24318 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification Pfi1LWTNQ, 4 318
Building Addma:7oZ
W� I � 1 �
wnere ane: APPLICA11UN5 bMILIALUALE
CITY OP CUPERTTNO-BUILDING DIVISION �O�Z �y e.,
ContrsnarName:
' LIc.No: APPLICATION / PERMIT —`-'�
BUILDING-ELECTRICALPLUMBINGMECHAMCAL CATEGORY CONTROLN
Architect/Engineer. Llr.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCR ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereacffimrmttatf iai.h 3ofthaderpmvLclonaof Chapter9(rommene- APPLIANCFSRESIDENTIAL JOB DESCRIPTION
Ingwith Section force aid effect. sitter Busineseand['roleselovCode,andm
license Is In full form and effect. PANELS �
License Cie. LICK 'PFK`VIa��C 1 ✓�..� f�l
Date Contractor
ARCHITECPS DECLARATION 301-1000 AMPS
, I understand my plmuehall beised as public rerorda. OVER1000AMPS SQ.IT.FLOOR AREA $/SQ.FT.
OC I
to Licensed Profeealowl SIGNSELECTRICA'L _ A'
¢ OWNER-BUILDER DECLARATION SPECIALCIRCUIT/
7p, Ihmebyaffirmthat l am exempt from the Contractor'sLicense Law for the -+
O p following reason.(Section 70315,Bu.iness and Prof.i.an Code:Anotlp
0zcy cuntywhichrequimsapermlttoconstwa,aiter,impmve,demolbh, rrealr 7E?dP.MEI'[R OR TOLE `-� - -� i�
K
'�q 7< any atrudure statement
that
to in licensed pursuant
to the
revisions of t e
V Cie a actors License
that he V r9(coed pursuant to the provisions o! the POWER DEVICES
Owl DATE
Contractors Llcem.e d(Chapter.Com).,tlng withssurapn7erefim and
�30G elon3ofthe Buslnwend Pro(esslovCode orthat hebnxempt therefromand SWBdh1ING TOOL TR[C VALUATION
Q �'S the basis for the alleged exemption. Any violation of Section 7001.5 by any
Wr a� uPpf--t fora pecan..bjectstheappla..Hoadvilperultyafnot=.than O�'E� � 'D `�� 2OO���
Gam' five hundred dollars(5500). NEW RESIDENTIAL ELECTR v
❑I,as owner of the property,or my employees with wages as their sole SQ'T' STORIES TYPE CONSTRICTION
compensation,will do the work and the structure isnot intended or offered for
O eale(Sec.704y Bualnessand ProfessionsCode:TMContractor.License Law
g does not apply to an owner of Property who Wilds or Improves thereon,and OCC.CROUP RFS.UNITS
whodoes.uchwark himself.,through hlsawnemployees,provided that such
Improvements are not Intended oroffered forsale.If,howeveq thebuilding or TOTAL:
Improvement Iswidwithln oneyearofcompletion,the owner-bulldereviil have -
tn�ardenof proving that he did not Wild or Improve for purpose classic.). QTY, PLUMBING PERMIT FEE
u FLOOD ZINE APN
L as mucor tr the property,(m exclusively Business
and Pro with Professions
PERMITISSUANCE
The Cotora to construct the project(Sec.appy Business end Iof property
Code:
The Coor impfs License law don not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
c lido or Improves thereon, and who contracts ice such plojects with a
cgp(pdar(skenexemptedpurewnt rotten Contractors License Law. BACK FLOW PROTECT.DEVICE FEE
OUSUMMARY
OUTSIDE FEES LII am exempt under Sec. B&P C for this reawn
Owner Date DRAINS.FLOOR ROOF,AREA,COND, SANITARY Y N—
N
WORKMAN COcemMPENSATION DECLARATION RECEIT T
AP SCI{OOL TAX Y N
❑I hereby a(fUm that 7 have a consent of conseto se14rcFDI PER TR
1neu
,or RECEPI'N
