP SCIfOOL TA% Y_ N
❑[hereby affirm that I have•certNcete of concent to opytherm ora /� RECEII'1'X
3800,Lab of Worken'Compeaatlonlnsurance ora certifkd ropythereof(Sec. gygpE,T- CY Uh PARK FEE Y N
3800,Lab CJ / .. - R7xEBTX
YoI1ry N AS FA.BYSITAf-OVEIi'1(EA)
Com any - BUILDING DI VIS NFEES
&KE'led copy is herebyfurnished.the city GREASE/ENDO w PLANCHECK T'i-
Ca Iffled copy b filed herebyiththe city inspection divides. �1L.�.. IJ.-
CERTIFICATE OF EXEM PPION FROM WORKERS' GRr-Aer-•uaur- PA
COMPENSATION INSURANCE - 10�
(This section need not be completed](the permit bforoa hundred dollen SEWER-SAMTARY-STORM EA.20017. Remi N
($100)orlca.) ENE E N ��
I mrtllythat In the performancoofthe work forwhlch this permit is Issued, WATER HEATER W/VENT/ELECTR —
I shall not employ any person In any manner so as to become subject to the WATER SYSMA/TREATING
Wurker%Compeaatlon Lam of California,Date PAIDsassit Is'
ZZ Applicant NEW RESIDENTIAL PLMB._SQ.FI'. Dale ReCe b IL
O NOTICE TO APPLICANT-.If,after making this Certificate of Exemption,you
f" should become subject to the Workem'Compensation proWions of the Labor TOTAL:
d) Cade,you mu at forthwith comply with such provisions or this pemit.hall be I G 'E ^�
W j deemed revoked.
CL G CONSTRUCTION LENDING AGENCY SEISMIC FEE cy
I hereby afErm that there b a constmctlon lending agency for the perform- ELECTRIC FEE ACZn
M Z ance of the work!or which that P"t b boded(Sec.3097,Civ.Q
0 O L.endere Name PLUMBING FEE �.�'+
LL ~ Lender'.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W ce
mInifythat I have readthbm
appllationand statethattheabove Information ��
1 Isrred.I agreeto comply with all cityand county ordinances and state laws PFRMTTISSUANCE FEES PAID:
} W relating to building construction,and herebyauthorizerepresentatlvcsofthb
I— Z city to enter upon the above-mentioned property for inspection purposes. ALTERORADDTOMECH, 61
— (We)agree to save,Indemnlly and keep harmless the City of Cupertino Dale Reeel t#
against liabilities,judgments,rusts and expenses which may in anywayaceruo AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
against did City in conseryenceofthe gm tingofths permit. AIR HANDLING UNITE(OVER 10,000CFM) CONSTRUCTION TAX
Signstumo(Appllcam/Contractor Data EXHAUSTHOOD(W/DUM CONSTRUCTIONTAK.I;ft1B�
HAZARDOUS MATERIALS DISCLOSURE
m ��
Wllltheapplia an orfature bulldingorpant store or handle hazardous HEATING UNIT 100,0D0 BTU) palC Recel H
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Ifralth and Safety Code Section 25532(a)2 HEATING UNIT(OVER 100,OW BTU) T
Yea No
olllthe eppBcentor tuns building occupant use equipment or devices VWIUATION pAN(SINGLE RFSID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Arca Air
.Ety Management District?
D}[PDR 100,000 BTU)
Yes ❑No
have read the hazardous materials requirements under Chapter 6.95 of BOILER-COMP(OVER100,000 BTU)
the California Health k Safety Code,Sediom 25505,25533 and 25531.1
undemandthatl uildingdoesnotmr have rLthat Itismy NEWRESIDENTIALMECH. SQ.FT. Q c
es ail, nUTfy the anvpan em kh
stria arm oft CeHEu Occu
( �
Owner ar authod agent Date ISSUEOBY:
OFFICE COPY
CITY OF CUPERTINO
INSPECTION DIVISION y
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