24050 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building
jL& Identification PELwTN24050
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4$FATr+A V. LAWN 2,5S-8166 CITY OF CUPERTINO-BUILDING DIVISION" ��� ^
Cor%6 LIc No: APPLICATION / PERMIT (—
v
Architect/Engineer. Lic.N. BUILDINGELECTRICALPLUMBINC-MECHANICAL CATEGORY CONTROL#
QTY ELECTRICPERMIT 'FEE BUILDING PERMIT INFO
Address; PEIMITISSUANCE ❑ ❑ sA ❑
I
LICENSED CONTRAROr DECLARATION
Mreby offarm hat la
tm licensed under provisions of CIaper9(comment, APPLIANCFSRESIDEN7TAL ]OB DESCRIVEION 11
IngweM1Sectioninfull force
dsian3oftheBusinessand Pro(esslonsCode,and my t. /���Y
license I,in full force and effect. PANES
LicatData Clam LIc 11 tr
Date - GOMnRor UP TO 200AEVq
ARCHITECTS DECLARATION 201-1000 AMT'S
MM;, I understand my plans shall be used as publiereordw OVER 1000AMPS SQ.FT,FLOOR AREA $/SQ.FT.
E U'Z Licensed Professional SIGNSELECTRICAL
]G OWNER-BUILDER DECLARATION SPECIAL CIRCIRT/MLSC
F'yd� I hereby affirm that l am exempt from the Contractor's License law for the
isofallowing..a.(Section 7071.5,Business and Professions Code:Any city or
Z grto TEMP.METER POLE INST.
p county which requlresa perMttomrotmuirtstheapmvnt forsuch Lsh,or repair
any atmcturetatement that he
silo rcqu pursuant
provisions
of to ppWEg DEVIC ��� I Il{
O�� to
itis a signed statement that he la Ilttnaed pursumt to the provlslons of the
µ� Contractor's License Law(Chapter 9(rommencingwith Section 7000)ofDivi.
t..,3 alon3olthe Businevand l'rofessbmuCode)orthat hebeumpttherefromand SWBdMING IDOL •ECTRIC !1 ��^.I - VALUATION
S°•5 IM basis for the alleged exemption. Any violation of Stolon 70US by any
65. OUTLETSSW17C1[ESEXTURFS
applicant for a permit subjects the applicant to a dull penalty of not more than Z
° f ndred dollars($500). [
NEW RESID• AL ELEGRs I E TORIES
(n I, s owner of the property,or my employees with wogss a their sale : T3TE CONSTRUCTION
cop n.atlon,willdolhework,andthestmcmre tsnotintendedor offered for
e(Sec.7644,Business and Prefeselmu Code:The Contractors License Law
S� does not apply to an owner of property who Wilds or impeoves Unman,and OCC.GROLM XIESUNTTS
whodoessuch work hlmselorthrough hlsoweemployces,provided that such
Improvements arc not Intended proffered forsale.If,however,thebullding or TOTAL:
Improvement b sold within oreyearofcompletion,the owner-bullderwill have
the burden of proving that he aid not build or improve for purpose ofule.). QTy, PLUMBINGPERMITFEE FLOOo7DNE ArN
1-11 as owner of the property,am exclusively contracting with licensed PERMITISSUANCE
contractors to construct the project(Sec.7044,Business and Professions Cade; / �•
The Contractor's License Law don not apply to an owner of property who ALTER-DRAIN&VENT-WATER TIM
Wilda or Improves thereon,and who contracts for jecta such ptuwith a
oqDI[=ctor(q licensed pursuant to the Contractors Lioneue Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
Lf I am exempt under Sec B& P C for this reason
DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y N ,
Owr^�_ �- Date at L RECEIPT
WORKM OMPFNSATION DECLARATION FIXTURES.PER TRAP
SCHOOL TAX Y N
❑I hereby afllhave a certifiale of consent to self-Innate ora
ceRECEIVE M
rtificate.lWorkers'Comperuation lruurancem.certified copythereof(Sec.
3800,Lab CJ GAS EA.BYSTEN-I INCA OUTLETS PARK FEE Y N
Policy# RECEIPT#
Cam an GAS EA.SYSTEMAVER 4(EA)
Y BUILDING DIVISION FEES
Cenlfied copy 6 M1ed with the city CREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
❑CertNed ropy V tiled with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' CREASE TRV' PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM FA.200FT. Date Recd t#
00) l.
(0 m ction need no[W complMed If the permit la(prone hundred dollare P
(81orlcssd WATER HEATER W/VENT./ELECTR ENERGY FEE Y N—
I
emphat in loy
persmanaoftmhe workso as to hich
pesubjcrmit is ito theed, —
I mk not employ any pemws in any manner n n to berome subject to the / WATERSYSTEM/TREATING
Woplicant mpensatlpn Gsva of Callfpmla.Date PAID
O Z Applicant
Z 0 NOTICE TO APPLICANT:$after ma king this Certificate of Exemption,you NEW RESIDGNT[AL P[.MB. SQFT, Date Recei t#
should Weeme subject to the Worloos Compensation provisions of the Labor TOTAL:
N Code,you must forthwith comply with such provisions orthls permit shall M BUILDING ked.
dcounted revo
C CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z Iherebyaf(irmlhatlhereTsaron.wctlon lendingaganry forlM perlorrry
0 E
F
ELECTRIC E
anceof the work for which this permit is Lsnoed(5ec.3097,Civ.C.) EELECTRIC EEE
V lander'.Name
IL F Iander.Addmea QTY, 'MECHANICAL PERMIT FEE MECHANICAL FEE
O W Icertlfythatl have recd[hlsapptlatlonend rtatethattheehowinformatlon
1 le correct.I agree to complywith all chyand county ordinances and state law. PERMIT ISSUANCE FEES PAID:
} relating to building cerutructlon,and hereby authorize representatives ofthis
N
i-
Z city to enter upon the above-mentioned property for inspection purposes. ALTERORADDTOMECIL Date Reeei t#
V _ (Na)agree to save,Indemnify an d keep harmless the City of Cupertino
ago Wt liabilities,jrdgmenb,coatanet..pens..which may In any way acme AIR HANDLING UNITED 10,000 CIM) SUBTOTAL:
against said Clty Ica m a of t gnntlng o(tM1iepe Icy
AL— AIRHANDLLNGUNIT(OVER 10,MOCFM) CONSTRUCTION TAX
nature of Appc /Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
AZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building ocaupanl store or handle hazardous HEATING UNIT(TO 100,000 BTT)) Date ReCel t#
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the
I ealth and Safety Code Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOT
❑yes u No
Will the applicant orfuture building oavpantuse equipment or devices VENTILATION RAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants a.defined by the Bay Area Air
Quality Maragement District? HOMER-COMP(31111 OR 100,000 HIM A y
4 Yea No a V
have read the hazar pian materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BN) ,
the California Health&Safety Code,Sections 25505,25533 and 75534.1 ///\ q� -
understandthatlitheWildingdonnotarrcntlyhaveatenanl,that it ismy, NEW RESIDENTIAL MECH. SQ.FT. UGFi .((Ias�
mpoe¢dbility to notify the occupant of the requirements which moat be met r 199
prim to issuance of a Certificate olOavpancy. •C/ Y Uf- k.UT
/+�Ct�IssU a
Owner or authorlud agent Date TOTAL: j ISSUEDRY:
�/K4rl°j
OFFICE COPY