24034 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
' - BuildingPm ed Identification - PIRMITNQ, 4 0 3 4`
Nullding Address:Owner.Name: '• .. ,
'1.'Z3�tio N . '
one: A.DA
CITY OF CUPERTINO-BUILDING DIVISION
Conv a.". - Lk.N. APPLICATION / PERM T
0 ►
BUILDING-F3.ECIRICAL•PLUMBINMCAL CATEGORY C11 o&:
Architect/engineer. ' � Lk ..N. - C7"'
Q]Y„��' ELECTRIC PE T L PEE VL , , 'BUILDING PERMIT INFO
Address: PERMITISSUAN ❑ ❑- ❑
LICENSmthat EDCONTR under rDECLA RATION
I hereby
Achonrtvthatl eivsiolicensed ofthcRrprovislo Pro Cs-sons 9,(ro and OR APPLIAN R NfIAL JOB ass, xx re—
le.
ION
ii with infull70007ofdelision3o(the Busineseand Profewione Code=and my D,'—
licenx le In full lorce and ee.N P
License Class LION
Date Contractor
ARCHITECT'S DECLARATION Ol-1(pO AM
1+p!•,❑O (understand my plana shall be used as publlercrords OVERT" PS SQ.Ff.FLOOR AREA $/SQ,FT,
E do 6 Licensed Professional SIGNSEL TRICAL -
�<<G� OWNER-BUILDER DECLARATION SPECIALC CULT/MISC
Ihereby affirm that lam exempt from the Contractor.License Law for the
pp following reuOn.tSectlon 7m 15,Businem and Profevione Code:Any city or
TEMP.METER OR POLE(NST.
county which recluirnsa permit tocommuct,alter,tmpmve,demolish,ormpat-
g �.a anystmdure prior to lV Lasuance,alw requlrestheappllant forauch permitto
Ofile a signed statement that he is licensed pursuant to the provisions of the POWER DEVICES
EOh Contractor's License Law(Cha Fier 9(rommencingwith Section 7000)ofDivl-
I �O� slOn3olNeBusineesand Protexkns Code)orthat he Lsaumpt Nere(romand SWIMMING POOL ELECTRIC VALUAZW
Ithe basis for the alleged exemption. Any violation of Section=B 5 by any O i/'rYs
applicant fora Mt sub' sthea applicant to a civil 1 of nor more than OUTLETS-SWITCHESFD(TURES ✓1
PP per leci PP penaryo
RE,
A Owner ($500). ��NEW RFSIDENTIAI.ELECsownerhe property,or he employees with wages r (her sok STORIES TYPRCONSTRUCTION.pensHon,w111dothe ss.eni kandlhes Code:Th Contot actornded oicense d for
Law. ppy Bu an ower ofmperty Co Wilds or impoRols Lereon Law apply to an owner olproperty who builds orimprovn thereon, - OCC.GROUP RFSUNRS "
C. who does such work himxlforthmugh his own employees,provided that such
Improvements are not intended or Offered fee sale.If,huweveq thebullding or - T
improvement.sold within oneyearofcomplctlon,the owner-bullderwill have
`F�"-�ry'rden of proving that he did not build or Improve for purpose of sale.). QTY. ' ".',PLUMBING PER . '+ ,,FEE .", FLOOUZDNE APN
AU L as Owner of the property,am exclusively contracting with licensed pERg(pp ISSUANCE -
contractorstoronatructtheproject(Sec.706y Buslnessand Profdslo®Code: - •.
The Contrectore License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
i builds or improvAs thereon,and who contracts for such jRpjects with a
cm,(.)Banxd pursuant to the Contrador'e License Law. BACK FLOW PROTECT.DEVICE }' FEE SUMMARY".
