24142 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
angmn Pro ee memtumadom PFxwTNQ, 414 2
Building Address: 'L)
a31 r�ckf--16DX GO 7 N l) C A s-0 I .
}.fr9 aria: One: APPLICA LION- MI
X�IY.14A 7 ( 1 CITY OF CUPERTINO-BUILDING DIVISION /1 .� 1��
enntnctora Name: lie.No: APPLICATION / PERMIT `�j�' /tel
�ULp_(i¢EEu I b JScYYPIaA4 "a7t50'5 BULDING-FlFLTRCALPLUMBING-MECFAMCAL CA7F BY CONTROLN
A.htwd/Engineer. Lk.No:
Qn ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address 040 (l.M a ij ries) E cj}IN P
PFRhETISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby halicansediunder of Chapte 9( nc APPLIANCES—RESIDENTIAL OD
FSRB�T/I�O
IthSHon7ODDl o3ofkhe8usinessandP /ealonsCdeandmyhone.Is In full force and effect
tPANELSLicenseClasLZ'1 VL' � L� -�t`(
Data Contractor UP TO 2DO ANTS
ARCHITECTS DECLARATION 201-1000 AMPS
rs0 7 I understand ery plans shallbe used as public records. OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
CO
`j Liremed Professioml SIGNS ELECTRICAL
OWNER-BUILDER DECLARATION SPECIALCItCUIT/MISC
t~ , Ihercbyafflrm that l am exempt from the Contractor's License law for the
7. following wason.(Seon 9031.5,Business and Professions Code:Any city or TEMP.MOR POLE INST.
Kg".'u� mutiMETERMETERntywhlchrequimaper tWcomimcalter, pmve,demollsh,orrepalr
v, anystmmmpAortolblawance,aWrequlreatheappBmntfmwOper tto POWER DEVICES
file a signed statement that he Is licensed pursuant to the provisions of the
O� ContractorsLicense Law(Chapter 9(emormicing with Section 9000)afDivi-
30GrGr' sion3 ofthe Business and ProfeadonsCode)orthat he la exem themfmmand SWIMMING POOL ELECTRIC VALUA
Y2 Y the basis for the alleged exemption. Any violation of Section 7Qi15 by any 11^2_06_ -qW
5 S a OUT E SSW TCHESF XTURES `�
applicant for a permit aubjMs Penalty applicant to a civil pelty dat m
eore than
B e ndred dollars(5500). NEW RESIDENTIAL ELECTR SQ.FT. STORIES TYPE CONSTRUCTION
? as owner of the property,or my employee with wages as their sole
pensation,will do the work and the structure la not Intended or offered for
osa a(Sec.9014,Business and Professions Code:The Contractors License Law
5 g docs not apply to an owner of property who builds or Improves thereon,and OCC.GROUT' RIS.UNITS
whodomsuchworkhimeelforthrough hisown employees,provided thatsuch
improvements are not intended oroffered forsale.If,however,thebuilding or TOTAL:
improvement bseld within one yearmf compinim,the owner-W Bderwlll have
tl)9..tudenot proving that he did nmbuildorimproveforpurposeofnle.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
LI I,as owner of the property,am exclusively rontmeting with llmnsed PERMIT ISSUANCE
contractors to construct the project(Sec.9014,Business and Professions Code:
The Contractor's License law does net apply to an owner of property who
Wilda or Improves thereon,and who contracts fee such pl mox with a ALTER-DRAIN -WATER(EA)
cq�[+ctoKs)Bernard pursuant m uathe Contractor's LiceLaw.Law. FEE SUMMARY
, I am exempt under Sec g e P for thio mason BACK FLOW PR T DEVICE
DRAINSFLOO OO ,AREA,CO D. AR Y_ N_
Owner Date RECEIrf p
WORKMAN COMPENSATION DECLARATION FD(TURES PERr ) - LTA% Y_ N_
• ❑I hereby affirm that 1 have a certificate of consent to self-insure,ora RECE117 N
mai@ateofWorke Compemattonlmumnceoramaifledmpythereof Bec. GAS EA.SYSfEM-1 WCAOUTLE75 x A FFEI Y_ N_
3800,lab C.)
1'rliry X UCEE'TM
y OAS FA.SYREd- DINGDIVISION FEES exl copy k,hereby ferni.lind.
Certified copy N filed with the city Inspection division. GREASE/INDUSTRLWASTE INTPRCQ'TOR siECK FEE
CERTIFICATEOFEXEMPFION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER SANITARY MR.M EA FOE. Date Remi t#
(fhb rell.rneednotbecompleted If thepermitb(.tunehundreddollars
($taB)nnen.) WATERHEATERW/VENT/ELECTR ENERGY PEE Y_ N_
I B or le that N the pedornance of thework(orwhkh thla permit b blued,
1 shall not employ any person in any manner so u to become subject to the WATER SYSTEM/TREATING
workfn'Compensation laws of California.Date PAID
O Z Applicant NEW RESIDENTIAL PCMB. SQ.E. Date Remi t#
Z O NOTICETO APPLICANT:ILaRer rmking thisCertifieteof Exemption,you
should become subject to the Wmicari Compematlon provisionsof the Labor TOTAL:
C N Code,you most forthwith comply with such provblons or this permit shall be BUILDINGa�
deemed revoked.
W > CONSTRUCEION LENDING AGENCY SEISMIC FEE
0. Iherebya(Brmthat there is a construction lendingagency forthe perforwry TOTAL: ELECTRIC FEE
3 Z a nm oftha work forwhichthls permit b Issued(Sec.3099,Civ.C.) PLUMBING FEE
02 Meter's Namc
LL H Lender's Address - Cry. MECHANICAL PERMIT FEE MECHANICAL FEE
O W I cenifythat l have mad this application and sUtethatthe above information
b correct.l agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
Y IL what ng to Wilding construction,and hereby authorize representative of thio
~ Z city to enter upon the above-mentioned property for Inspection purpose. ALTER OR ADD TO MECH. Dale Receipt>f
(We)agree to save,indemnify an d keep harmless the City of Cupertino U AIR HANDLING UNIT(x010,000 CFM)against liabilities, costs and expenses which may in anywayamme SUBTOTAL:
againstuid City In consequcn (the canting of this permit.
,�• t 1/ AIR HANDLING UNIT(OVER 10,0)0CFM) CONSTRUCTION TAX
18% 'pplimnt ontra Date EXHAD$THOOD(W/DIX:p CONSTRUCTION TAX PAID:
HAlARDOU ATERIALS DISCLOSURE
Will the appLi. or future lou ing occupantslore or handle haaardom HFATINGUMT(TO10),000BTJ) Date RCCeI 1
moterlalascieftnec bytM Cupertin Municipal Code,Chapter 9.1 Z and the
Health and SafetyCode Sccion25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTA 1
❑ YeM No
Will the a pplicant or futu re building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hanardoes air contaminants as defined by the Bay Area Air
. Quallly Management District? BOILER-COMP QHPOR 100,000 BTU)
Yea n No s 6
I have mad the ha>ardcus materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU)
the California Health k Safety Code,Sections 25505,25533 and 25536. I
understand that if the building does not currently have a tenant,that it N my NEW RESI DE TIAL MECH. SQ.Fr.
responsibility issuance
to ce of afythe cateocupa Occupancy.requirements which mustWmet C�fy ® 19e
prior tolssuance day ent theocteofrof the ( O4,
Owner or authorized agent Date ISSUED BY.—
TOTAL:
OFFICE COPY