24355 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
BUBdingAddre,a a / x/41 Ll shanl?01) 24355
Ac,(
ane: (� Phone:
na A A AA
e/15 on % -335 CITY OF CUPERTINO-BUILDING DIVISION
• °no-annre"ane: Ue.No: APPLICATION I PERMIT 12r
Architect/En mer `� BUILDINGELFJCTRICAI.PLUMBING-MECHANICAL CATEGORY CONTROLN
pt Llc.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address:Z34GlJifodar�[ �/ 4,7 I'FRhBTISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION41
I hereby affirm that l am licrosd under provislons of ChaWr9(mmmenc APPLIANCES-RESIDENTIAL JOB DFSCRII'ITON
ingwith Section7000)of Division 3mfthe BU91ne9and ProfesslonsCode,and my w '`
liconse Is in full d ef(eci. PANELS
Limnss���Clasai%�LIc.N �3cJ
DatComraRor �n/�,/
ARCHITECTSDECLARATION / OVER
100015
q�+
Ob 1 understand eery plan shall be used a public records OVER 101 AMPS SQ.FT.FLOOR AREA $/�.FT.
�U E Licensed Profmakmi l SIGNS ELECTRICAL
�¢6 OWNER-BUILDER DECLARATION S[+ECIALCR2CUIT/MISC
f' � Iherebyaffirm that l am exempt fromthe Contmcmrb Llconse Lawforthe
o following reason(Section 7115,Business and Professors Code:My city or
FZi"o� countywhich requires a permit to construct,alter,Improve,demolish,orrepair TEMP.METER OR POLE INST.
`� s anyatruciurcprlor to ih bwance,aborequlreetheappOmnt(°reach perrtdt to
Fs O a fly a signed statement that he Is licensed pursuant to the immb Ions of the POWER DEVICES
Q�wp fn Contractors License Law(Chapter 9(mmmencing with Section 701)of Divi- SWIMMING POOL ELECTRIC
slon3 of the Business;and Pro(exons Code orthat he b exempt therchomand VALUATION
the basis for the alleged exemption. Any violation of Section 711.5 by any /�745 ,
� f
<n
applicant fora permit sub' theapplicant to a civil 1 of not more than OVTLEISSWITCHES-FIXTURES
PP Pepenalty
five hundred dollars he pr. NEW RESIDENTIAL ELECTR
�m ❑I,as owner of the property,or rtry employees with wage v their sole AFL STORIES TYPE CON5MUCTION
mm(S..70K Rosinsthewor r and i..Code:
cW reh not W ended or offend for
5 O dile(S..70K to Rosins,,andf property Code:The or improves
Llceve law
S docs not apply to an owner of property who builds or Improve thereon,and OCC.GROUP RES.UNITS
who
ove entsworkhimself edorwgh hisownemployees,providedthat gor
improvements
mprovement issold intendreyear foompletiorered for sale.themvnveg ilderhe wdl have TOTAL:
Improvement i.sold within oneyearofcompleliory the owner-buioer will have
harden of proving that he did not build or improve for purpose of sale). QTY, PLUMBING PERMIT FEE p1ppDZONS APN
u L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
to comtrud the project(Sec.7044,Business and Professlov Code:
The Contractor's Liconse Law does not apply to an owner of property who ALTER-DRAIN&VENT-WRIER(FA)
Wilds or Improves thereon, and who contracts for such p�o)ects with a
off,ctor exempt
under ax,to the Contraciorl Lkxn:Law. BACKFLO R D FEE SUMMARY
L�1 am exempt under Sec B k P C for tots rcawn
Owner Date DRAINS Fur�RSA,'CO�J[). SA ARY Y_ N
. WORKMAN COMPENSATION DECLARATION _ AECMITN
❑I hereby affirm that I have a certificate of consent to self-insure,or a FDiTUAES PER SCH L TAX Y N
conifimte of Workers Compensation Imuranco or a certified copy thereof(Sec. �,p����rrr��..��� RECEITN
381,Iab C.) / G EA.SYFt&0jum..4 OUTLETS
11.11 If ��59lrG — 4 PA FEE Y_ N_
RECEIPT N
Comany ay�a Aii� GAS LA.SYSITM-OVER4(FA) BUILDING DIVISION FEES
Cenmed copy ut beroby fumished.
[Q.CeTrtified copy b filed with the city inspection division. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
CERTIFICATE OF FJ(EMPFION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE
(Thissectionmed not bec°mpletM lithe pcmdt lsforone hundred dollars SEWER-SANITARY-STORM EA.2I17T. Date Remi t#
($11)orlee) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
(certify that In the person
pemdtis Ltoti,
I shag not employ any person in any manner m v m become subject to the
Workcrs'Compematlon Laws of Cah(ornfa. Date WATER SYSTEM/TARRYING
PAID
O Z Applicant
Z Q NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you NEW RESIDENTIAL PLMB. SQFI'. Date Remi t#
Fshould become subject to the Workers'Compmuttlon probions of the Labor TOTAL:
WN Code,youmustfMhwithmmplywlthauchprovislovorthispermitAallbe
j deemed revoked. 6UILD1 G 'E
d CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby aorkf that there Is a construction s(Sec. agency for the perform
n 0 ante of the work(orwhich this pemdtVRauM(See 3M,Civ.C) TOTAL: ELECTRIC FEE
u2 Lender'.Name PLUMBING FEE
LL Ienaerandarese QTY. MECHANICAL PERMIT FEE
IcortilythatIhavemadthinappbmBonandstatethattheaboveinformation
O w MECHANICAL PEE
is
a mrrect.I agree to complywith all city and county ordinances and state laws PERMIT ISSUANCE FEESPAID:
>. Nrelating to Wllding mnstmcilory and hereby authodu reprexntativea of this
F Z city to enter upon the above-mentioned property for Inspection purpose. ALTERORADDTOMECH.
— (We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Receipt#
aga Inst liabilities,judgments,mstsand expenses which may In any way accrue AIR HANDLING UNIT(TO 10,10 GEM) SUBTOTAL,
agaWtsald City in conseque ofthegrantin this permit. ^,
I P/����/ AIR HANDLING UNIT(OVER 10,000 CFM) CONST RUCTION TAX
Sigvvrc of pplinnt/C o or
ZAR S MATERIALS DISCLOSURE pate IXHAl15'THOOD(W/DUCT) CONSTRUCTION TAX PAID:
HA
Wllltheapplicant orfu lure building occupant store or handle hazardous HEATING UNIT(TO 11,ODOB
material as defivdby the Cupertino Municipal Code,Chapter 9.12,and the TU) Date Reeel t#
Hc❑alt,and Safety Code,Se)olon 255321)?No
UNIT(OVER 11)X10 BTU) TOT
Will the applicant or❑future building occopant use equipment or devices VENTILATION FAN(SINGLE RES ID) ISSUANCE DATE
which coat hazardous air contaminants a.defined by the Bay Area Air
Q. lity Management Distri? BOILER-COMP OHPOR 11,000 BTU)
4Ye No
havCread,heh arSioty CWc,a diom25505t 255der Chapter 6.95 of BOILER-COMP(OVER 11,000 BTU) p B
the
understand
t Health building Safety Code,Sections 25505,25533 sad,that i I A
understand that)(theteoccupant note currently encs tenant,that beis mymet NEW RESIDENTIAL MECH. SQ.I"f
pHor tresponsibility ce notify theiate Of oftherequirementswhich must be moa
prior to issuance of Certificate of Occupancy.
DEC - 919
Owner or authorised agent Date
'TOTAL: ISSUEU BYf�- I...nV
OFFICE COPY