24262 APPLICANT -O FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PFN ONLY
- Bulldin Pm eH identification p p PERMIT N2 4 2 6 2
Building Addmss: rI^laF��
one: p
CITY OF CUPERTIN6BUILDING DIVISION r1j _aZ/j��rr�
Con tr rtort Lk.No: APPLICATION /PERMIT
BMLDING-aE RICALML BING-MECFIAMCAL CATEGORYI�
Architect/Engineer. Lk.No:
\ QTY ELECTRIC PERMIT PL•B BUILDING PERMIT INFO
/ Address: PERMITISSf1ANCE t0'J lam
LICENSED CONTRACTOR'S DECLARATION Lb•� �/�
Iheh Seciaimntlut lamncrnud under eBusi provisions 9(roandm MI'LIANC[SRESIDE )OB DFSCRIPDON
ingwlthSettlan 7000)ofDivielon3efthegusinessand ProfesslonsCr,de,andm
license lsln full(oma and effM.
PANES
aClass oFFA
Data Lic.#
Dta —Contractor ' a
ARCHITECTS DECLARATION 201-1000
07 I understand my plans shall be used as publicrecords, OV i PS SQ.FT.FLOOR AREA $/SQ.FT.
w ODCTRICAL I
Licensed professional
Q OWNER-BUILDER DECLARATION
b`,• Fit ]ALCIRC / TSC
owing reason.
that lam01.5,B fromthe ContractorsLlcenaeV fort
following reason.(Section 71315,Business and Pro(essbne Code:Any or qp POLE ST.
countywhichmqubesa permit toconstmct,iltr,knprove,eemolbh.orrepalr ET
�� any struRurc prlortoib Sscsance,alcorequirestheappBcaN(w such permltm IXq
file a signed statement that he is licensed pursuant to the provisions of the
Contractor's License Law(Cha cr9(commencin ithSection 7000)ofDivi-
'"30rn slon31 ofthe Business and ProfessionsCode)orthaghe is exam therefromand SWId NG LEL[CI1IC VALUATION
y.' the basis for the alleged exemption. Any violation of Section 7¢31.5 by any OUTLE TCHESHXTURES
al'
applicant for.PermBaubjeetstheappllcanttoa civil penalty ofnct morethan
tr five hundred dollars(¢500). NE ESIDENTIALELECTR SQ.FT.
1,as owner of theproperty,or m em lom with wages as their sole STORIES TYPE CONSIRUC'I'ION
C7Q
F-1 nsatlon,will dothwrand th my
b not intended or offered for
S O sale(Sec.7034,Business and Pmfossmas Code:The Contraetols License law
HE docs not apply to an owner of property who WM
builds or improves thereon,and OCC.GROUP RES.UMTS
E. whodoessuch werkMmsel orthrough his own employees,provided that such
Improvements arc not intended oroffered for sale.IL however,thebuildleg or TOTAL:
Improvement b wld within oneyearofcomplatoo,the owner-bundcrwlll ha
th, urden of proving that he did not Wild or Improve for purpose of sal.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
Lf L as owner of the property,am exclusively contracting with licensed PFRMRISSUANCE
contndoetto mrutruct the project(Sec 704,Business and ProfessionsCode:
The Contrsctorb License Law does rat apply to an owner of property,who ALTER-DRAIN k VENT-WATER(EAI
Wilds or Improves thereon,and who contracts for such poajects with a FEE SUMMARY
c r1actor(s)licensed pursuant to the Contractor'sLicense Law.
I am exempt under Sec. B k P C for this re BAIX FLOW PROTECT.DEVICE
LJ
DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y_ N�
Owner Data RECEIPT T
WORKMAN COMPENSATION—DECLARATION FlX'fURFS PER TRM �,� SCI{OOL TAX Y_ N_
❑I hereby affirm that I have a certificate of consent to self-Tore,ora RECEIPT'X
ertiflente of Workers Compensation Insurance or a certified copy thereof(SeeGAS EA.SYSIFM-1 INCA OUTLETS PARK FEE Y N
100,lab C.) ftECEEPT a
Conry p GAS EA.SYSTEM-OVER d(FA)
Cit y LDING DI RECEPT VI ON FEES
rtlfled copy 3s hereby furnished. GREASE/INDUSTRL WASTE INTERCEPTOR PLAN 1�
Certifiet ed copy is filed with tcity inspection division. { I
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PA71
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200FT. Data RiiGG
(This section need not W completed lithe permit la for one hundred dollars
($100)ortess.) WATFRHEATERW/VENC/ELECTR ENERGYFEE Y-1 `t'1 I�
I comfy that In the performance of the work forwhlch this permit Is Issued,
1 than act employ any person In any manner w as to become subject to the WATFlt SYS'IEhf/TREAHNG
Workeri Compensation Iowa of California.Dat PAID
OZ Applicant NEW RFS DENT AL PLMB. SQ FT.
O Date Remi t#
TI
Z NOTICE TO APPLICANT:If,after making this Certificate of Exemption,
should become sub}ct to the Workem'Compematlun provisions of the Labor T •AL: _
F4, Code,you must forthwith comply with such provisions or this permit shall be -BUILDING ••E
ccj deemed revoked.
W CONSTRUCTEN
ION LENDING AGENCY SEISMIC FEE
CL —� IhercbyafOrm thattherebaconswttlon kndingagency forthe perform T ELECTRIC pE• —e
M Z an ce efthe work for which this permit is heated(See.3097,Civ.G —�
U O lender.Name PLUMBING
f Iamcrt nddress QTY. MECHANICAL PERMIT FEE MEC R # AL •E
OW Icenlfythat l beveread this application and statfhatthe aWve Information
a Is correct.I agree to comply with all city and county ordinances and statelawa PERMIT ISSUANCE ` FE 1 •
>. relatingtobulldingconsuution,and hereby authorim representativesofthis I.- N city to enter upon the above,mentioned property for inspection purposes. ALTERORADDTOMECH.
_ Date Rcccipt#
Z
(We)agree to save,Indemnity and keep harmles which
the City y Cupertino AIR FIANDLING UNIT(f010,000CFM)
T..I agaWtllablBlns,pcotaaq erocofthoexpenseawhichmayin anyway accrue SUBTOTAL:
againstal Itylnconseque eoftW granting o(mid permit CONSTRU ION TAX
• ' AIR HANDLING UNIT(OVER 10,000CrM)
s w reef Applicant/Contract r t��� D(HAUS'THOOD(W/DUCT) CONSTR TION TAX PAID:
HAZARDOUS MATERIALS DISCIASURE _
WIIl thcappliontorfulum Wlldingo pantstomorhandleha rdms HEATING UNTT(TO 100,ODO BTU) Date eceI t
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
f lealth and Safety Code Settion 2S532(a)? HEATING UNIT(OVER 100,000 BTU)
❑Yes M No
Will theappllant or future building part use equipment or devices VENTI:ATIONFAN(SINGLE RESID) ISSUXNCE DATE
which emit lu rdomair contaminantsas defined by the Bay Area Air
Qtp
lity Management District? BOILER-COMP OHP OR 100,ON BTU)
Y. I—I No
avereadthehazardousmatcrlabrequim=nbunaerChapter6.95of BOILER-COMP(OVER100,000 BTU)liforria health 6 Safety Code,Sections 25505,25533 and 255]1.
stand that If the Wilding does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FTW[•�nsibility to really the occupant of the requirements which must be met DQ00
o Issuance of a Certlfkate of Occupancy. 9CI1� ( .,LCL JJ 1•. rtllr..�r or authorized agent Data ISSUEDBY:
TOTAL
OFFICE COPY