24103 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES USE BALL POINT PEN ONLY
Building Project Identification PERMITNO,
Building Address: f") A 0 P'31
if 9014' G 4
wnera ame: ,QQ II__ __ one: pcm
OLte7e
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1� CITY OF CUPERTINO-BUILDING DIVISION
contraetousNName: LIc.N. APPLICATION I PERMIT
,551 o^ e'„'*kA 'r �'�'� BOLDING-ELECTWCAI PLUMBING-MECHANICAL CATEGORY CONTROLN
Arohitrglnee w Lic.No:
I 0BUILDING PERMIT INFO
n QTY ELECTRICPERMIT FEE
Address:/ �� Prr^A.tpu- ` a ' PERMTISSUANCE ❑ 1:1 ❑ �Q
LICENSED CONTRACTOR'S LARATION L�7
thereby affirm But l am licensed under provisions of Chapter9(mmmenc- APPLIANCFSRESIDEM'IAL JOB DESCRIPTION
Ingwith Section 7000)of DiWa..3bfthe Businemand ProfmsimsCode,and my
license b In(ultmleffect. LS
PANE ,
License Clam C- Licit
Date a._t i. 47 Contactor
-T�—�ARCHITECT'S DECLARATION 201-1000AMPS
M Z- I understand my plana shall be used as public remeds.- OVER 1000 AMPS SQ.FI.FLOOR AREA $/SQ.FT,
CO
Q(/ Licensed I'mfessiorul SIGNS ELECTRICAL
4� OWNER-BOLDER DECLARATION SPECIALCIRCUIT/MISC
Ihereby affirm that lam exempt frunithe Contractor's License Lew for the
2o following reason.(Section 7031.5,Business and Profemiona Code:An city or 1
FZI"'o9
=following
wcomt ct,alter,improve,dengWh,orrealr P.METER OR POLE]NST.
anystmclure prlorto imla'sume,also requlrestheappllcant forsuch permittu POWER DEVICEk
O file a signed statement that he Is licensed pursuant to the provisions of the
30I� Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi- ;�G ��
1 slon3 ofthe Business and Pmfemlom Code)orthat he b exempt therefromand ( IVIMFII�IPOOL ELECTRIC d VALUATION
0 the basis for the alleged exemption. Any violation of Sectlon 70115 by any O E'fE-5lNI7Cf1ESE7 '�
applicant fora permit subjects the applicant to a civil penalty o(nU more than
live hundred dollars($500). 1 x
�n ❑I,as owner will
the property,or he structure
Its with wages m[herr dole
NE RESIDENTIAL EL SQ.FT. STORIES TYPE CONSTRUCTTON
Q,
compensation,70 Busmastux! k.and rofesionstmcturebnaHntendedoicense d for
Law a,L
O set,(Sec.7044,Buelnem and Professions Code:The Contractor'sLicense law
$$ does not apply to an owner of property who Wilds or Improves thereon,and OCC.CROUP RES.UMTS
who does such work himself or through hisown employees,provided that such
Improvements are not Intended or offered for sat,.If,however,the building or TOTAL;
Improvement is,sold within one yearofcompletion,the newer-WIlderwill have
tlg:karden of proving that he did not Wild or improve for purpose of sale.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
Lj I,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
mntracmre to construct the project(Sec.7044,Business and I'miemlom Code:
The Contractor's License law does not apply In an owner of property who ALTER-DRAIN kVENT-WATER(ENWild.or Improves thereon, and who contracts for such projects with a
Mtjactor(s)licensed pursuant to the Contractor's Llmnse Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec. _ B k P C for this reasonOUTSIDF FEES
Owner Date
DRAINS FLOOR,ROOF,AREA,CON I. SANITARY Y N
RECENT N
WORKMAN COMPENSATION DECLARATION FIXTURES-PER TRAP SCI100L TAX Y N
I ate of affirm that I have• ]mum to of consent to self-insure,ora RECEIPT N
caw,,Lab of Worken'Comperuatlanlmurance on certllled ropythereo((5eo. GAS F.A.SYSTEM-1 INCA OUTLETS PARKFEE Y N
330Q Lab CJ
Polley N RECEGAS IA.SYST M-OVER 4 MA) DING DI N
Company BUILDING DIVISION FEES
Certified copy is heed with the city GREASE/INDUSTR,WASTE INTERCEPTOR PLANCHECKFEE
rj CertlOetl copy b(fled with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-s10RM EA.200FP. Date Recei t#
(Thissectlon need not be completed If the perm t t,fmone hundred dollars
($1000.,1...) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
Icertify that in the performance of the work for which this permit le bated, _ —
I shalt not employ any Person in any manner m as to become subject to the WATER SYSTEM/TREATING
Workers'Compensation Lawdof California.Date PAID
0Z Applicant NEW RESIDENTIAL PLMB. SQ.Fi. Daft Remi t#
Z O NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you
Fshould bemmesubjcci to the Workera Comperuatlon provblom ofth.Labor TOTAL:
W Code,you moat forthwith comply with such provisions orlhb permit shall be
LU y deemed revoked. _.BUILDING FEE
1 C CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z' Ihereby affirm that there is a construction lending agency for the perform- TOTAL: ELECTRIC FEE
ance of the work for which this permit b issued(Sec.3 ,Civ.C.)
V O Lender's Name PLUMBING FEE
LL H I.ender'd Addrese QTY. MECHANICAL PERMIT FEE MECHANICAL FEE r'
U Icerti(ythatl have read thus appllcatWnand statethatlheaboveln(ormatlon
> W bcorred.I agreeto comply with all cityand mu.tyordlnancee andetalelit. PERMIT ISSUANCE �"�' FEESPAID:
IL relating tobulldingmestructlon,and hereby author@t representativee.(flat
city to enter upon the above-mentioned property for irupectlon purpose-. LTFRORADDTOMECH.
Z (We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Reeei t#
V against liabilities,pdgmenls,mstsandexpama.which may In any way accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
against said City In consequence of the gram Ing of this permit.
AIR xANDENc ungT(OVER 1(LooB CFM) CONSTRUCTION TAX
Slgnatureof Applicant/Contractor Data EXHAUST 11000(W/DUCT) CONSTRUCTION TAX PAID:
. HAZARDOUS MATERIALS DISCLOSURE _
Will the applicant orfuture building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date Recei
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
oUL-
Health and Safety Code Section 2M12(.)1 HEATING UNIT(OVER 100,000 BTU) TOTA --•
1-41 Yes MN.
Wllltheappliwnt orfuwm building occupant use equipment ordevlces VENTILATION FAN(SINGLE MID)
ISSVAA(:f 1VA
TE
whkhemithaiaircoaneasdefned bythe BayAreaAlr
Quality ManagementDistrict?
BOILER-COMP pHPDR100,000 BTI])
4 Ycs QNo AUg 14 q
haveread Health
ety Codrlalarequi 25505, 5533 andunderChapter6.95of BOILER-COMP(OVER100,000 BTU) I���
the California Tleallh&Safety Code,Sections 25505,25533 and25534.I /x7
understand that if the building does not currently have a tenant,that It is my NEW RESIDENTIAL MECH. SQ.FT
responsibility to notify the occupant.(the requirements which at he met — CITY Ur VUI"Chl�ypsGil
rlor sofa he occupant
neq
Owner or authorlreda ntate ISSUED BY�;n�
OFFICE COPY