24091 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Addrt
ztBuildin EIt�I
Project Identification PTN
s R.unto �• 24091
am: Phone: AppucAM
w G CITY OF CUPERTINO-BUILDING DIVISION
w er APPLICATION /PERMIT 2
Arc Itect/Fsglneen c °. BULLDINC-ELFCTMCALPLUMBING-MECHANICAL CATEGORY CO {sp
QIY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: PER&ITISSUANCE 'r El
CONTRACTOR'S DECLARATION
I hereby affirmthat l amllcensed under provlsionsofChapter9(conunme- APPLIANCESRESIDENIAL JOB DESCRIPTION
Inanne1Section 7000)°(it died.
ButlrmasandProfeselonsGodc,and my
license 1,In full andeffect, PANELS
Licaroacky
Datel�Contnctor L
ARCHITECrs DECLA ATI 201-1000 AMPS
M
q�q�vv 0 O I understand my bro s dl be used es pu records OVER 1000 AMPS /SQ,Fr.FLOOR AREA S/SQ.FI'.
E�L Licensed PiWeEinal SIGNS ELECTRICAL L _CarMass xl .,
�<<6
OWNERjf6LDER DECLARATION SPECIALCIRCUIT/ Vim r
z p., Iherebyafl.that lam exempt from the Contractor's ntrar's Lima.law for the
ppp following reason.(5ectlon 7031.5,Business and Professions Code:Any city or
F )'ni county which requimsa permittomestmct,alter,Improve,demolish,orrepalr TEMP.METER OR POLE INST. .
q`' ,77 vystm=mpdortolts Wuame,aborequlreelheappBantforwchperrrdtto
t5 1+ file a.signed statement that he k licensed pursuant to the provisions of the TOWER DEVICES
Q6 3 0, Contractor's License Law(Chapter 9(mmmencing with Section 7000)of Dlvl-
O SWV•(MING POOL ELECTRIC
the basis fo the alleged Professions Any violation f Seem 7MI.5 by any VALUATION
Q 5 the baste for the alleged exemption. Any violation of Section not L5 re any UTLETSSWITCHESEXTTRiFS
GW4ji fiveapphunt fees permit dred delta.($500). the applicant too dull penalty of not more than Lse V(�f•/
five 1,as owner of thep0). NEW RESIDENTIAL ELECTR SQ.Fr, STORIES , TYIaECONSTRUCTION
�n ❑I,as owner of the property,or my employees with wages as Iheir sok
mpensatlon,wOldothe work,and thestructure Is not Intended or offered for
0 sale(Sec.7044,Buslneuand Professions Code:The Contradoes License law
p�R does not apply to an owner of property who builds or imprerves thermn,and OCC.GROUIs RES.UNITS
whodoes such work himself orthmugh his own employees,provided that such
improvements am not intended oroffered forsale.If,however,the building or T ��
improvement ksold withinoneyearofcomplatlon,theowner-bullderwill have
tYAlZrden of proving that he did not build or Improve for purpose ofsakJ. QTy, PLUMBINGPERMIT" - FEE FTOOD LONE APN
LJ{as ownerof the property,am exclusively contracting with Ilanse PERMRISSUANCE
contractors m construct the project(Sec 7014 Bualnesss and Profe aims Code
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
builds or Improves thereon,and who contracts for such ppojects with a
.qRt�+ctoef"ficensed pursuant to the Contractor's License I. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec. B &P C for this reawn
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N_
Owner Date RECEIPT M
_ WORK MAN COMPENSATION DECLARATION FIXTURES PER TRAP �.e SCHOOL TA% Y_ N
❑e1 hereby affirm that I have a Imumne of consent to opythwre,ora RECEIPT N
rertiflab o(Worken'CompewHern Wuanceoracerti(kd copythereof(Sec. GAS-EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
3000,Lab CJ
Policy# RDCCAS.EA.SYSTEMOVER 4(EA) T N
Com any BUILDININ94 V,ION FEES
Certified copy k heed withfurnished.
ecity GREASE/WDUSTRL WASTE INTERCEPTOR PLANCf}
Certified mpybflled with the city Inspection division.
CERTIFICATE OF E XETIPHON FROM WORKERS' GREASE TRAP ITA
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200FT. Date ReceI t#
Eml
( ection need not be completed if permitthe permit k fornc ohundred dollars
($100 Y
Im)blrtlfessythat in the pedormanceofthework(orwhlch this permit is Issued, HEATER W/VENT/E,ECTR ENERGY FEE Nued, —
I shall not employ any person In any runner n as to become subject to the WATER SYSTITt/TREATING
Worlu a'Compensation Laws of California.Date PAID
licant
Z O NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you NEW RESIDENTIAL PLMB._SQFT. Date Recei t#
should bemme subject to the Workers'Compensation provisions of the Labor TOT
N Code,you mostforl hwith comply with such provisions or this permits hail M IN
> deemed revoked. Bull
W
CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there is a mnstrudlon lending agency for the perform ELECT
D Z ance of the workfor which this permit Is Issued(Sm.3097,Civ.C.) 74
V O Lcnder•s Name - PLU I i_ —•
IL F Lcndes's Address QTY. MECHANICAL PERMIT- FEE . MEC I E
OW 1cmifythat l haveread thlsappllation and statethallbnabove information
1 isca ect.l agree to comply with all cityand munlyordlnances and elate laws PERMIT ISSUANCE FEES PAID:
} relating to building construction,and hereby authorize representatives ofthk
F Z city to enter upon the above-mentioned property for Inspection purposes. ALTERORADDTOMECH. I
ReC I t
Z (We)agree to save,Indemnity an d keep harmless the City of Cupertino P
against liabilities,judgments,mate and expenses which may In anywayaceme, AIR HANDLING UNIT(TO 10,000 CFM) S
aga but said City In coneequcna the grant Ing of rmlt.
AIR HANDLING UNIT(OVER 10,000CFM)Signature o(Appliant/Contractor Date IXHAUST HOOD(W/DUC'D ON
HAZARDOUS ERIALS DISCLOSUREWllltheappli nt orfuture building occupant store or handle hazardous HFATING UNIT(TO IM,ODO BTU) RCCC. t#
material as defin d by the Cupertino Municipal Code,Chapter 9.12,and the -
FkalthandSafetyCodera.�Section25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOT L.
❑
Via u No
Wlil the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUA CE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management District? BOILER-COMP PHP OR l O,000 BTU)
'F]Yes ]No
`7 have read the bacanderas materials requirements under Chapter 6.95 of BOLFR-COMP(OVEt I00,000BN)
the California Health&Safety Code,Sections 25505,25533 and 25534.1 pp p
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. P SQ.Fr K
responsibility to notify the occupant of the requirements which most be mel
prior to Issuance of a Certificate of Occupancy.
2 OMEN
Owner or authorized agent Date
TOTAL: ISSUED By; i(
OFFICE COPY MF