24019 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address:
24019
nets 11.mc �+ pAPPLICA: A
le i-/� CITY OF CUPERTINO-BUILDING DIVISION ^ � _4
Cmtf,�aor'e Namyes� Lk.Na APPLICATION /PERMIT
wed f—` -�" 3a - BUILDINGELECTRICAGPLUMBING-MECHAMCAL CATEGORY CONTROL p
Archimet/Er glneer. Lie.No:
J' m-3 QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Addre s �. . /j3 PERMITISSUANCE 1:1 El ❑
LICENSED CONTRACTOR'S DECLARATION
Ihereby affirm that l am licensed under provisions of Chapter 9(commenc APPUANCESRESIDENTIAL JOB DESCRIPTION
inensei In fon force of Dlvffect. fthe Busimssand Pro(essionsCode,and my
lice..is in full fora andeffect. PAM75
License Ch. Lk.N
Date Cru n,tor �—ysa T
ARCHITECPS DECLARATION 201-I000AMPS
N C2O I undemtand my phos shall be used as public records. OVER 1000 AMPS EA S/SQ.IT.
Zt' Licensed Professioml SIGNSELECTRICAL l
<c. OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC . I ED IN I
zE' G Iherebyaffirenthat I am exempt lromthe Contractors License Lawforthe
oo following reason.(Section7031S,BusinessandProfessions Code:Any city or I` C� ^
FZp'u9 cauntywhlchrequmbesapemttommtmMMd r,lmpmve,demo)bh,orrepalr TEMP.METER OR POLE INSf. t K
3r anyctcture prier to its htuance,aborequireatheapplicant forsuch permit to
O file a signed statement that he h licensed pursuant to the provhioos of the POWER DEVICES
Contractors License Law(Chapter 9(commencing with Section 7000)of Dlvl-
P�O sion3 ofthe Business and Professbns Cade)orthat bets exempt therefromand SWP1h9NG IDOL ELECTRIC TE L LUATIO/
y3 the bash for the alleged exemption. Any violation of Section 7031.5 by any
x.55 <Qi appBnnt for a permit subjectsthe applicant to a civil pe mltydnotmorethan OUTLETSSWITCHFSFIXTURFS t `
a i
five hundred dollars($500).
,Z ❑I,as owner of the property, NEW RESIDENTIAL ELECTR sQ.Fr. STORIES IYPECONSTRUCTION'
p perry,orhe employees iswithwages their
compensationec701,Buswill iness
work and ions Code:Th not Wended or coffered for
k�o sale(Spc.7044,Business and Professions Code:The Contractors Lirense Law
r$ doesnotapplytoan owner ofpmperty who builds orimprovestherem,and
who doesnuch work himselforthrough Msown employees,provided thatsuch OCC.GROUIs RES.UNRS
improvements are not Intended orofered for sale.IL however,thebuilding or TOTAL:
improvement hand within oneyearofcompletion,theowner-bullderwitl have
tl3£krrdsn of proving that he did not baud or improve for purpose of sale.). QTY. PLUMBING PERMIT FEEFLOODzoNrE
U L as owner of the property,am exclusively contracting with licensed APN
/ P IT ISSUANCE vO
contractors to mostruct the project(Sec.7014,Business and Professloos Code: 1
The Contractor's License Law does net apply to an owner of property who
buALTER-DRAIN kVENT-WATER(EN
Wilds or Improves thereon, and who contracts for such ,pjnts with a
cgaEactor(s)licensed pursuant to the Contractor's License Law. BACK FfAWPROT�CT.DEVICE
FEE SUMMARY
LJ I am exempt under Sec B k P C for this reason
Owner Date DRAINS FLOOR ROOF,AREA,CONE). SANI'T'ARY RFCEBTN
WORKMAN COMPENSATION DECLARATION
01 hereby affirm that I have a artificam of con ent to sell-insure,ora FDCTUTRA 1 LOQ SC 100L TAX Y N
