24030 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Pru en Identification PE hIIT NQ 4 0 3 0
Building Address:
ners Phone: ✓
j1,J CITY OF CUPERTINO-B'U' DING DIVISION
Contractor's Name: s �Ly, APPLICAT11 PERMIT -7 - 2q—q7—
Ear
e 2� 2—
• 'fie BUILDINGELECTRICAL (1JJMMMBING-MECHAMCAL CATEGORY
Architect/ glneer. LIa Na:
QTY ELE PE IT FEE BUILDING PERMIT INFO
Add. PETWRTI /� 1�1Ne
LICENSED CONTRACTOR'S DECLARATION L�J
I hereby affirm that l am licensed under provisions.(chapter 9(commmc D JOB DFSC ON
Ingwllh SecHon9,"ot Dlvlsion3ofthe Buelneuand ProlesslonsCode,and my
license is In f ill d dfetl. P
License C/1a�w._ Lic.p
_1
Conrad.
V RCHITECPS DECLARATION "SICNSE:LEC
O I understand my plans shall be usad as Public record. AR $/SQ.FT.
� j M Li
Limned Pmfcalonl CAL
6m OWNER-BUILDER DECLARATION
IherebyafOrm that]ass exempt from the Contractors Lksnse Law for the SI'[CULCIRCUIT/MLSC yy
'6 oo�� following reason.(Section 7031.5,Business and Professions Code:Any city or 241
O'2" TEMP.METER OR POLE INST.
�� county which requlreea pertN[lomnwct,alter,lmprove,demolish,or repair
any stmcture pdorto Its Wuame,also requiresthe applicant forsuch permit to POWER DEVICES
file a signed statement that he is premed pursuant to the provision of the
3 w Contractors lAcroe Law(Chapter 9(commencing with Section 700)of Divi.
don3ofthe Bm
usit,....dProfessroCode)mthat hebm
exempttherefroaM VALUATION SWIMMING POOL ELECTRIC ��
yyy the basis for the alleged exemption. Any violation of Stolon 70315 by any OUTLETSFS
SWITCHEXTURES '?S) 000
ps' applicant fora permit subjects the applicant toa civil penalty of not morethan
five hundredsowner of the W). NEW RESIDENTIAL ELECTR SQ.FT, STORIES TYPE CONSTRUCTION
�n ❑I,as owner of the properly,or my employeeswithih wages as[herr sale
compena 7ton,Basin.,I do and
Porndlhe..Codurebnountended or offered Law
O sale(Sec. pply to alnowandfpropety Code:The Contractors Limns Law
£$ whod.does tsuth roan owner ofpropertywho Wlldaorimproveadhermnanh OCC.CROUP RES.UNITS
whodoementsa not himself Intended hrough his owne.If,ho es,er,th buildi nor
Improvementsaren.tintended earafco (.male.If,however,theerildingve QA
Improvement V Boldwlthln oneyeam(compldiorytheowner-W Bderwlll have
t)LGpvd en of proving that he did rout bund or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD TONE APN
Lj L as owner of the property,am exclusively contracting with licensed ppnMlT ISSUANCE
contractors to construct the project(Sea 7094 Business and Profeal.n Code:
The Contractor's License law does sat apply to an owner of Property who ALM-DRAIN A VENT-WATER(EA)
Wo
builds or Improves thereon,and who contracts for such PSo)ects with a
,,DatfTinctor(s)licensed pursuant to the Contractors License law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
i- u I am exempt under Sec. B k P C tar this rcawn
DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y N
Owner Date RECEIPT
j WORK MAN COMPENSATION DECLARATION FDT1URFS-PER TRAP 5CHOOLTAX Y N
❑I hereby affirm that 1 have o Ingurate,o consent to op thereof
ora REC=M
certificate C.) ricers'Compenallonlnunnre ora rertlfled copythemof(Sec, GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
P icy00, b C.)
Poliry ftECEl''f M
Co an CAS EA.SYSTFAf-0VER4(EA)
y BUILDIN V 1 FEES
ertilied copy 11 hereby td. GREASE/WDUSIRL WASTE] E'TOR PLANCHEC 1
ertlBed mpybfiled withh the
e city inspection division. � D
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAI
COMPENSATION INSURANCE SEWER-SANITARY- RM EA.2(gFT. Recei t#
(fNe section neetl cad W completed tithe permit V from hundred dollars
($100)mless.) WATER HFA /VENT/ELECTR L'N ,Y FEE N
I certify that N the per(.mu nm of thework forwhich this permit is issued,
I shall not employ any person In any manner n as to became subject to the WATER$Y /TREATING
Workeri Compensation lawanf Callfomla.Date PAID
z Z Applicant - NEW DPNIIAL PLMB. Date R f#
Z O NOTICE TOAPPLICANT:If,after making this Certificateo(Exemptlan,you SQJT'
Fshould bemm.subject to the Warkars'Compenal ion prov ,us of theL vor TOTAL:
N Code,you must forthwith comply with such provision or thin permit shall be BUILDING
FEE
LU > deemed revoked.
C F3 CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby.fit that there Iso convection lendiagagenry forthe perform-
M Z ELECTRIC FEE
scam otlhe work(or which thU permitis issued LSN'-3W7,CIv.C3 TOTAL: _
02 Lenders Name PLUMBING FEE
IL F Icnder.Add. QTY. MECHANICAL PERMITFEE MECHANICAL FEE
his app
O WEE
bavereadtlication and state that the above Informal...
1 bmrred.l agree to comply wlthall dtyand countyordinanres and state laws PFRMITISSUANCE FEES PAID:
>. N relating to building construction,and hembyaulhorize representative..(this
F Z city toe.terupon the abovtmenlion.d property for inspection Purposes. ALTER OR ADD7O MECH. if
V — (We)agree to save,Indemnify an d keep ha ess the City of Cupertino Date Receipt#
against Ba pdgarade, aa.de.pen whlchmaymanywayamrue AIR HANDLING UNIT QO I0,000CFM) SUBTOTAL:
ago] id aI ceo(thegra olthlapermlt AIR HANDLING UNIT(OVER 10,WOCFM) CONSTRUCTION TAX
Sigr5ture7of Applicant/ ontractm Date EXHAUB'r HOOD(W/DLX:T) CONSTRUCTION TAX PAID:
HA7ARDOUS MATERIAL ISCLOSURE
Will lheapplianl or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date RCCeI
material as defined by the Cupertino Municipal Code,Chapter9.17,and the
gm
Healthand Safety Code Se11on25S32(a)7 HEATING UNIT(OVER 100,000 STI) TO ,
F-1Y. No
Will the applicant oruture bulldingoccupant use equipment ordevicas VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants as deRoed by the Bay Area AIr
Quality Management District? BORER-COMP QHP OR 100,OM BTU)
4
Yes
n No pp
't have read the bazar (say C e,S r l..2m05,25S Ser d 2S5M.95 of RORER-COMP(OVER 100,000 BTU) zV B
theersta dt Health building
Code,Section25505,ve a tand75534. 1
undrosposiandthai notify
the occupant note currentlyhavewhich
that b isat NEW RFS[DFI4'f1AI.MECH. SQ.FT AUDI
rnor to bility Issuance
of acerb Icu,.f Ocflherequlrcrrcnts which must be met - _ _ b
prior to Issuance ora Certificate o(Occopanry. Il— ��t rlp7 �IrY p.y
U
Owner or authorized agent Data ISSUED BY:-.
OFFICE COPY