24080 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Proles Identification PTh'Q. O R V O
Building Address: �G)
ZZ%O ALM Ave
em. ams: hone: A b . AA
SMA ma kQoo�>4�, CITY OFCUPERTINOIIUILDINCDIVISION -��-�Z
comeaeor's Narm a .Na: APPLICATION / PERMIT
BLILDINGELFCTRICALPLUMBINC-MECHAMCAL CATEGORY CONTROL 1
zchuect/En Lie No:
DEAe QTY - •ELECTRIC PERMIT FEE - BUILDING PERMIT INFO,;;;.
Address, PFRMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION Lr
Iherebyalfirm thatlam licensed under provolone of Chapter9(conunen<- APPLIANCESRESIDENTIAL JOB DESCRIPTION
ingwlth Section7000)of Dlvision3ofthe Businessand Pmfeaslom Code,and my � ` l
license lslaiul rre and effect. — PANELS VCiY1
Llcan .m n
Date mtractor
ARCHITECP$ E RA D:V 20ER1000 PS
AM
Z I understand my plansshall be a as public records OVERIWOAMIsS SQ.Fr.FLOOR AREA 5/SQ.FT.
0,
SIGNS ELECTRICAL
-^.U�j Licensed Professlovl
<i1O OWNER-B UILDER DECLARATION
L�jj (hereby affirm that l am exempt from the Contractors License Law for the SPECWLCIItCUIT/MIST
�OJ9following reason.(Section 7MI.5,Business and Professions Code:Any city'' TEMP.MEIG¢ORPOLEINST.
county which requires permit to construct,alter,Improve,demolish,or reps
q,Zi S'j any swcture prior to its Issue ace,a lino requires the applicant for such permit to LOWER DEVICES
:'S fio a signed statement that he is licensed pursuant to the provisiom of the
IO_ Contractors License Low(Chapter 9(commencing with Section 7000)of Divi- PO
SWIMMING OL ELECTRIC
0andP
5 sion3oftheBitunesamfosedmaCode)orthatheis,exempttherefromVALUATIO
ami pyy
I - the basis for the alleged exemption. Any violation of Section]0315 by any OUTLETS-SWITCHES FIXTURES OOO C-0
applicant fora permit subjectsthe applicant o a civil pewltyelf not more than j
t m five hundred dollars($500). NEW RESIDENTIAL ELE-CTR SQ.FT. SI'OFOFS TYPECONSTRUCTION
.. n 1,as owner of the property,or my employeeswith wages as their sole
CZa campensation,wBldothework,andthestructumieen intended or offered for
j p vle(Sec.7044,Business and Professions Code:The Contractor's Liereue Law
es$ does not apply to an owner of property who Wilda or improves thereon,and OCC.CROUP RES UNITS
who don such work himaelf orthratigh hisowe employees,provided that such
improvements are not Intended orolfered forxle.If,however,thebuiiding or TOTAL
Improvement issoldwithinoneyearofcompletion,theowner-WBderwill have z.
th rden of pewleg that he did not Wild or improve for purpose.feale.). Qct. BI NG PERMIT""-, FLOOD ZDNE APV
_I,as owner o!the property,am exclusively contracting with licensed P - R LSSVANCE
contractors to construct the project(Sec 7094,Business and Professlom Code:
The Contractor's License Law does not apply to an owner of property who AL -DRAIN&VENT-WATER(EA)
WII s car Improves thereon, and who contracts for such ptojects with a 1� 'i
acts('.) apw,uant to the Contractor's Liceax Law. BAUC FLOW PROTECT.DEV( :•':FEESUMMARY'/'_v
Ica t u B&P for th reason �__ �PLRt� - �
D NSFLWR,'POO , SAtI1TARY Y N
rte Data RECE97 s
ILe ANC �MSATION DECLARA ON FDMRpS PFR.�Ap SCHOOL TAX Y_ N_
he aflirm that I have a rertificate of conxm to self-Insure,ora RECERrT N
to,
BcaCompematlon Insurance or a certified copy therref(Sec. GAS EA.SYSfEIf-1 INCA OUTLETS PARKFEE Y N
800,Lab C.) RECEP T M
Policy 0 GAS F.A.SYSTEM-OVER 4(FA)
Com any BUILDING DIVISION FEES
Certified copy o hereby furnished. GREASE/WDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
.Certified copy is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' I GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.20�T. DRIC Recei tk
(Thissection need not W completed lithe permit o foram hundred dollar
($100).,I..) WATER BEATER W/VENT/E.ECTR ENERGY FEE Y_ N_
I artily that in the perforreame.f the work(.,which this permit is stand,
1 shall not employ any person In any morme s°as to became subject t.the WATER SYSTEM/TRUIING
Workers'Compensation I aws of California.Date PAID
O Z ApplicantNEW RE DENT AL FILMS. Q T. Date Receipt
making
Z NOTICE TO APPLICANT:If,cher tCertificate of Exemption,You
0 should become subject to the Workers Compemation provobns ofthe Labor TOTAL'
N Code,you=at forthwith comply with such provisions or this permit shall be BUILDING FEE �•
W >
dPen1Cd`eVOlkeii" SEISMIC FEE
CONSTRUCTION LENDING AGENCY
fl (hereby work
forwhhereoacomtmttdont gued(Sec.309,cy Civ. he peAortn TOTAL, ELECTRIC FEE
Z ance of work brwMchtho permit obs,m(Sec.3097,Clv.Cd .. PLUMBING FEE
LL O Laader'a Name - :MECHANICAL PERMIT'" �iFEE
ly 0 I<nder's Aadrcu '� MECHANICAL FEE
O w onect.Ia t I have readagree to
with allcitynand dmartethat yordinancesa dgatelaws FEES PAID:
t bailees complywo ,alndhereb authorize
erprese and gate laws PERMIT ISSUANCE
} U) cityrelating oenteru Pon t consove-nen,andberebyrtyodurcptionpurpo .(this
HZ myW)tereon theasavementfy an d property for inspection Cit purposes. ALTER 0RADDTOMECH. Date RMCIPI#
(We)agrre t'save,Indemnity an d keep harmless the City of Cupertino
V age Wt Mttlsp'judgmem carts dexpenxs which may In anywayaccrue AIR FIAhT)LINC 11MT(TO 10,1100 CFM) SUBTOTAL:
ag s Id cue 'a t e granting of this perm
AIR HANDLING UNIT IOVER I0,W0 CFM) CONSTRUCTION TAX
sig App want/Gun actor Date 92 IXHAUSTHOOD(W/DUCn CONSTRUCTION TAX PAID:
HAlARDOUS MATERIALS DISCLOSURE HEATING UNIT t00,0006TU)
Wllitheapplicant or future building occupant store or handle hazardous Date RCCCI tq
material as defined by the Cupertino Municipal Cod,Chapter 9.12 and the
health and SafetyCods Srlb,75532(a)t HEATING UNIT(OVER 10,000 BTI)) IOTA
n Yes d No
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
Q.rality Management District? BORER-COMP OHPOR 100AU BTU) C L
4YesNo
havcreadthe har2utmaterials requirementsunder Chapter 6.95of BOILER-COMP(OVER 100,000 BTU)
the California Health&Sf BCode,Sedions2S505,25533and2SiM. 1 fly RESIDENTIAL MCCH. SQ.IT. ��� ,� U IJJ
understand that lithe building does not current) have a tenant,that it b my L
responsibility to notify the occupant of the requirements which must be met
prior to Issuance of a Certificate of Occupancy. �,I
Vv(Ln I II IV
Owner or authorlmd agent Date TOTAL: ISSUED BY:
OFFICE COPY