artlfkateof Worken'Compevtimimuranamacenifkd upythemof(Sec. RECEIPTN
3800,Lab C3 GAS EA.SYSTEM-1 INC.4 OUTLETS PARK FEE Y N
Policy#
anGAS EA.SYSTEM-OVER 4(EA) RFCIDPT
Co�Ccnified copy h hereby furnished. BUILDIVISION
V
ISION FEES
❑Certified copy h filed with the city inspection divhion. CREASEANDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
CERTIFICATE OF EXEM PFION FROM WOR KERS' GREASE TRAIT PAID
COMPENSATION INSURANCE
(rhlssedlonneed not becompietedi(thepermit later one hundreddollare SEWER-SANITARY-sToR,M EA.2ooFT. Date Recei t#
(s100)orless.) WATER HEATER W/VENT/ELECTR ENERGYFEE Y N_
Illnet that lathe dmon ian the work forwhkhthb Fermat is issued,
I shall not emplo n pereon in any ry er m u t99be���tylG�t to the
Workere'Co Ls 1( �let 7/+�Y.(% WATER SYSTEM/TREAT)NG PAID
C1 Z Applicant
Z O NOTTCE7oJNPIICANT:If,after making this Cenifloteof Exemption,you NEW RESIDENTIAL PLMB. sn.FE Date Reeei t#
�'N should become subject to the Workers'Compensation provisions of the Labor TOTAL:
_ Code,youmustfarthMthcomplywithsuchpmvhbosarthhpermitshallbe
LU > deemed revoked. BUILDING FEE
CL c CONSTRUCTION LENDING AGENCY SEISMIC FEE
= Z I herebyaffirmthat there b acoosbuctlon lendingagency forthe perform
nceoftheworkfor wNchthh permit h haued(Sec.3097,Cry,CJ TorAL: a-7p ELECTRIC FEE
LL O Landers Name
Add PLUMBING FEE 7
Iy L) L nders Address QTY- MECHANICAL PERMIT FEE MECHANICAL FEE
O W Iceni(ythatl have read fhb appliratbnand statethattheabovelnformation
Q. hcorrect.I agree to comply with a 11 city and county ordinances and slate laws PERMIT ISSUANCE FEESPAID:
I- W relatingto building construction,and herebyauthoracrepreentativesofthis
Z city to enter upon the above-mentioned property for inspection purposes. ALTERORADOTOMECH.
(We)a save,Indemnify an d keep harmless the City of Cupertino Date Receipt#
.,ins'
galos ablli ,judgmenh, expcmeswhlchmrylnanywayamue AIR HANDLING UNIT CFO 10,000 CFM) SUBTOTAL'
aga City a of ting of this permit.
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
vture of Applicant ontmetue Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Wllltheapplicant or future building occupant store or handle hazardous HFATINGUNITGO 100,000BTU)
materialasdefined by the Cupertino Municipal Code,Chapter 9.12,andthc Date RCCeI t# `
Health and Safety Cod e,SemNo on 75532(a)t HEATING UNIT(OVER 10,000 BTU) TOTAL: e _�
ElYea ❑
Will the applicant or future buildingo pant useequlpmentordevims VENTILATION FAN(SINGLE RFSID) E DATE ISSUANCE which emit hazardous air contaminants as defined by the Bay Area Air 43 C
Qu lits Mawgement Dhtnct7 BOILER-COMPOHPOR 100,000 BTU)
4Yes No
havpreadthehua�ousmaterlalsrequirements under Chapmr6.95of BOILER-COMP(OVER 100,000 BTU)
the Califomh Health&Safety Code,Sectiom 25505,25533 and 25534.1 JUL 241992
understand that lithe building does not currently have a tenant,that it is my N7:W RESIDENTIAL MECH. SQ.FT
responsibility to notify the occopant of the requirements which at be met
prior to Issuance of a CertificateofOca,pancy. ClIY'Ur uurrnilnv
t
Owner or authonud agent
Date r
TOTAL: ISSUED BY:
OFFICE COPY