„U I am exempt under Sec. B &P C for this reason
DRAINS FLADO R SANITARY Y. ' N
Owner Date - R ODE,AREA,GOND. RfEQTN
WOit KMAN COMP tT'SATcam DECLARATION FIX'URES.PER TRAP SCHOOL TAX Y_� N—
❑I hereby affirm that I have o lmu rata of consent to Alf-tmum,or RECER'T N
f 3800,abofWorkan'Compensatlo^Iruuranceora renlfkd ropy thereo((Sec. GAS PA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
- 3800,dab C.I
Policy N RECEIPT Or
GAS EA.SYSTEM-OVER d(EA)
Co a^Y BIII LDING DTVI. ()N FEES
erertified copy with the
city Wim copy is herebytumty inspection divielan. GREASE/INDUSTRI,WASTE INTERCEPTOR PLANCFIECK FEE If
` C
GREASE TRAP N
CER' COMPS SATIOEXEMPIN FROM WORKERS' PAID
COMPENSATION INSURANCE SEryyER-SANITARY-STORM EA.700FT. Date Recei t#
RM1issedion need na be completed If the permit V(Drone hundred dollirs
($10 unify that
WATER I[EATFR W/VENT/EI.ECTR ENERGYFE -Y N
lanot that employ
an perfomunany mannerhe work AOr s to become
is a subjmit is Issued, — —
I shall not employ any person In any manner m u to become subject to the WATER SYSTEM/TREATING s
Workera'CompemaHOn laws of California. Date LAID_
O2 - Applicant NEW RESIDENTIAL PLMB. C Recei t#
Z O NOTICE TO APPLICANTaf,after making this Certificate of Exemption,you SQ.FE
should become subject to the Worker?Compensation provisions Of the Labor - TOTAL:
~ W Codgyou=at forthwith comply with such powisi6m orthis permit shallbe B 1 —
.(LLU j' deemed revoked.
CONSTRUCTION LENDING AGENCY S IG FEE
IherebyafRmr,that them 19 a construction lending agency for the perform, EL- TRIC FEE
O- Anne of the work for which this permit in Issued&c.3097,Civ.C.) TOTAL: -
(� _ Lender's Name - PLUMBING F
IL F Lender'a Address QTY. MECI4ANICAL�PERMIT, FEE;" MECHANICA FEE
O W 1cenlfythatl love re dthb application and statelhattheabove Information
Isconed.Iagreeto ly with all city and county ordinances and statelaws PERMIT ISSUANCE. FEES PAID;
} S relating tobulldln tmdlon,an herebyauthonurcpresentativeaatthls -
F_ 2 city to enter.up^ above- property for Wpection purposes. ALTER OR ADDTO MECH. -
- (We)agree se an d kap harmless the City of Cupertino Date Recei t#
agairutllabillt ,jJ at$and expenses which may lne ywaya rue AIR HANDLING UNIT(TO 10,"CFM) SUBTOTAL:
against uld I na of granting of this permit. '
AIR FIA NDLING UNIT(OVER 10,000 CFM) CONSTRUCTI NTAX
n lAppli m ontrador Dat F EYHAUSTHOOD(W/DICT) CONSTRUCTIO TAX PAID:
HAZARDOUS MATERIALSDIS LOSU E '-
ill the applicant or future building ocrupant store orhandle hazardous HEATING UNIT(TO IDg000 B'fU)
materialDate CCC( [#
as defined by the Cupertino Municipal Code,Chapter 9.17,and the -
Health and Safety Code Sedke,25537(a)? HEATING UNIT(OVER 10000 BTU)
❑ Yes , MN^ q1
Will the applicant orfumm building occupant use equipment Or devices VENTILATION FAN(SINGLE RE ID) ISSUA A MATE
which emit hazanlous air contaminants as defined by the Bay Area Air
Quality Management District? BORER-COMP OHP OR 100,DX BTW
4 Yes r;
�Na ju 2 0 19
have read the hazy ous materials rcqulrcmentsunder Chapter6.95of BOILER-COMP(OVQt l00,00(BN)
the Califernla Iimlth&Safety Code,Sections 75505,25533 and 75539.I
understand that lithe building does not currently have a tenant,that It[Amy NEWRESIDENTIALMECH. SQ.FT CITY Ur Wrer""" '
rcporaibility to n^ti(y the occupant^(the rcqulrements which must be met
prior to Issuance of a Certificate of Occupancy.
Owner or authorized agent Date
-' TOTAL: ISSUE BY:
OFFICE COPY,