24438 APPLICANT TO FILL IN INFORMATION WITHIN R/ED, LINES — USE BALL" 1P�OOIINT PEN ONLY 24438
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BuildingProject Identification hp5 AL:705 lT/Tr`� 2— —7 2 AAAA) / pE1tM1TNG 4 4 3 8
auuaing Address:
?.0863 5720TJs CR-r-£� WiLujo S o
wnere sine. , AVIIU�IION SUBMITTAL DATE
.S%7✓1A)5
Cr
rF,J7F/? �350L CITY OF CUPERTINO-BUILDING DIVISION
Contlactor's Nams: Lk:No: APPLICATION /PERMIT
( r�
BUILDINGf7.EC770CA41'LUMBING-MECHAMCAL CATEGORY
ArcLitM�p, LIc No:
QTY - ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addreae:z2Ja''�3 7Z f V PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION IJ/�T
thereby affirm that l am Bcensed under probonaol'Chapler9(incomes APPUANCESRESIDENTIAL JOB DESCRII'IION
Ing with Section 7000)of Division 3 ofthe Business and Profess(onsCode,andmy
homse Is In full force and effect. PANELS
License Ckss Lir.#
Date Contractor —UP TO 200 AhTS
ARCHITECPS DECLARATION 201-1000 AMPS
09 Iunderst.nd my plans.Lal]be used as public records. OVERI000AMPS SQ.FT.FLOOR AREA N/SQ.FT.
O � I
Licensed Prolembnal 9CNS ELECTRICAL �a2
6 OWNER-BUILDER DECLARATION
p., 1hembyafBrmthat lamexemptfrom the Contractor's License Law for the
SPECIALCRCUIT/MISC
O O-. followin reason.(Section 7071.5,Business and Professions Code:An d or
OZi.µ� g Y city TEMP.METER OR POLE INST.
l;� musty which requires ol permit ,aWo uuireath,improvgdemolbhprretto
anya signed statement
that
M is Licensed pursuant
t lithe pr such s,of t e POWb DEVICES
g�d� file a signed statement that he b Licensed pursuant to the provblow of the
eek Contractor's 3 License Law(Chapter9(commencingwlthSectimn7000)ofDivi-
p SWIMMING POOL ELECTRIC
thesiobasis for
the
aess lleged Profession Any)viothat lation is exempt therefrom and �a,., VALUATION
l/:J —y
F
� the bolts for the alleged exemption. Any violation of$ectlon 70715 by any /.
five hundred dollars
penalty o(not more than ETSSKTCHFSFIXTIJRES I _
4
five hundred dollars($500). sUMNEW RESIDEN77AL ELECTR SQFT. CC71
�n ❑I.as owner of the property,or my employees with wages as their sole STORIES TYPE CONSTRUCTION
ptr..don,will do the work and the structure Is not intended or offered for
C n sale(Sec.7014 Business and Profession Code:The Contrectole License Law
does not apply to an owner of property who Wilds or Improve,thereon,and OCG GROIR' RFS.UNITS
who doessuch work himself or through his own employees,provided that such
Improvements arc not Intended oroffered for sale.If,however the bulldingor
improveme sold withlnoneyearofcompletion,the owner-bullderwill have
t of provingthat he did not Wild orlmprove for purposso(sale.). QTY. PLUMBING PERMIT FEE HAOD 7ANE APN
as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to coralruct the project(Sec 70K Business and Profeealoru Code:
The Contractor's License law does not apply to an owner M property who ALTER-DRA -WA
builds or improves thereon, and who contract, for such PVImtx with a )
,Il�actor(8)Brenda pursuant to the Contractor's License Law. BACKFLOW FEE SUMMARY
U I am exempt under Sec. B &P C for this reasonOUTxinr FEES
Owner Date DRAINS R B1A MTARY Y_ N_
• RECEErI N
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCI100LTAx Y_ N_
❑I hereby aiflsm that I have I certlRote of consent to selLlnsum,or RECER N
certificate of Workers'Comperuatlanl y/once oramrtifledmpythemo((Sec.
