24234 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY 7
buildingProject Identification PERMIT N(y 4 L! 3 4
Building Address: Z
caner aces: one:
!Dre)071
2 CITY )FCUPERTINO-BUILDING DIVISION
contra or Name: APP
LIc.Na APPLICATION / PERMIT �.
BUILDING ELECTRICALPLUMBING-MECHAMCAL CATEGORY CONTROL Y
Arch Oct/En nrer: '
` QTY ELECTRICPERMIT FEE BUILDINGPERMITINFO
Addrcsm PQtMITISSUANCE - 1:1 1:11�V" El
CONTRACTOR'S DECLARATION L
Ihth Sedtfflrtnthat Dimi,i 3.ftheunder Busir laloneof ChapteCode,andmc- APPWANCESREADENTIAL JOB DESCRR'HON
Ingwilion.1.in full fame,f d diedn3oftheguslruresand ProfeslansCode,end my
licence le In full form and died. UP ELS
TO
License C}ry Lletr
Date -l/. ContnRor
ARCHITECT'S DECLARATION I01-1000AMPS IL
9ZO lundentan my phns shaBbeused upubllcrcmrds OVER 1000 AMTS j - .FT. I�l7O�R Y $ SQ.FT.
V� � V 1
m Licensed Professional SIGNS ELECTRICAL
OWNER-BUILDER DECLARATION ON a SPECIAL CIItCU1T/MISC
7F' � Ihercme
hereby
that xempt(romthe Conlnctorl Llrenae law fmthe
p following reason.(Sedlon 7011.5,Buslnea and Proleabns Cada:Mydty or n
OZi.� TEMP.MEfIRORPOLE INST. DAT D
p� muntywMch requbma permhro consteuct,alten aprovgdeonlbh,or repair
1 anystmcturcpdortolm Issuance,alsliceredpursueat to the Provisionsattach
tto
o POWER DEVICES
1 Xa floe a signed statement that het licensed pursuant it the pro 7M) the
w Conl.1the usineslaw(mfmir9(commertlng with herefof and
{-i, SWIMMING IK70L ELECTRIC
slon3e(the Bualnessand Pro(emlons Code)orthat Fels exempt thercfromand VALUATION
the basis for the alleged exemption. Any violation of Section 7011.5 by any OUTLETSSWITCHES-FIXTURES
applicant fora permit subjects the applicant toa eivil pemlty of not more than
pj five hundred della.(SSD9). NEW RESIDENTIAL ELECTR
GG11 I,as owner olthe property, —SQA. STORIES TYPE CONSTRUCTION
�n ❑ p party,or my employee with wages r there sole
compensation,K B.shusl do he workand the s Code:
dere Vnot intended ercensed for
Law
O doe(son apply
to an owner
f property Co buildsThe or impr ore License Law
who cluessuch
roan owner of throng his one mpoyees,povidedoven reoryand OCC.GROUP RIS.UNITS
whodoe encs am n himself or ed oraagh Msowne.If,hoe,provided that such
Improvementsarenot Intendedearo redfor ale.ILhower-balder ill have TOTAL:
Improvement lawldwithinoneyxvrofcompldWrylheowner-W BderwBlhave
tlBI,kurden of proving that he did not build or improve for purpose ofsale.). QTY, PLUMBING PERMIT FEE FLOOD ZONE ApN
L..j L as owner of the property,am exclusively mntracing with licensed PEtMITISSUANCE
mntnRors to muatmct the project(Sec.70K Business and Professions Code:
The Contradoes Limnse law does nor apply to an owner of property who ALTER-DRAIN&VENT-WATER ffA)
Wilds or Improves thereon,and who rout ems for such plojects with a
C7Bj�ectmW homsed pursuant to the Contractor's Limme Law. FEE SUMMARY
LJ I am exempt under Sec. B &P C for this reason BACK FLOW PROTECT.DEVICE
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N�
FEES
Owner Date RFGaP'f p
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOL TAX Y N
Of hereby affirm that I have a rerti(ka.of consent to opytnerea ora RFOEp+T M
