24373 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification - PERMIT NO
B.0diag Address' 24373
la. WI Id-(lOvaev Cv "n0
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t 5 CITY OFCUPERTINO-BUILDING DIVISION /
contactor. m,e: Lde.No: APPLICATION I PERMIT L Ge'2
Arohlr ./Engineer, Stn)I Llc No: BUILDINC.ELECTRICAL-PLUMBING-MECFIANICAL CATEGORY CONTROL p
QTY ELECCRIC PERMIT FEE BUILDING PERMIT INFO
Address: PFJMTISSUANCE El ❑ ❑
LICENSED CONTRACTOR'S DECLARATION -
IherebyalfUmthat lamgemsed under provisions of Chapter 9(commenc- APPLIANCES-RESIDENTIAL OB DESCRIPTION
It...I lectin 70W)ofd affon3oflFe Busineseand ProlesslowCede,rend my �'��
Incense Is In fug(ora and effect. PANELS 10
Lianw Chss LI[.N
Date Contractor UP TO 2DO ANTS
ARCHITECTS DECLARATION 201.1000 AMPS
2 I understand my plane shag be used as public records. OVER 1000 AMPS SQ.Fr.FLOOR AREA S/SQ.Fir
O SIGNSELECTRICAL I ( ^-
Licensed Professfowl - I,., ® IN
< OWNER-BUILDER DECLARATION
Z a a SPEClALCIRCUIT/MLSC _
t"' following reason.
Sutlamexempt fromBusiness
dPrafContractor',Li enseCade:
Lw fort he
pp ocaudyngreason.ots.en7031.5,8ualness and Professions Code:Any ctepor ir
Ok,Z � . 177ttP.METER OR POLE INST.
countyctore prior.its
pertNttomwoaq doestheaplieset moWh,or repair
qqq any structuretatemetlhat he is line rsed pursuant t the provision of the POWER DEVICES /Y1
5 Ole a signed statement that he V licensed pursuant t9 the provisions of the V
3u, Contractor's License Law(Chapter 9(commencin,with Section 7000)ofDivi.
�OS slon 3 oflhe Business and Professions Code)orthat he 1.exempt therefrom and SWIMMING POOL ELECTRIC _ ALUATIO -
O F the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWTTCHES bRXTURES
applicant fare permlteubje the applicant to a civil penalty elect more than
{Q Ive edreddo11a.01500). WDFN77AL ELECTR STORIES TYPE CONSTRIX:TION SQ.FT.
I as owner of the property,or my employees with wages as their sale
c p nution,wgl dothework,and thestructua is not intended or offered for
r) to(Sec.70K Business and Professions Code:The Contractors License Law
j$ oes not apply to an owner of property who builds or Improve,thereon,and� OCC.GROUP RIS.UNITS who does such work himself orthrough his awn employees,provided that such
impmvements am not lntendW oroffered for ule.I/,however,the building or TOTAL:
improvement iswld withinowyearofcompletion,theewner-builderwill have
tden o(proving that he did not Wild orlmpown for purposedfsale.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to mnehuct the pmject(Sec.7044,Rusiwss.nd Pmfesslens Code:
The C.Me ctoe.License Law does net apply to an owner of property who
n
build. car Improve,therem,and who ce tracts for such IxViece with a ALTER-DRAIN kVENT-WATER(EA)
Tl�ado,(.)liaised pursuant to the Contractor.Licences,Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY•
J I am exempt under Sec. B k P C for this recon
•
DRAINS FLUOR ROOF,AREA,COND. SANITARY Y N_
FEES
Owner Date
WORK MAN COMP UI95ri DECLARATION RECEIPT R
C31 hereby affirm that I have a certl0ate of consent to saInwFIXTURES PER TRAP SCHOOL TAX Y_ Nl(-
re,or RECEIPT s
380D,LabCr) orkers'Compensatlonlnsurancemacertifled copy thereof(Sec. ' GAS EA.SYSTEM.1 INC40UTLE15 �--. PARK PEE Y N
Policy p RECEIPT p
CAS.EA.SYSTEM-OVER 4(EA)
Com any BUILDING DIVISION FEES
Certified copy b hereby td. GREASE/INDUSTRL WASTE.INTERCEPTOR PLANCHECK FEE
Certified copy V tiled withh the
he ccity Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' CREASETRU' PAID
COMPENSATION INSURANCE
(Thiswcilon need no,becompleted lfthe permit isforons hundred dollars SEWER SANITARY STORM EA,200FT. Date RCCCI tit
(5100)erfWATER HEATER W/VENT/ELECTR ENERGY FEE Y N
Icertl(y that In the performance of lhewak(or which this pemIssued,dt is Issued,
I shall not employ any person in any runner ro u to become subject les the WATER SYSTEM/TREATING
Workeri Compensation Laws of Callforela.Date PAID
0 Z Applicant NEW RESIDENTIAL PLMB. SQ.FT. Date RCCCI tel
Z 0 NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
should become subject to the Workers'Compensation provialone of the Labor TOTAL:
Cade,you most forthwith comply with such provisions or this permit shall he DIN
deemed revoked.
O. c CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that them is a construction lending agency for the perform- ELECTRIC FEE
Z anmofthcworkforwhiehthbpermR Fslswed(Sec.3097,Cie.C.) T T ELECTRIC FEE •—"'—"
V 0 Lender'BName
LL I— Lender's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW 1artify that l have read thi.appilatlonrend nate thattheabove lnfonwllen
IL ismrrttt.l agree to cemplywith all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
>. W al.tingtobuildlegmwhuction,anhere
d by.wWrixerepresenrativesafthis
U) city to enter upon the above,mentioned property for Inspection purpose,. ALTFR OR ADD TO MUCH. Date RCCCI 1N
(We)agree to save,and cruelly an d keep harmless the City of Cu portion
V against liabilities,Odgments,"a and expenses which may in any way same AIR HANDLING UNIT ITO 10,000 CFM) SUBTOTAL:
agaWtcid Ci Nconsryuence of the granting of this permit.
K�t�e lall9� AIR HANDWNGUNIT(OVER IO,00CFM) CONSTRUCTION TAX
IgnsNreel Applicadetractor Data EXHAUSTHOOD M'/DUCT) CONSTRUCTION TAX PAID:
FIA RDOUS MATERIALS DISCLOSURE
Will the applicant or fuwre building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date RCCCI tq
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health and Safety Code Section 25532(a)2 HEATING UNIT(OVER 100,(1(0 BTU) TOTA • —
RYes No
llltho applicant or tore building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which omit harardous air contaminants as defined by the Bay Area Air
Qua lity Manegcment District? BOILER-COMP OHP OR 110,000 BTU)
4Yu ❑No
haveaa Health
Safely ode, exons 25Snbundcand 25546.95 of 80R.ER-COMP(OV[RIW,000 BTU
She Calunderstand
t Health building Safety Code,S t curr 25505,ve a t cad 25534.1
understand that If the notifytheoccupant not a rreellyhevea tenant that It Is mybe
NEW RESIDENTIAL MGCH. SQ.Irf 11� 8
responsibility to bility to of.Cthe cats o occupant of the mquircmente which must be met
prior to Issuance o(a Certlllate olOttvpanry. as�
Owner or authorized agent Date ISSUFDa:
TOTAL: v
IVU
OFFICE COPY