3800,tab C.) n // _ ('ASSY PARK ISE Y N
Policy �.�L�� J' RECEIVr
Com an 1 GAS A)EA.SYSTEM-OVER Y BUILDING DIVISIONIiGS
Certified copy b hercbytd.
�Certifica copy b filed withh the tW city W GREASEANDUSIRL WASTE INTERCEPTOR PLANCHECK FEE inspection division. �t
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP URAPAID � —
COMPENSATION INSURANCE
RseWpermit
hlactlon need not completed If the SURA Is for onehundred dollarsSEWER-SAM.I.ARYSTOAM 12 :20017 Date ecel of
(81ro)or lemJ WATER HFATIRW/VEN/ELECTR ENERGYFEE Y N_
I —
I shall not employ any person In any manner an as to become subject to the WATQt SYSTEM/TRFA7ING
Workese'Compemation Laws of California.Date PAID
0 Applicant NEW RESIDENTIAL PLMB._SQFT. ae Recei tN
Z O NOTICE co esubje notes orkere*Comfter mking er ationlmteof Exemption,eLyou
should become subject to the W y wit Comper visa n provision of the Labor TOT
�L'N CMI deemod revolutforthwith comply with euchprovblon arehb permibhall be B
j deemed invoked, _
LU
G CONSTRUCTION LENDING AGENCY SEISM FEE
I hereby affirm that there its romtructlon lending agency for the perfor n, ELEGTRIG FE
Z armofthe workforwhlch this permit is issued(Sec.3097,CN.C.) TOTAL:
U O lander'.N.rc PLUMBING F E
LL I— Lenaer'.Adares. Qrv. MECHANICAL PERMIT .,FEE MECHANI LFEE
OU Icertlfythatlhave read thlaappUmtlonandoatethataheabovelnformation a•'^
W ismred.I agree to complywlth all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
} 1 relating to building construction,and berebyauthorkerepresentativesofthis
[— 2 city to enter upon the above,mentioned property for lrupxxt npurpoxs. ALTER OR ADD It1
— (We)agree to save,indemnify an d keep harmless the City of Cupertino Date Receipt#
against liabilities,PcIgments,roots a nd expenses which may in any way a¢rue AIR HANDLING UNIT(TO I DODO CFM) UBTOTAL:
against said City In consequence of the gra sting of this permit
AIR HANDLING UNIT(OVER lO,ODOCFM) CONSTRUCTI TAX
Signature of Applicant/Contractor Date FXi FWUST HOOD(W/DICT) CONSTRUCTIO TAX PAID:
HALA RDOUS MATERIALS DISCLOSURE
Wllltheappllrunt or future buadingomv tatmebrhandl,h.,rdou. HEATING UMT(TO 100,000BTU) DffiC CCI t
materlli ss tlefind by/he Cupertut c pal Code,Chapter 9.12,and the -
HeslthaadSafetyCcde Sect 32(.)7 HEATING UMT(OVER 100,000 BTU) T
Yes o
Wiilthe applicant orfuwm Wilding ocmpantuse equipment ordevicos VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contends. as defined bythc Bay Area Air
Quality Management District BOILER-COMP OHL OR 100,0(10 BTU)
Mi
Yes o
ikjt Ituvereacithehaza ous materials requirements under Chapter 6.95 of BOILER-COMP(OVER I0D,000 BTU) fr {l
the California Health&Safety Code,Sections 25505,25533 and 25534. I •'G ,
understand that lithe building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT. /)/O�
rmpmwibilitytond cmm
Bythe pant ttierequirementawhichraustbeet ry-Tr'(
P rior to issu co(a Ce finite ,[ panty. CIrV:
14
r41
doge ace ISSUED BY:
OFFICE COPY