24191 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pct IdendHcation / �, pIT N2 4 1 91
BuIWinBB/C��dd 2
wners aces: AA A A
CITY OF CUPERTINO�BUILDING DIVISION a Q�
enact°:a"aces: u " APPLICATION ( PERMIT —` —1
BUILDING-ELECTRICAL-PLUMBINGMECHAM _
CAL CATEGORY CONTROL#
Architect/Engineer. Lk.No:
(' QTY ELEC•TRICPERMIT FEE BUILDING PERMIT INFO
Address:513 �5 J S+Q�9/ PFRMITISSUANCIR ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter 9(commene APPLIANCES-RESIDENTIAL JOB DESCRIPTION
tngwlth5ect1on7000)ofDlvlelon3oftheBusimssand Pmfmion.C°de,and my - ,tea...
Lilic . Chis force and t.# PANELS n ass"
1/ti
Llrenee Clam Lic.#
Date Contractor UP TO 200AMPS
ARCHITECTS DECLARATION 201-IOW AMPS
Oa Z 1 understand my plans shall be used public records. OVER IODO AMPS SQ.Fr.FLOOR AREA S/SQ.FT.
ti 1Licensed Professional SIGNS ELECTRICAL
t;'4< OWNER-BUILDER DECLARATION SI'FGLkLCIRCUIT/MISC [E�
CV '4 Ihercbyafflrm that am exempt from the Contractors Llmose IA.for the �• C� D N
qqqq following reason.(Section 7071.5,Business and Professions Code:Any dty or
Fq coontywhkh mqumsA permit tocommud,alter,Improve,demolish,orrepair TLMP.MErE[i ORPOLE(NST.
a anystructure pdarto its knsion,elao requirestheappllcant(orsuch permittaTER
O floe a signed statement that he b licensed pursuant it the Section
of Ne POWER DEVICES
1y.
Contractor's of the License Lw(Cluster9(com)orthatwithxemptthrefolDivi.
301 to basis for
thealleedexemption, Any orthrtheb exempt there(mm and SWIMMING POOL ELECTRIC ' LUATION
the bash!or the alleged exemption,on. Any violation of Semon not res by any
OaS eppBantlora permit eubjMsthc applkant too civil penalty of not marc l9an OUILETSSWrCCHESFIXTURES
(q Ive rd dolians, . SQFT, STORIES TYPE CONSTRUCTION
�as owner of the property,cur my employees with wages as their sok NEW RESIDENTIAL EECTR
nllon,willdo the work,and theslr ac ure b not Intended or offered for
O ,(Sec.70 H..1cassandProf.10MCode:TMContradors Llcetue Law
$ does not apply to an owner of property who build,or Improves themoo,and OCC.GROUP RFS.UNITS
who dare such work himself or through his own employees,provided that such
Improvements arc not Intended oro((ered lorsale,If,however,the bulkla gor TOTAL:
Impmvemeatissoidwlthln oneyearofcompodlon,theowner-buildereviol have
tliEtfurden of proving that he did not build or Improve for purpose ofsole.). QTY. PLUMBING PERMIT FEE -FLOOD ZONE APN
u L as owner of the property,am exclusively contracting with licensed PERMRISSUANCE •�
contractors to occomact the pmjed(Sec.7094,Business and Professions Code:
The Contmetore License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
1)ullds or improves thereon,and who contracts for such ptojed.with a
(pdo,(.)Unmied pursuant to me Contractor'.Limns Law. FEE SUMMARY
J 1 am exempt under Sec B &TP C for this reawn BACK FLOW PROTECT.DEVICE
OUTSIDE HTa
Date
Owner
DRAINS.FLOOR ROOF,AREA,COND. SANITARY Y N
RECEIPT#
WORKMAN I have-SAfkam DECLARATION FIXTURES PER TRAP SCIi00L TAX Y N
❑1 hereby affirm that I have o certlfkate of convent to imif-tmam,ora �!e RECEIPT#
380LanificateofWorken'Compewatlonrmurance oracertified copy thereof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS
38N,Lab CJ PARK FEE Y N_
PolCom an GAS EA.SYSTEM-OVER 4(EA) DING Of#
Y BUILDING DI VISION FEES
Certified copy is hereby famished.
