24181 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address: 24181
m: one: A
` CITY OF CUPERTINO-BUILDING DIVISION n N�
-� Contractor's Name: Lm.No: APPLICATION I PERMIT `1 ( _
BUILDING¢ECRICAI MUMBING.MECIIAMCAL CATEGORY CONTROL N
Architect/i,nipmer. Ge No:
QTY ELECFRICPERMIT FEE BUILDING PERMIT INFO
Addrcu: PERMIT ISSUANCE ❑ ❑ �] 11LICENSED CONTRACTOR'S DECLARATION l�
I herebyim,700hat lamllcenudunder pressand eofCtsimuC(commen APPOANCEB.RESR)ENTUL JOB DESCRIPTION
ingwlth Semon 7000)of DlWslon3 ofthe BuNneuand Pro/eulonsCade,and m
license la In fug(orae and died. PANELS
'License Che Lle.N
Data ContractorUP TO 200 AN"
ARCHITECTS DECLARATION 201-I(DO AMPS
00z I understand my plam,hall be used as public records. OVERIODOAMPS SQ.FT.FLOOR AREA $/SQ.pr.
Fi I� Licensed Profculonal SIGNS ELECTRICAL
<< OWNER-BUILDER DECLARATION
lye SPECIALCRCNT/MLSC
zp, owing refit.ason.
tectum31.5,Bexempt(ro ossa Contractor's License Law fort he
following recon.(S e a p ryWtto Business and r impmns Code:Any city it
I O TEMP.METER OR POLE INST.
I rr, countywhlch requiesa permlttocorutmn,elter,lmpmve,dennlish,orrepalr
F
any structure prior to its Issuance,also requires the applicant for such permit to
flle a signed statement that he Is licensed pursuant to the provisions of the POWER DEVICES
Oµrp Contractor's License law(Chapter 9(commencing with Section 7000)of Divl-
F30:f sion3ofthe Business and PmfeulomCode)orthat he Is exempitherefromand SWIMMING IDOL ELECTRIC VALUATION
q O.•�]] the IcaW for the alleged exemption. Any violalbn of Section 7MIS by any OU7LETSSWITCHESFI%TURFS
applicant for a permit subjects the a pplicam to a civil pens ity of not more Dan
Rv�1,asoundrodollars NEW RESIDENTIAL¢FGIR SQ TYPE CONSTRUCTION
1,n owner of the property,car my employee with wage as their Bale
compemation,will do the work and the structure Is not intended or offered(or
� O sato(sec 7064,Rusbwas and Prvfeubro Code:The Contractors License law
�,I�R don not apply to an owner of property who builds orimprovethereon,and RON' RFS.I/NI'I5
CC whodansuchworkMmreVarthmugh hisown employees,provided thatsuch
Improvements arc not Intended oroffered formic.I(however,thebulldingor 7
ImprovementIswldwlthNoneyearofcompletb theowner-bugderwWhave
tfE,tiurdenof provingthat he did not build orlmprove forpurponeofsakJ. QTY. PLUMBING PERAAr FEE FLOOD TONE AIN
L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contactors to construct the project(Sec.70A Business and Professions Code:
The Contractor's License Law does not apply to an owner of pmperty who — ALTER DRAIN&VENT-WATER(EA)
Wilds or Improves thereon, and who contra for such ptnjects will a FEE SUMMARY
cgp�aaor(q llcensed pursuant to the Contractor's License Law, BACK FLOW PROTECT.DEVICE
L�1 am exempt under Sec. B &P C for this reason
DRAINS-FLOOR ROOF,AREA,COND. SANITARY Y N
. Owner Date RFGF7I NY
WORK MAN COMPENSATION DECLARATION Fq(TUFIF_5.I'FR 77Wa SCHOOLTAX Y_ N
❑I hereby.,ke that I have a fuumAe of consent to self-insure,ors�nifiteRECEM N
3800,Lab
ttdllid mpythereaf(Sec. GAS EA.SYSTEM-1 WCAOUTLE1S PARK FIE Y N
3800,lab C.)
Policy RECEDING Df N
GAS EA.SYSTEM-OVER d(RA)C��ra���myypyypany BUILDING DI VISION FE ES
copy is herebydwith he city GREASE•/INDUSTIL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy Is tiled with the city Inspection division.
CERTIFICATE OF E%EMPTION FROM WORK CRS- GREASE TRAP PAID
COMPENSATION INSURANCE
(Thlesection need not becomSEWER SANITARYpleted lithe permit Isforone hundreddollara STORM FA.200FI. Date Reml I#
($100)or less) WATER HEATER W/VENT/¢FGTR ENERGY FEE Y N
I certify that In the performance of the work for which this permit is Issued,
I shall not employ any Person In any manner n as to become subject to the WATIR SYSTEM/TREATING
Workem'Compenutlon Ua of Californ9.Date PAID
-
zZ Applicant NEW RESIDENTIAL PLMB. SQ1rr. Date Reml t#
Z O NOTICE TO APPLICAM:If,after making l his Certificate of Exemption,you
should become subFct to the Workers''Comperwti m provisions of the Labor TOTAL:
LO Code,you must forthwith comply with such provisional or this perMtehall be BUILDING FEE
Bl > deemed revoked.
d C CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hercbyalBrm that there Is a coutruction lending agency for the perform- ELECTRIC FEE
7 Z ante of the workfor which this permit b r
Issued ete3097,CIv.C.) TOT
jC f,) O Under'sName PLUMBING FEE i+
LL H Lender'sAddress QTY. MECHANICAL PERMIT PGE MECHANICAL FEE
Icedifythall have mad thisappllcation and antethe the above Information
O W .
IL Is correct.I agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
>. IA relating to building construction,and hereby authortee representatives.(this
H Z city to enter upon the above-mentioned property for Inspection purposes. ALTER OR ADDTOMECH. Dale Reeef t#
(We)agree to save,IndemNfy an d lamp harmless the City of Cu ped ins
V aga Ilides,Pdglards,costs a rad expenses which may In any way accrue AIR HANDLING UNIT CFO 10,000 CFM) SUBTOTAL:
a butes Ckyincon ermoft .,ting of this permit AIR HANDLING UNIT(OVER]O,ODOCRt) CONSTRUCTION TAX
jig o ppga /Contractor /^ - t IXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Bl the applicant or fobam building ocapanbmre or handle harardous HEATING UNIT(TO 100,000 BTI!)
Date Recei (#
nutcrlal as dented by the Cupertino Municipal Code,Chapter 9.17,and the -
Health and Safety Code Seaton 25532(a)? HEATING UNIT(OVER 100,000 BTU) TOM.
❑Yea fn No
Will the applicant or future building occupant use equipment ordevices VFNDTATION FAN(SINGLE RESID) ISSUANCE DATE
which emit harardoua air ear aminanb as defined by the Bay Area Air
•
Quality Management District? 130I1LER-COMP OHP OR 100,0(10 BTU)
❑Yea ❑No
lhave r.dthe hazar onateriab rcqulrena,anunder Chapler6.95of BOILER-COMP(OVER 100,000BN)
the Callfomia Health&Safety Code,Sections 25505,25533 and 25536.I
understand that if the building does not currently have a tenant,that It Is my NEW RESIDENTIAL MECH. SQ.FT SEP .- 1 92
vibilityta rally the occupant of the requirements which=at be met r h7y
rior LLssuance o(a ' `% panty.
A:1�! 41iTY v�
•r oraWhori dagent IF Date ISSUED
TOTAL:
OFFICE COPY