24365 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project Identl(it o PERMIT NO
Building Address: ./'1` G �L n—
24365
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one:
(�WQRTH CITY OF CUPERTINO-BUILDING DIVISION d / (�!_92�
en trot r jam}e/:r Lte.No: APPLICATION / PERMIT
4� �0�� `� BUTLDINGELECnUCALPL(MBINC-MECHAMCAL CATEGORY CONTROL#
Archilm/Eng/neer. � Llc.No:
�g QTY ELECTRIC PERMIT FEE BUILDING PERMITINrO
Addres
I'FRhETISSUANCE ❑ ❑ ❑
LICENSED CONTR under rDECLARATION
[Fth by Section nothat 7000)of
amlicensedoftheusluesandPovisions fChapte Code,andmc APLIANC6SRESIDGM['fAL JOB RITION
IngwlthSMlon70007of d effect ofthe ButlneuandProtesslonsCode,and my
license IS In fill( and effect PANELS
License CWv LICK tAT
Date L�IJ ontractor (/��ARCHITECPS DECLARATION 201-1000 AMPSQZ Iunderatand my pbwsWObe used espubllc rem OVER] ftffb �SLSQYq'.
�?0Licensed Professional SIGNSEL I1N'N�OWNER-BUILDER DECLARATION SPECIAL T/ ISCI' K'IherebyafNren that l am exemptfrom the Contractor'.License Law forthe 'iJg, ••'O Z.. following reason.(Setion 70115,Business and Professions Code:My dty or7p METER POLE
p� ceuntywhich requires a permit teconamod,alter,Improve,demolish,or repairaoystrocture prlorto ire Issuance,alnorequiresthe applicant for such permit to ' DEVICES
�i file a signed statement that he is licensed pursuant to the provislota of the
3kI� Contractors License Law(Chapter 9(commencing with Section 7000)of Divi- gWIIAMING POOL FLE
OJ a sion 3 ofthe Buslnessand Prefessio®Code)orthae he is exempt therefromand VALUATON.•77 the basis for the alleged exemption. Any violation of Section 7031.5 by any
sppBeant fora permit subjects the applicant to a civil penalty of not more than OUTLETS-SWITCHESI-MURFS
6 g oa
five hundred dollars(5500). NEW RESIDENTIAL ELECTR SQFT, SIO FS TYI'ECON5II2UCTION
�n r-11,as owner of the property,or my employee with wages as their sole
compensation,wllldothe work,andthestrocrom V not Intended or offered for
Osato(See.7074,Business and Professlme,Code:The Contractors License Law
$ does not apply to an owner of property who W06 or Improves thereon,and OCC.GROUP RIS.UNITS
who doessuch work himself orthrough his own employees,provided that such
improvements arc nm Intended oroffered for ole.If,however,thebullding or TOTAL:
Improvement lssoldwithinoneyearofcompledon,theewner-Wilderwill have .
tf1„4urden of proving that he did not build or improve for purpose of sale.). QTY, PLUMBING PERMIT tFEE FfpODZDNE APN
Lj 4 as owner of the property,am exclusively contracting with licensed
contractors to construct the project(Sm 7014,Business and Profeaslom Code: PERMIT ISSUANCE
The Contractor's License law does not apply to an owner of property who
Wilds or Improves thereon,and who contract. for such lupjcots with a ALTER-DRAIN -WATER[EA)
ro
ryn([oeer(s)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
Lf I am exempt under&e B &P C for this reason
OUTSIDE FrITS
Owner DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N_
Date RECESl N
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRA SCI1OOLTAX Y_ N
❑I hereby affirm that I have•,certificateInsurance
c of consent to copy thereof
ora RECEIPT Y
certiflceleofWorkeri Crmpewtionliauranaora certifled ropythereoff$ec. GAS FA SYSrEMi INCA OUTLETS PARK FEE Y N
3N00,Lab C.)
Pollry N RECEGAS EA.SYSTEM-OVER 4(EA) DING DI M
Com any BUILDING DIVISION FEES
[�Certlfied copy is herebydwith the
cityed. CREASE/WDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
❑Certified copy to filed with the tlty lespectlon division. �—
CERTIFICATE OF EXM ITION FROM WORK ERS' CREASE TRAP PAID
URA
COMPENSATION INSURANCE
RMsnection need not be completed If the permitSURA h for one hundred dollars SEWER-SANITARY-STORM EA MFT Date Recel t#
($IM)mless.)certify WATER HEATER W/VIM./Fl.ECTR ENERGY FEE Y N
I rtify that In the performance of the work for which this permit is iswed, —
I shall not employ any person In ray many.,so as
tP nya,ro.� the
Workers ComperµfldN La of Ilfor la. LLL WATER SYSTEM/TREATING PAID -
ZZ ApplicaNOTICE // �� a NEW RESIDENTIAL PLMB. SQFr. Date RCCCI t#
O NOTICE 70 APPLICANT.It,after ma gthb Certltlate of Exemption,you
should Wcomesubpdt0the Works ' ompersatlou provislmaofthe Labor TOTAL'
W CoCgyou must forthwith comply with such provisions orthls permit shall be
ccj deemed revoked. BUILDING ds"'
W
G CONSTRUCEION LENDING AGENCY SEISMIC FEE
I herebyafithat there Is a construction lending agency for the perform-
M Z once of the work(orwhich this permit bLwN(Sec.3097,Civ.C.)
TOTAL: ELECTRIC FEE
V O lenders Names PLUMBING FEE
LL F- Lender'.Address - QTY. MECHANICAL PERMIT 'FEE MECHANICAL FEB
O W I entity that l have read thisapplic tlonand stalelhatthe above Information
Iscorrect.l agree to mmplywith all qty and county ordinances and gate laws JPFRMITISSUANCE FEES PAID:
} IL relating to building corulmctlon,and hereby authorize representatives of this
F W city to enter upon the above-mentioned property for Inspection purposes, ALTERORADDTOMMi.
? (We)agree to save,indemnify an d keep harmless the City of Cupertino Date Receipt#
O against llabN4a,judgments,cortsand expenses which may In anywayacente AIR HANDLING UNIT 10,000 CFM) SUBTOTAL:
against said City in consequence of the granting of this permit.
AIR HA NDLING UNIT(OVER 10,010 CFM) CONSTRUCTION TAX
Signature of Applicant/Contractor Date EAHAI75'r HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfumre building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU)
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the _ Date Reeei t#
Ilealih and SrfelyC Se on 25532(a)7 HEATING UMT(OVER 100,000 HIM TOT
❑Yes No
Wiilthe applicant or tore Wllding occupant use equipment ordevlces VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air Q
Quality Management trier? � BOILER-COMP(311POR 100,000 BTU)
�� Ycs o
.. 4have read the hazy usmaterlaisrequtrements un derChapter6.95of BOILER-COMP(OVER 100,000 BTU) OCT
the California Health&Safety Code,Sections 75505,25533 and 25534. I Vyl � [! 199,E
u ndersle ad that if the building does not currently have a tenant,that Itis my NEW RESIDENTIAL MEiaL SQ,FI'. C 6 f
responsibility to notify the ocmpart of the requirements which most be not CITY Ur
PH. to uanced;Ccrtlfl;2 f parry, /�� �allfC(pt
�6� S)
Ownerorauthorized t - Date
TOTAL: ISSUED BY
OFFICE COPY