24237 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Prate n Identification PERMIT NO.
Bwming Adaredd� 24237;
one: A
CITY OF CUPERTING-BUILDING DIVISION a�
cont or'aName Uc.1N�o: APPLICATION /PERMIT 1 4
G BUfLDING-ELECTRICALPLUMBING-MECHAMCAL CATEGORY CONTROL N
Architect/Engineer. - Lie.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: I �� R, EJ ❑ -
PERMITISSUANCE LYI
LICENSED CONTRACTOR'S DECLARATION 4S
T hereby affirmthat lam llcmeb underproviUons.f Chapter9(mmmmc APPLIANCESRESIDRNTIAL OB DFSCRB'['TON
ingwlth Sedion7000)of DtWson3ofthe Buslnewand Professlonsc.de,andmy
I icense is In full fp5ce and effect. PANF]S (�(���•P/
Limn Iass�T_LI[.N
Data Cor .ranor. ajL0194 �j�.��v'
ARCHITECTS DECLARATION 201-IOOOA.MPS • 1
aOZ I understand my plans shall be used m public records. OVER1000AMP5 SQ.FT.FLOOR AREA $/SQ.Fr.-
uu���j O Licensed rensed Profrssknsl
SIGNSELFCTRICAL
<¢m OWNER-BUILDER DECLARATION
In Fni SPECIAL CIl2CUIT/MLSC
mm
s, Thereby afRnthallam exempt Contractor's Llrenu Law(.r the
following mission.(Section 7MI.5,Business and Prolcomars Code:Any city or
7ac.untywhichrequbesapen ttomMtmci,alter, pmdemolbh,orrepalr TEMP.METGR ORIOLE INST. .
any stmeture price to its Issuance,also requires the apparent for such permit to POWER DEVICES
file a signed statement that he b licensed pursuant to the provisions of the
Contractor's License Law(Cha 9(commencin with Section 7000)of Divi- VALUATfSN
Ann 3oftheBualneasandProfenknsCode)orthattheis exempt there(romand SWPIMNG POOL ELECTRIC }� CJN
y� Q the basis for the alleged exemption. My violation of: 70315 by any OVILETI SWI.I.CHFSFIXT"URESJ.� C ^�
i' applicant fora permit subjeRatheappliomt to a civil penalty.(not moretbn Vim[' J
Q five hundred dollars(¢500).
9, NEW RESIDENTIAL ELECTRSQ.FT. STORIES TYPE CONSTRUCTION
I,as owner l the a work,a or my employees with wages as their sole
7. mm;T7UZaBusiroth sworkand theatrocW re isnot Intended or offered for
Odale(Esc.apply
to a noss and Professions Code:The or improves Llm or,Law
$� donsnmaruchoan owner
dproperty hisobuilds nemplyees,pvested that
- OCGGROUP RFS.UNITS
whodoemodsa n tintended
me dedaroffe Maowne.If,ho eprovidedthat noruch —
improvementsarerwllntendneyear focroend pewit.the however, deer ill have T
Improvement b sold within oneyearolcomplelbn,the owner-builder will have -
th�r¢arden of proving that he did notbWldorlmproveforpurposeofsabJ. QTY. PLUMBING PERMIT FEE FLOOD TONE APN
01!V
L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE' -
contractors to coasted the project(Sec 70K Business and Professions Code: - '
The Contractor's License law does not apply to an owner of property who ALTER-DRAIN 6:VENT-WATER ff.N
builds or Improves thereon,and who contracts for such piojeM with a FEE SUMMARY
c actors)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
LJ I am exempt under Sec. B A P C for this reason '
Owner / Date DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
RECEIPT
WORKMAN COMPENSATION DECLARATION TRAP SCHOOLTAX Y— N—
❑I hereby affirm that I have•reftifeate of consent to self-Insure-ora RECEBN
crniticateofWorkers'Compeu tlonlre mnreoracertifkd copythermf(Sec. GAS _�, PARK FEE. -Y N
3800, bCJ
Iuicy N Ol 10'-1 a�--OI I RECEBT N
CoP IT
m anv ! Cl r.,nn _ - GAS .S BU ILDING DI VI SI FEES
in
copy b hereby furca shed. — EASE r
®CertUed copy b filed with the city inspection division. S •��j
CERTIHCATE OF EKEMPI'ION FROM WORKERS' EASE/1NDUSIRL W Erro PLANCHECK FEE
AID"
11 COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200FT. Date BCCI t#
(Thissection need net be completed lithe permit b for one hundred dollars
(SIM)or less.) WATER HEATER w/VEM/ELECTR ENERGYF Y N—
I rertify that In the performance of the work forwhlch this permit Is issued,
I shall not employ any person in any manner so as to become sub)m to the WATER SYSTEM/TREATING
Worken'Compensation L�sa•161 GIRomb.Date PAID
O Z Applicant NEWRESIDENTIALPLMB. SQ.FT. ate Recti t#
Z NOTICETO APPLICANT.If,after making this Certificate of Exemption,you
should become subject to the Workers'Compensation provblons of the Labor TOTAL:
F W Code,you most forthwith comply with such provisions or this permit shall be BUILDING `+
W > deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE d.
CL I hereby affirm that there b a construction knelingagency forthe perform ELECTRIC FE
Z ac..fthc work forwhichthls per ed(Sec.3097,CIv.C.) TOTAL:
00 I<naer.Name PLUMBING
LL I- Lrndcre Address - QTY. MECHANICAL PERMIT FEE
O W Icedifythat l have read thbapplicatlonand dtatethat theabove Information MECHANICAL
4 6correct.I agree to complywith all city and county ordinances and nate laws PERMIT ISSUANCE FEES PAID:
} W relating to building construction,and hereby authorize representatives ofthb
Fcity to enter upon the above-mentioned property for bapedtion purposes. - ALTER ORADDTO MECH.
Z (We)agree to save,Indemnify an it keep harmless the City of Cupertino Date ReC t#
L.I against liabilities,pdgments,cressand expenses which may In any way accrue AIR HANDLING UNIT CTO 10,000 CFM) - SUBTO L:
against mid City incone quenre oft ting of this permit
— -
an AIR HANDUNG UNIT(OVER 10,00oCHn0 CONSTRUCTION TAX
Signature u(ApplHAZARonOUS Date
E%HALsrl1O0D(w/DUCT) CONSTRUCTION TAX PA
HAZARDOUS MATERIALS DISCLOSURE
Wit1theapfificint d by the Lurebudding oaipal Code, hhand9.ha and
HEATING UMT(TO 100,000 BTT!) Date RCCCi t#
material nd dented by the Cupertino Municipal Code,Chapter 9.12,and the G
Piralth and Safety Codr Section25532(a)? HEATING UMT(OVEIi 100,000 BTU) TOTAL:
❑ Ym 0 No
Will the applicant or(uture building occupant use equipment or device VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air _
Quality Management District? - BOILER-COMPOHPOR 100,000 BTU)
4Yra �yI No P � ' D
have read the haur�o.s rtaleriab requirements under Chapter 6.95 of BOILER-COMP(O,VER IW,000BN) '
`M Califomia Health k Safety Code,Sections 25505,25533 and 25536.I
ndersland that if the building does not currently have a tenant,that It it my NEW RESIDENTIAL MECH. 5Q.F7 }' SEP �'7 1x
responsibility to notify the occupant
pant of the requireenls which=at be met
prior to Issuance ofd Cert Tote of Occupancy. — —
L��.a,l�t 2h7l9z CITY ur r'��e
wrier orau&orewd agent Date/- - ISSfJED OY:
TOTAL:
OFFICE COPY