24627 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
CITY OF CUPERTINO
BUILDING- " RICAL PERMIT NO.
BUILDING DIVISION APPLICATION[PERMIT PLUMBING-MECHANICAL 24627
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
tris
M LOT# 1 �
OAME' PHONE: sixCTOR'S NAVE*
LIC NO:
N/C CONTROL#
N'111TECT/ENGINEER: LIC NO: A
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
a C"IN Al El
BLDG CLEC PLU EC
1 PERMIT ISSUANCE Lh
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIA JOB DBSCRIPTION
paZ I herchyaffirrathits.liecroadunderprnvisimeifChaptermm
9(Coencing with
POO Section 0000)of Division 3 of the Business and Professions Cadq and my license is in PANELS
�Fyall force end effect. 1^ n _` ��t✓�\ �I _
a License Class Lic.q �] IY#-"GN1`r- UP T0200 AMP
by Date Contractor 2 -I P
ARCHITECTS DECLARATION V R I PS SQ.FT.FLOOR AREA MO.FT.
02Z^O 1 understand y plans shall be used i s public records.
OSI S LECTRICAL
Licensed Professional
L� OWNER-BUILD RDECLARATION SP CIAL CIRCUITaffirm'�OaU 1 hereby affirm that 1 am exempt from fiContractor's e Connaors License Law for the
00'3 W y following reason.(Section 703 1.5,Business and Professions Code:Any city or county TEMP.MR INST.
f� which requires a permit to construct,alter,improve,demolish,or repair any sweture
2 prier issuance,also requires the applicant for such permit to file a signed statement POWER C S
I W G O that he is licensed pursuant to the provisions of the Contractors License Law(Chapter
�j�0 9(commencing with Section 9000)of Division 3 of the Business and Professions Code) SWINISH OOL ELE IC VALUATIOM�
Way onhat he is exempt mercfrom and 0e basis fonhc alleged exemption.Any vi homnof OUTLETS'SW1T S-FIXTURLS n
I—>¢ Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of `
W p not momthan roftheive roddollars rty,ormye ply. NEW RESID IAL ELECTR _SQ.FT. STORIES TYPE"CONSTRUCTION
e'�m ❑ oche wrk,anhepmtructue is not ployeeswithwegesasalei(Sec.compensation,
will dorhewons ande: staContistornt License
awesffered of apply
to an Business
and Professions Code:The Contractors License Lew does not apply to an owner of
property whobuildaorimpnoves a,it mthereoRvermanand d a a.,such
mandad mselforthtact,I, OCC.GROUP RES.UNITS
.wriemployees,ldin i orrthatsver imp is sold within
ne earofdorofferod theow e,
howeer ,will avec a human ofprovinnmetg thathe did
not build or ,improve
thrower- T
builder will have the burden of proving that he did not build or improve for purpose of
mleJ.
❑ 1,ae ownaof the propeny,am exclrsively oentrading widt licensed cen[raaorst QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
onstmet the project(Sec.0094,Business and Hofessloas Coda)The Contractors
License lawdees not aWlyto an ownerofproperty who builds or improves theater,andPERMITISSUANCE
who contracts for such projects with a conareamns)licensed pursuant to the Committees
License Law. ALTER-DRAIN&VENT-WATER(F.A) Wi FEE SUMMARY
❑ 1 am exempt under Sec. B&P C for this reason OUTSIDE FEES
BACK FLOW PROTECT.DEVICE
SANITARY Y N
Owner Data RECEIPTH
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,ROOF,AREA,COND. SCHOOLTAX YN
❑ Thereby affirm thatlhaveucenificme of cnnsenuo self-in,ure,aracenificateofFIXTURES-PER TRAP 000""' RK
It
Workers Compensation Insurance or a certified copy thereof ISea.3800,Luh CJwhich RKFEE Y N
covers all employee's under this permit. RECEIPT#
P GAS-TiA.SYSTEM-11 C.4 ETS
Policy# / BUILDING DIVISION FEES
Y GAS-EA. ) PLANCHECK FEE
enified copy is hereby famished.
❑ Certificate.,is fled with the city inspection division. GREASE/I T O G DING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRY NILS FEE
COMPENSATION INSURANCE
(This section need not he completed ifthe permit is for one hundred dollars(SIM) SEWER-SANITD- ERGYFEE
or less.)
I acidify that in the peranee of the work for which this pert is issued,I shall WATE EATER W/VENT/
fmmmiELECTR
not employ any person in any marmer so as to become subject to the Workers' PAID
Compensation Laws of Califomia. Date WATER SYSTEMITREATING Data Receipt
O z Applicant
z NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should N EW RESIDENTIAL PLMB. SQ.IT. TOTAL:
become subject to the Workers Compensation provisions of the Labor Cade,you must
forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE -
Q
Lkl CONSTRUCTION LENDING AGENCY SEISMICF
z I hereby affirm that there is a construction lending agency for the performance of TA ELECT E
V O the work for which this permit is issued(Sec.3097,Civ.CJ
p.t Landers Name
0 L^ Lenders Address QTY. MECHANICAL PERMIT FEE PLU NGTEE
LU2-I I certify that 1 have read this application and state that the above information is CH ICAL FE
0. met.I agree to comply with all city and county oninances and state laws relating to PERMIT ISSUANCE
U
building construction,and hereby authorize representatives ofthis city to enter upon the CONSTRUCf10 TAX
LLLLU���i z above-mentioned property for inspersion keep has. ALTER OR ADD TO MECH.
(We)ugreeto,costindemnityand kap hay i.a the City ofbaga tsagelnst
liubilities,judgments,costs and npenses which may in any way aaruenga nstsai City AIR HANDLING UNIT(TO IO,f1IXl CPM)
equcnce of the gramin f /Z1/ n /Z AIR HANDLING UNIT(OVER 10,(100 CFM)
Signature of ApplicanUContr t Data EXHAUST HOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Do Receipt#
Will the applicant or future building occupant sham or handle havWous material
as defineHEATING UNIT(OVER 100,000 BTU)d by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety TO AL"'
Code,Section 25532(¢)1 VENTILATION PAN(SINGLE RESID) L Is
❑Yes ❑No
UANCE DATE
Will the applictinerfmuro building occupant useequipmentordevices which emit, BOILER-COMP(3HP OR 100,000 BTU) P A
haeaNeus air contaminants as defined by the Bay Area Air Quality Management BOILER-COME(OVER 100,000 BTU)
District
❑ 7
Yes ❑No NEW RESIDENTIAL MECH. SQ.ET. DEC •
I have read the hazardous materials requirements under Chapter 6.95 of the `
California Health At Safety Code,Sections 25505,25533 and 25534, I understand that
if the building does not currently have a tenant,that it is my responsibility to notify the CII Y Ur is U Y LI II uxwwn
occupam of the requiremems which masa he met prior m issuance of a Certificate of
Occupancy.
Owric'motaloncedagent Data A ISSUED BY:1
OFFICE