24317 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PFR?AT NO.
Budding Address:
scar - 24317 ,
ALWAIL
M1l • T \` us-mo CITY OF CUPERTINO-BUILDING DIVISION (� „M
Cnntr.rur'ef�ime: LIc.No: APPLICATION /PERMIT .- ^�(�
UfAlEK BUILDING-ELECTRICAI.PLUMBING-MECHANICAL CATEGORY CONTROL p
Architect/Engineer. Lk.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address PERMITISSUANCE ❑ ❑
by LICENSED that ED CONTRACTOR'S DECLARATION
I hercectionaffimtE.lamlken3eunder prnesand ofessloer9de,and c APPLIANCES-RESIDENTIAL JOB DESCRIPTION
[I...Ing with I.fail 7D0force of Division, thegusinessand Pm(eseionef]ode,and my W�aa„,/�/� 1 -jke rir�
license ie in(ul tome and.(fess. PANELS •411H,r�a1�Vy�' a
Lear.Clam_11k.#_
Data Contractor —UP TO 2DOANT9
ARCHITEC3`5DECLARATION 201-IMOAMPS
FQ±
9
0 O I understand my plans shall be used as public records. OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
E Licensed Professional SIGNS ELECTRICAL
<«< OWNER-BUILDER DECLARATION
In SPFGIALCRRCU[T/MLSC
7F, Ihereby affirm that lam exemptfromthe Contractor's License Law far the
qqqqqq following reason.(Section 7031.5,Business and Professlons Code:Any city or
F f' countywhichrequWapert tWmmtmcnalter,lmpmve,demolish,orrepalr P'MEPER OR POLE INST.
S� aystmcture pdorto its Luuaae,alsorequlree the applicant for such permitto
s[5 file a signed statement that he as licensed pursuant to the provisions of the POWER DEVICES P 1 \41 -
OI" Contractor's License Law(Chapter 9(commencing with Section 7000)of Dlvl- V
SWIMMING POOL ELECTR[
3 0 the basis
fo the alleged
Professions Any)violation f exempt therefrom and ; j _3 -- VALUATION
y.' the basis for the allege exemption. Any violation of Section 7QTI5 by any J f; I fr
<R OUILETSSWITCI-ffSAXTIlR
applicant fora permit subjects the applicant to a civil penalty of nu morethan
ve ndreci dollars($500). NEW RESIDEN7RAL E 1R IIQTFb Fp 'lyl'E CONSTRUCTION
as owner of the property,or my employees with wages a their sole
Q, c pensation,will do the work,and thestruchem is not intended or offered for T s
p'f D sx a(Sec 7014,Business and Professions Code:The Contmdoes License Law '
µ$$ does not a pply to an owner of property who builds or improves theater,and OCC.GROUT' R[S.UNITS
FC who ducesuchwork hlmxRorthmugh hieown employees,provided that such
improvements are not Intended oroffered forsale.IL however,thebuilding or TOTAL:
Improvement Is sold within oneyearotcompletion,the owner-builder will have
t LJ L rden of proving that he did not build or improve for purpose of sale.). QTY, PLUMBING PERMIT FEE OD ZONE AIN
as owner of the property,am exclusively contracting with license FLO
contractors to construct the project(See.7044,Business and Professions;Code: PERMIT ISSUANCE �
The Contractor's Lletue Law don nn apply to an owner of property who PETER-DRAIN&VENT-WATER(EA)
Wild.or Improves thereon, and who contracts for such p1lojeds with a
ctor(.)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE .FEE SUMMARY
LJ I am exempt under See. B&P C for this reason
OUTSI DE FEES
Owner DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
. Date
WORKMAN COMPENSATION DECLARATION RECEIPT
FIXTURES PER TRAP SCHOOL TAX Y N
❑I hereby affirm that I have o Insurance
a c of consent to self-Insure,ora RECEIPT M
3800,Lcortificab of Worken'C.mpensatlonlaurance oracertified mpythereof(See. GAS EA.SYSTEM-1 INCA OUTLETS PARK ITE Y N
3800,lab C.)
Paltry M GAS EA.SYSHM OVM 4 LEA) DING DI M
Cam any BUILDING DI VISION FEES copy 6 herebyfurnished,the city GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
Certified copy V(fled with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 200FT Date Remi t#
RMssection need cad be compine tithe permit Ethernet cahundred deism
($100)eWA W/VENT/ELPCTR ENERGY FEE Y N
(certifyifythat lathe performance ofthewwk(or which this permit is issued, —
I shall not employ any person In any manner so as to become subject to the ATE2 SYSTEM/ GTING
Workeri Compensation laws of California.Date PAID .
OZ nppuam Date Remi t#
Z 0 NOTICETO APPLICANT:R,after raking this Certificate of Exemption,you RESIDEN77AL PLMB. :OFT.
should become subject to the Workers'Compemation provisions of the Labor TOTAL:
N Code,you at forthwith comply with such provblo.mthie,perrat.hail be
j deemed revoked. BUNG
LU CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby afOrm that them la a construction lending agency fFEE
or the pedorm-
Z ance of the work for which this permit is Issued(See.3097,Civ.C.) ELECTRIC FEE
C1 O Lender's Name PLUMBINGFEE
ly H Leader's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W ]mrtifythatl haveread this application and state that theabovelnformetlon
iacorrcn.I agree to comply with all city and munty ordinances and state laws PERMIT ISSUANCE FEES PAID:
} IL relating to building coatructlon,and hereby authorize representative ofthls
F N to enter upon the abovementioned property for Impaction purpose. ALTERORADDIOMECEL
? (We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Receipt#
V
city a tat llabilltks,judgments,costa and expenseswh lch may In any way me AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
a slab ity in ronsequen o(the gra tlnsg o/ Wit.
�7 �� ARHANDLING UNIT(OVER IO,000CEN) CONSTRUCTION TAX
5lgaturcot Applicant/ ..trader /0b/.,_t EXHAusrHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant atom or handle hazardous HEATING UNIT(TO 100,000 BTU) Date Recei t#
material as define by the Cupertino Municipal Code,Chapter 9.12,and the
Health and SafetyCole�a.�Section25532(a)? - HEATING UNIT(OVER IDE"RTI) TOT
❑ Y. u No
Wllltheapplkant or futures building occupant use equipment ordevins VEMILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit haaardous air contaminants as defined by the Bay Area Air
• Qu a Illy Management District? BOILER-COMP DTUPOR 100,000 BTU)
Yea P❑No �k yy
Ihave read the bazarcausnuleriasrequiremnb (� 6�AundcrChapter6.95of BOILER-COMP BTU) 0
the California Health&SafetyCode,Sealom 25505,25533 and 25534. I
understand that lithe building does not amently have a tenant,that it is my NEW RESIDENTIAL MF.CH. ,S,.FT
mor to bllity uanc ofnota Certificate
requirements which must be met OCT, ay-19.92
priortolssuance ofay the to oft.f the req {/ A i1�Ly��ji7•TD[`V.
Owner or authorized agent Data
TOTAL: ISSUED BY: �4/—i �—,
OFFICE COPY