24094 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification 7 ' 'T"24094
Building Address: AA�� �J � .,
O 600 Z`~ �IQ`W �, '
oars sine: one. APPUCATRp
CITY OF CUPERTINO-BUILDING DIVISION 8-1-27—TZ,
c, ann:a 'Y�OL3�l APPLICATION /PERMIT
J V BUILDINGELECTRICAL-P UMBINGMECHAMCAL CATEGORY CONTROL
�O.Lt COus�.
� k�t �� ee� S (7 o/y��°L
+° 3Tn R'L' BUILDING PERMIT INFO
// TT QTY ELECTRIC PERM PEE
BiLUU
AddmZY /Ll *' 1'"� (26-LF sax• ,ISSUAN �� -
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter 9Eco
mmen
ingwith Section7000)of Dvlho3of hesinQand^'-rol
lesslonaCod, m A
JOB
DESCRIPIlON
"
license is In full foce and ofe
At
nV � Venr/ / 12 Tn
D201-1ARCHITECI'SDECLARATION
°1Z l understand my plans shall be used as public records. OVER I'S SQ.FT.FLOOR ARF $/SQ'F.
uW�O
r4 U o Licensed Professional SIGN LECTRI �
<� OWNER-BUILDER DECLARATION SPEC R2CUIT/MLSC
F �a 5 I hereby affirm that l am exempt from the Contractor's License law for the
7 following reason.(Section 70'315,Business and Professions Code:Any city or TIMER.METER OR TOLE INST.
Q, cmotywhich requiresa permit toconstruct,alter,improve,demolbh,orrcpa
E ,1 anystmmmprlortolts Wuance,aborequimtheappbontforsuch tto POWER DEVICES
Yi 0 file s signed statement that he Is licensed pursuant I, the pro of the
Contractor's License Law(Cha(Chapter with In F< R w SWIMMING POOL ELECTRIC 0
30 slon3of the Businem and Professl°m Code)orthat he Vexemptthere/romand VALUATION G
the basis for the alleged exemption. Any violation of Section 70315 by any ETSSMICHFSFIXTURES ^J
0�
applicant fora permit a,dt"theappllcanttoacivll penalty dna morethan 1 O
five hundred dollam($500). NEW RM- DFMIAL ELECTR SQ.FC. STOW65 IYPECONSI'RUCTION
.- ❑I,as owner of the property,or my employees with wages as their sole
compensation,will do the work and the structure is not intended or offered for
G
sale(Sec.7044,Business acad Profeviom Code:The Contractors License Law
�j5$ does not apply to an owner of property who builds or improves themes,and OCC.GROUIs RES.UNITS
who docs such work himself or through his own employees,provided that such
improvemams arc not intended or°/fared for sale.If,howoveq thebullding or
improvement issold within one year efcomplalok flM owner-buRderwill have
try..¢+rdco of proving that he dm not wild or improve for purpose ofsak.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
LJ L as owner of the property,am exclusively contracting with licensed PERMITISSUANCE
contractors to construct the project(Sec.70K Business and Professions Code:
The Contactors License Law does act apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilds or improvm thereon, and who contractsfor such pt,oject,with a
ryWfactor(s)licensed pursuant to the Contractor's Limn Law. FEE SUMMARY
�I 1 am exempt under See. B k P C for this reason BACK FLOW PROTECT.DEVICE
OUTSIDE FEES
DRAINS F OOR ROOF,AREA,COND. SANITARY Y N_
Owner Data RECEIPT N
WOR"AN COMPENSATION DECLARATION pp(TURps PER TRAP SCHOOL TAX Y_ N_
❑1 hereby affirm that I have a certificate of consent to self-insure,ora RECEIPT N
rerti(Icateof Worken'Compere Bolin mnmoramdifksimpythereof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
MW, ab C.) RFiCE NN
Policy N GAS LA.SYSTEM-OVER 4IRA)
Com any BUILDING DIVISIOY FEES
Certified copy Ls hereby fumbhed, GREASE/INDUSTRL WASTE INTERCEPTOR PLANC}-IECKF /
❑Certified copy b filed with the city Impaction division. ` O 21
CERTIFICATE OF EXEMPTION FROM WORK OR S' GREASETRAP P ^ ['sl
COMPENSATION INSURANCE SEWER-SAMTARY-SNRM FA XIOF-T ate RRC i tt# 7
(rhlasectl°n need not be complaed If the permit V forom hundred dollars
ESIM)mless.) ENERGY FEE Y
I mAifythat in the performance of the work for which this permit is issued, WATER HFATEH W/VENT/E'EC7Rsaa
"7I shall not employ any p,mon in any manner so as to become subject to the WATER SYS171,1/.IRFA.IItx 1 4 O
Workem'Compensation laws of California Date PAID
0Z Applicant NEW RESIDENTIAL PLMB. SQFf.
e Date Remi t#
Z O NOTICE.TO APPLICANT:If,after making this Certificate ofF Exemption,you
Fshould becomsubject the Workers'Compensation provislons of the Labor TOTAL_:
CC
Code,you must forthwith comply with such provisions or this permit shall be BUILDING FEE _
W _ deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE0.
M 0 Ihereby aorkfo construction 0 Issued
lending 097,Clforthe perform TOTAL: ELECTRICFEE _
0 Z Larder's
work for which this perMtb LasuN(Sec.3097,Civ.C.) PLUMBING FEE
LL O Lender'.Name
F Lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEEIcertil
0 U omect. tagreet comply
with allcatlondc county
ordinances
above information
0 W romtl.]ag agree to complywllh alicity and countyo dinanm and gate laws ` IrFRMTTI55UANCE [ FEES PAID:
} (L
N relating to building constmetion,and hereby authorlae,representatives ofthls
I" city to enter upon the above�nnaaloned property for Inspection purposes. ` ALTERORADDTOMECH. 4
_ Z Date Receipt#
(red)agrcemsave,indemnify anexkeep
es w1dssthen.ryCity Cupertino AIR HANDLING UNITED 10,000 CFM) SUBTOTAL:
V red liabilities,ydgments,c°staand expenses which may In any wayacaue
q nst said City In con uG ofthe granting of this permit.
� z- AR HANDLING UNIT(OVER I0000CIM) CONSTRUCTION TAX
Sig tum of A+plicant/Contras Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
`` HAlARDOUS ATE RIA LS DISCLOSURE
Will the appllont or Polurc building rampant store or handle haanlous HEATING UNIT(TO 100,0006'fU) Date RC 1
material as def red by the Cupertino Municipal Code,Chapter 9.12,and the
I lealth and Safety CoA Ion 255320)7 HEATING UNIT(OVER 100,000 BTU T
❑ Yes J�QN°
Will the applicant I Sure building occupant use equipment or devices VENTILATION PAN(SINGLE REBID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Arca Air
Qu a lity Management l'at 7 BOILER-COMP PEE'OR 100,000 BTUs PAID Yes No M
4have read the has o smaterialsrequlrer nnunder Chapter6.95of BOILER-COMP(OVER 100,000 BN) 1
the G liferala Health&Safety Code,Sections 25505,25533 and 255M.I SEP 11 1992
understand that if the building does not currently have a tenant,that it I,my NEW RESIDENTIAL MECH. SQE_r.
r mibility to rally the occupant of the requirements which must be met
no t°issuance of a Certi cat Ocmpanry.
SScCIIYU rcnbuuV
Ower or auth I agent Date �a ISSUED BY:�..- Tjf�es-LNN—�f
OFFICE COPY