3800,Lab o(Worken'Compensatlonlnsurance ora certl(kd copy thereo((Sm. GAS EA.SYSTEM.1 ING40UTLETS PARK FEE Y N
3800 Lab CJ
Policy Y RECEIPT M
QMBRCAS EA.SYSTEM-0VER4(EA) BUILDING DIVISI ON FE ES
Y
IOed copy is heed with the
cityad. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
CcrtlOed copy V Tiled with the tlty InspMlon division,
CERTIFICATE OF EXIM pDON FROM WORK ERS' GREASE TRAP PAID
COMPENSATION INSURANCE
(Thlssedlonneed outbecorepleted i(theperout lsfmorehundred dolls. SEWER-SANITARY-STORM EA.200FT. Date Reeel t#
($100)mlees) TEIW/YpN.I./o,pG.I.R ENERGY FEE Y N
I mrtlfythat In the performance of thework for which this penult is blued,
I shall not employ any person In any manner as as to become subject to the W ER ITM/TREATING
Workers'Compensation Laws of California.Date PAID
O Z Applicant NEW RESIDENTIAL PLMB. SQ.IT. Date Reset i#
Z O NOTICETO APPLICANT:If,after nuking this Certilateof Exempptt ion,you
should become subject to the Workers'Compematlon provisions of the Labor TOTAL:
� yCode,you must forthwith comply with such provision orthls permit shall be BUILDING FE
W 7 deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL C I herebyaffimthat there is a comtmctlon lendingagemy forthe perform
Z ance of the workfor which this permit b Issued(Sec.3097,Cle.Cd ELECTRIC FEE
U O larders Name PLUMBING FEE
LL I— Lenders Addreae QTY. MECHANICAL PERMIT FEE MECHANICALFEE
OW ismrI cMlfythat l have read thla appUcatinnand matethat theabove Information
IL mt.I agree to comply with all crystal county ordinance and mate laws PERMIT ISSUANCE FEES PAID:
relating to building construction,and hereby autho em representatives ofthls
Zcity to enter upon the above-mentioned property for Wpeclon purposes. ALMORADDTOMECH. Date RCtel f#
_ (We)agree to save,Indemnify an d keep harmless the City of Cupertino
against liabilities,judgments,comaand expenses which may In anywayaceme AIR HANDLING UNIT CFO 10,000 CFM) SUBTOTAL'
age amt said City In cons cluence of the Starting of this permit.
X/1 AIR FIANDIJNG UNIT(OVER I0,000 CFM) CONSTRUCTION TAX
Si rature of Applicant/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the a ppllcant orfutu or building occupant store or ha odic hazardous I[EATING UNIT CM 100,000 BTU)
material as defined by the Cupertino Mu Ndpal Code,Chapter 9.1 7,and the Date Recel t#
I lea IIt and Safety Cod atL+—.S1tortion 75532(a)i HEATING UNIT(OVER 100,000 BTU) TOTAL
Y.TNIII the appliant Men building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air armamimnts as del and by the Bay Arca Air
Qua llty Management Dist BOILER-COMP OHP OR 100,000 BTI.
❑ f4�
Ye No I
havercadihehazaN ouarmteAalsmqulremenhunder Chapter6.95 of MOILER-COMP(OVER 100,000 BTT)
�x the Califomoa Health&SafetyCode,Sections 75505,25573 and 75534.1
understand that if the building does net currently have a tenant,that It is my NEW RESIDENTIAL MECIL SQ.FT.
responsibility issuance
roti(ythe occte m0cnt fthe pancy. rcments which must bemet Cly`, r e99z
psponsibivanae of anot Certificate ncy. I Ott,
rCfY
Owner or authorired agent Date ISSUED BY:
TOTAL:
OFFICE COPY