24415 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project IdentificationI -PF3LV[IT NO
Building Address: LvF.-2flWo 24415
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�.cK7 CITY OF CUPERTINO-BUILDING DIVISION nA
�. c 'aUh � .��� APPLICATION 1 PERMIT
BUILDING-ELECTRICALnUMBING-MDCHAMCAL CATEGORY CONTROL#
Architect/Engineer. Lie.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter 9(mmmenc APPUANCESRESIDENHAL JOB DFSCRB'1'ION
ingwith Section 7000)of DMslon3ofthe Businessa/nd'P'7mfesslomCade,and my a/��\
license I.
f ll fo andLdc p. 2 2 d7 -6 PANELS J`� on,
to Contractor Pon,
RCHITECT'S DECLARATION 20MEEKIAMPS
q�q�vv IundenwndmyplamaMBbeusedaspublicrecords. OVER1000AMPS SQ,FT.F1,30RAREA $/SQ.FT.
faz Licansed Professional SIGNS ELEC XAL
OWNER-BUILDER DECLARATION SPECIAL C T/MISC
L., owing raf0mSectio 7exempt froarthe essad Profictolns Code law to the �� ��
following recon.(Section 7031.5,Business and Profesiona Code:Any city or
F -T'u9 county which requires a perMetomretrun,alter,improve,detroLLsh,orrepalr TEMP.M LEINST. asz ,
M anystructum pdorto its Lseunce,also requirettheapptiant for such permit to
Oa Ale a signed statement that he is Bansed pursuant to the provisions of the POWER DEVICES
Contractor§License Lew(Chapter 9(commencing with Section 7000)of Divi-
S ei o3ofthellogeessand ProfeselonaCode)orthat helsexampttherefremand S1V�MI"" VALUATION
sFyp5V' Q 5 the basis for the alleged exemption. Any violation of Section 7031.5 by an WI �,,,,,,// �T —
applicant for a permit subjects the applicant to a civil penalty of not mo or than OUTLETSSHy( I �4[ rl(te r+
p� five hundred dollars($SM. NEW RESIDENTIALE
n I,as owner of the property,or my employees with wages as their sole �'�' STORIES TYPE CONSTRUCTION
C compensation,will do the work and the structure is not intended or offered for
5 O sale(Sec.7076,Business and Prefessiom Code:The Contractor's Liarue Law
$ does not apply to an owner of property who Wilds or Improves thereon,and OCC.GROUT' AES.UNITS
who doessuchwork himself.rthrough hisownemployees,providedthat such
impmvemenb are not intended muttered forsae.IL however,thebuilding or �•
improvement Isseld withinoneyearofcompleiogtheowner-W ilderwill have
tr rden of proving that he did not build or Improve forpurposeofsale.). QTY, PLUMBING PERMIT FEE
Lj L as owner of the property,am exclusively contracting with licensed FLOOD ZONE MN
contcacmrs to construct the project(Sce.70K Bushes and I'miessimes Code: PERMIT ISSUANCE �
The Contradoes License Law does nor apply to an owner of property who ALTER-DRAIN&VENT-WATER
Wilds or Improves thereon,and who contracts for such pSajets with a era
co
,,__(I(Tator(s7 Brenn-a punuanttotheeontmtoes Llmnw Law. FEE SUMMARY
LJ I am exempt under Sec. B A P C (or this reason BACK FLOW PROTECT.DEVICE
OUTSIDE
Owner e _ DRAINS FLOOR ROOF,AREA,COND. SANITARY RECEIPT R .
WORKMAN COMPENSATION DECLARATION
❑I hereby affirm that I have a cartifiate of conaendto self-Insure,or a TURFS PFR TRAP /� SCHOOL TAX Y N_
cartl(late o(Workers'Compensatlonlrouana or a cartl(led copy'lo"em(Sec. RECEIPT#.
380D,lab C.) GAS EA.SYSTEM-1 INCAOUTLES �� PARKFM Y N
Policy## RECEB'T N
Comma y GAS EA.SYSTEM-OVER6(pq) BUILDING DIVISION FEES
Certified Crtified copy Is herebytd. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
fed copy a filed withh the the city inspection division. �.y� a(
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAIco `
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 200FT Date R
(0)m I ion need not becompleted tithe permit a(.rove hundred dollars 'meg
($100) WATER HEATER W/VFNT/ELECTR ENERGY FEE Y w,
Ill not thatoyan person
tmanner for which this permit la issued, —� V� '—
Ishall not employ any person In any manner n u to become abject to the WATER SYSTEM/TREATING V
Worked Compensation laws of California.Data PAID
O Z Applicant
Z ONOTICE TO APPLICANT.If,after making this Certificate of Exemption,you NEW RE4DENIAL PLMB. SQF7, Date VGA CZ
should become sub}at to the Workses'Compereation provisions of the Labor TOT
N Qde,you twist forthwith comply with such prom s perm
vtsioor this shall be
W > deemed revoked, B LDI C FE' O
tl DING AGENCIf
Ihereby sill
CONSTRUCTION
them vim.Icowtrunloon lending agency for the perform- SEISMIC FEE
Z anceof the work(. which this permit is issued(See3097,Civ.C.) TO ELECTRIC FEE
V O Iender's Name
QTY. MECHANICAL PERMIT PEE PLUMBING PEE
LL Iandefa Addres MECHANICAL FEE
O W 1certltythatl have mad this appllationand statethat(heab.ve Information
bconect.I agree to comply with all city and county ordinanon and state laws , PERMITISSUANCE ��' FEES PAID:
} a relating to building comtruction,and herebyauthorim mprexntatives oftha
H Z citytoenterupon the above-mentioned property for inspection purposes. ALTER OR ADDTO MECH.
_ (We)agme to save,indemnity an d keep harmless,the City of Cupertino Date Receipt#
against liabilities,pdgments,mansard expenses which may in anywayamme AIR HANDLING UNIT(to 10,000 CFM) SUBTOTAL:
against said Clty In conuquen of she granting le permit.
AIR HANDLING UNIT(OVER IQ"CEN7 CONSTRUCTION TAX
'Ignature of Applicant/Contractor Date EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfuture building occupant store or handle haeardous HEATING UNIT(T010D,000HTIA
material as defined by the Cupertino Municipal Code,Chapter9AZ and the •Date Re #
Health hand Safety Code,Section 25532(a)7 HEATING UNIT(OVER 100,000 STU) .I.
Will theapplicant orfuuturebuilding occupant use equipment.rci,ices VENTILATION PAN(SINGLE RESIDE ISSUANCE DATE
which rout haeard.us air contaminant,as defined by the Bay Area Air
Quality Management charter? BOILER-COMP OHPOR IW,000 BTU)
4Yea n No 1� I.vk U SY
havercadtheh arousmteria equiremnbunder Chapter 6.95ot K FR-COMP(OVFR100,000BN)
the California Halth 8:Safety Cod,Sections 25505,25533 and 25534.I
understand that if the bu lld ing does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. OCT 29 7992
responsibility to notify the occupant of the requirements which must be met
prior to issuance a a Certificate of Occupancy.
Owner.'authorimd agent Data Gily
T ISSUED BY:
S
OFFICE COPY
CITY OF CUPERTINO
INSPECTION DIVISION
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