certificate of Workers Compevationlesurance or a certified copy thereoflSec. GAS G.SYSTEM-I INCA OUTLETS
3800,Lab C.) PARKFIX - Y_ N_
Conry N GAS G.SYSTEM-OVER 6(EA) ftECHI'3'p_
Co GAS. BUIL DING DI VI SIGN T:ES
�Certlfled copy is filed hereby
thecity
furnished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE ',O
Certlfed copy V filed with the tlty Inspealan division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GRGSETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORMPA.MIFT Date R 1 t#
(Thlalcia.) need oat Mcompleted I(the permit is(or ane hundred dollars
(81I mmlth aved WATER HEATER W/VFNT/ELECTR ENERGY FEE Y
Illnot thatoy an person
uInanynce eworkw as
become
eermitb4oth,
I shall not employ any person f any manner w u to become wbjeet ro the WA.I.LR SYSTEM/TREATING
Worken'Compenaatlon laws o(Oilfomla.Date PAID
C) Z Applicant Dat Recei t#
Z O NOTICE TO APPLICANT;If,after making this Certificate of Exemption,you NEW RESIDENTIAL PLMB. SQFT,
should become subI to the Workers'Compensatlon provialov of the Labor OTA).:
N Cole,you mu at forthwith oomplywlth such pmvbkinamthl.perom shall be
1 deemed voketl. B N
N
a
re
O CONSTRUCTION hethem is
aLFcTDING AGENCY SEISMI E
(hereby affirm for w therebaronstmction ssued(Sec. agency 7,Cla. .) perform ELEC IC E
� Z acre of the work for which this permit is issued(Secs 3097,CIv.C.) TOTAL:
02 ],oder.Name PL R GFEE
LL H Lander'.Add was QTY. MECHANICAL-PERMIT FEE HA ICA). 'E
O W (certify that l have read t his application aM state that the abovein(orevtion
Ismrmct.Iagrceto complywith alldtyand countyordinances wdstate laws PRRMITISSUANCE FEES PAID:
} U) relating tobuiliingaonstructlon,and hereby authomic representativesofthe,
2 city to enter upon the abov&nsntioned property for inspection purposes. ALTERORADDTOMECH. -
(We)agree m nave,Indemnify and keep harmless the City of Cupertino Date Receipt#
V agalvtliabilltin,judgments,roatsandexpenwa which mayfnanywayamue AIR HANDLING UNIT DO 10,000CFM) S BTOTAL•
agal Id Ityl con once of anfing of this permit.
I
AIR HANDLING UNIT(OVER 10,000 CTM) CONSTRUCTION AX
Sig stye of plant/C m etc at IXHAUSTI40 DD(W/DUCT) CONSTRUCTION X PAID:
HAZARDOUS MATERIALS DISCLOSU
fit
or future building occupant store or his dleh ,sous F{FATINC UMT(TO 100,000 BTIp
cwt cal as defined by the Cupertino Municipal Code,Chapter 9.1$and the Date R el t#
-
tire and SafetyCode Section 2>532(a), HEATING UNIT(OVER 100,00)8TIn T A60
❑ ce No
Will the applicant or future building rampant use equipment or devices VENTILATION FAN(SINGLE REBID) ISSUANCETE
which emlt harardoua air contandwnt.m defined by the Bay Area Air
Quality Management District? BOILER-COMP(3HP OR 100,IX0 BTU)
Yea ❑❑
4No
havereadthehazasaa.materiabrcqulrementsunderChapter6.95of BOILER-COMP(OVER100,000 BTU)
the California health&Safety Code,Sections 25505,25533 and 25534.1 p
understand that lithe building does not currently have a tenant,that it is my NEWRESIDENTIALMECH. SQ'Fr W V
responsibility to notify the occupant of the requirements which rust be met
prior to Issuance of a Certificate of Occupancy. noIV
6
Owner or authorired agent Date TOTAL: �le{`}UIED�Y°Tiirrr
OFFICE COPY