city❑Certified copy b(fled with 1k ty ty inspection division. CREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
CERTIFICATE OF EXFMPrION FROM WORKERS' GREASETRAP PAID
COMPENSATION SEWER-SANITARY-STORM RA 2001--r. Date Recei [N
ITeedlon need not be complded I(1he pemNt laforone hundred dollars
($100)orlcss.) WATER HEATER W/VENT/EFGTR ENERGY FEE Y N
I ll out that o the person I.any
co work.as to h this eertNj c oto the
1 shag not employ any person in any manner at u to berome abject to flu
O WATER SYSTEM/TREATING
Workers Compensation]ewe of California.Date PAID
Z NOTICE
N
Z Z NOTICE TO API'LICAM:If,after making this Certificate of Exemption,you NEW RESIDENTIAL PLMB. SQFL Date Recei tH
should become subject to the Workera Compennot on provisions of the Labor TOTAL:
N Code,you creast forthwith comply with such provbioru orthls permit shall he BUILDING FEE
> deemed revoked.
LU CONSTRUCTION LENDING AGENCY SEISMIC FEE
a. I hereby atfirmthat there la a construction lending agency forthe per(Drm ELECTRIC FEE
M Z anceofthe work!or which this permit b Issued(Sec.3097,C1v.C.) T �^�' _
U O lender's Name PLUMBING FEE
LL ~ Lender's Address Cry. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Imnllythatl havereadlhisappllcattonand statethatthexboveleformation
1 Is correct.I agree to comply with all dty and county ordinance and slate laws PERMIT ISSUANCE FEES PAID:
Making to building construction,and hereby authentic representatives olthts
Zcity to enter upon the abovementioned property for inspection purposes. ALTERORADDTOMECH. Date
V — (We)agree to save,Indemnify an d keep harmless the City of Cupertino Revel tin
against llablllties ' Agerients,m,lsand expenses which maylnan wayacdue AIR HANDLING UNIT(MI0,000CFM) SUBTOTAL:
agoin/said C1 i encs of t Ing of this pe it.
).— AIR HANDLING UNIT(OVER IQ0f70CFM) CONSTRUCTION TAX '
neof Ap icant/ Comma to EXI IAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZA ROOD 7ATERIALS DISCLOSU RE
Wllltheappllcent or future Ildingoccvpant stare or handle ha'rardous HEATING UNIT(TO 107,000 BTU)
matedal as defined by the Cupertino Municipal Cade,Chapter 9.12 and the Date Recei t#
I ealth and Safety Code Sedton2SS32(a)I HEATING UNIT(OVER 100,(100 BTU) TOTAL
F1Yn No
Will the applicant Mon building occupant use equlpmenl or devices VENTILATION FAN(SINGLE RESIO) ISSUANCE DATE
which emit haeardous air contaminants as defined by the Bay Area Air
• Quality Managemcm Dbtdd7 BOILER-COMP(3HPOR IOO,OM BTU)
Yes No
have read the haza ous materials requirements under Chapter 6.95 of BORER-COMP(OVEt 100,0!)BTU)
the California Health&Safety Code,Sections 25505,25533 and 25539.1n U' A
understand that lithe building donot currently have a tenant,that it bmy NEW RESIDENTIAL MECH. SQ.FT f��k A N
omponiblltty to notify the..part of the requirements which most be met
prior to Issuance of a Certificate of Ocmpancy. SEP al0
_ as 0A10:)Owneror auth°daed agent
Data 'TOTAL: ISSUEDB,NJ�d�`�/'1�� 71
OFFICE COPY