24022 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
•
Building Project Identification PERMIT NQ ,�
Building Address: Z
Ut2b ea� .
22
ry s ante: one: A A
CITY OF CUPERTINO-BUILDING DIVISION
lift
cano-aaor.wrm: uc.No: APPLICATION if PERMIT ���/ 711
2- BUILDINGELECTRICAL.PLUMBINGMECHAMCAL CATEGORY CONTROL M
Arch tett/Engimee Lk.No:
1 QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address lk , Qj ee Pr I �J -s PERMITISSUANCE1:1 1:1 1:1LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am hemend under provisions ofChapter9(commnc- APPLIANCFSRESIDENTUL ]OB DESCREMON
ingwith Se Uon7f1(())of Division 3ofthe BusiMmand PrefesslonsCode,and my _
Inc..Is lI..!a Q and dtetl�o PANES -
IcenseC fI�1.L—(-�"LICN S �� (1- 4f^f��1� A��]=f'i••w{/-/Vy
Date / 1 Contrador
ARCHITECTS DECLARATION AI-IoOBAMP'S a
a0 7 I understand my plans shall be used as public records. OVER 10BB AMPS SQ.FT.FLOOR AREA $/SQ.FT.
wO
mf4!� Licensed Professional SIGNS ELFGTRICAL
<Q w OWNER- UILDER DECLARATION
Eli SPECIAL CIRCUIT/MISC
`!n
F' 4 Ihcrcby a(Orm thatlam exBemptfromthe Contractorb LicenseLaw(m the
O9F� following reason.(Section 7031 S,Business and Professions Code:Any city or TEMP.METER OR POLE INST.
countywhich mquirma permit tomnstruct,alter,Improve,demolbh,orrepair
'`�,�a.'ri anystmdurepriortoleb ame,aL requircstheappEcantforsuchpermitto POWER DEVICES
file a signed statement that he t licensed pursuant to the provisions of the
Contractors License Law(Chapter 9(commencing with Section 7000)of DWI- SWIMMING IDOL ELECTRIC
elon3oftheBusiness and ProfesseorsCode)orthatthe6exem therefmmand r VALUATION �a
S n (31.5 by any OUTLETS-
five
J
<� applicant fora permit subjects the applicant to a civil penalty of not more than
the basis for the alleged exemption. Any violation of Sectio7J
c. five hundred cuts.($501B. NEW RESIDENTIAL ELECTR SQFT.
r-11.as owner of the property,of my employees with wages as their sok Sf Bus ) -TYPECONSPRIICTION
�7a compensatlon,wllldo the work,and the structure is not intended or offered for
❑ sale(Sec.7W4,Business and Professions Code:The Contractors License Law
�SQ don not apply to an owner ofproperty who builds or improves thereorx and OCC.GROUT' RES.UNITS
who ducssuch work himself or through hisown empluyns,provided that such
improvement am not Intended oroRered forser.If,howcveq thatthilding or TOTAL:
Improvement bsold within omyearofcompldbn theowner-bu0derwill have
tdenofprovingthathedid not build or improve for purpose of sale.). QTY. PLUMBING PER FEE FLOOD LONE APN
r�v as owner of the property,am exclusively contracting with licensed PFRMI.I.ISSII
co undoesto construct the project(Sec 7064,Business and Professions Cade:
The Contractor's License law dm net apply to an owner of property who
-
Wilda or Improves thereon,and who contracts for each p5ojecb ALTER-D with a - WATER(EA) FEE SUMMARY
,,W1Rffactor(s)licensed Pursuant to the Contractors License Law. BAS FLOW PROTECT.DEVICE
LI I am exempt under Sec. B&P C for this neon
OUTSIDE FEES
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_
Owner RECEIPT M
WORKMAN COMPENSATION DECLARATION FD TUREL PER TRAP SCHOOLTAX Y_ N
�[hereby affirm that I have a certificate of consent to self-insure,ora RECEIPT M
certificate ofWorkers'Compemation Insurance or a rertified copy thereof(Sec. CAS EA.SYSTEM-1 INCA OUTLETS PARKFfE Y_ N
3800,Lab C.) RE=N
Policy Y GAS EA.SYSTEM-OVER 4(EA)
Co BUILDING DI VI S ION FEES
ny
citified copy b hereby furnished. CREASE/INDUSIRL WASTE INTERC13PMPAID
PLANCHECK FEE
Leri ied copy b filed with the city Inspection division. aa.
CERTIFICATE OF ER EMI`TIO.N FROM WOR KERS' GREASE TRAP se� PAID
COMPENSATION INSURANCE SEWER-SANITARY-S1OR.M EA.Zoom DOIC Recti t#
(fhb mesion recd nor be completed if the permit is for one hundred dollars
($100)orless.) WATER HEATER W/VENT/FLECTRENERGY EiL
_ N_
I notify that In the performance of thework forwhlch this permit Is Issued,
I shall not employ any person in any manner so as to become subject to the WATER SYSTEM/TREATING
Workers!Compensation Laws of California.Date
licant
Z Z NOTICE TO APPLICANT:]Lafter making this Certificate of Exemption,youWIDFN77AL PLMB. SQ.FL. 1
O should bvomg.abject to the Workem'Compemation provisions ofthe Labor TO _
N Codc,you=at forthwith comply with such provisions or the permit shall be 1 DIN
W j deemed revoked.CONSTRUCTION LENDING AGENCY SEISMIC _
CL I hereby affirmthat therce a mretructlon lending agency for the perform TOTAL: ELECTRIC FEE
MZ ante of the work for which this permit In Issued(See3097,Clv.CJ PLUMBING FEE
(.) 2 1<nder'.Name
U. F Landers Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW Ittrtifythat I have read this application and pate that the above information
C Lscornet.l agree to comply with all ettyand county ordinances and state laws PERMITISSUANCE FEES PAID:
relating to building construction,and hereby author e representatives of this
f.. N city to enter u pan the abovcmentlimd property for inspection purposes. ALTERORADDTOMECH.
Z
_ Date Receipt#
(We)agree m save,Indemnify an d keep harmiees the City of Cu part[no
O age last liabilities,judgment,coasand expenseaw hmay In anyway accrue AIR HANDUM
NG UT(f010,000 CFM) SUBTOTAL
ZAyynald City In mry
nauenre of the gra Ing th permit.
\�//\ AIR HANDLING IINI"1'(OVER 10,000 CFM) CONSTRUCTION TAX
Signature of Appll t/Contra or Date E(HAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATER LALS DISCLOSURE
WIIIMeapplla ntorfuturebuildingoccupantstonorhandleh..M.. HEATING UNIT(TO IDgOBO BTU) Date Receit#
mocri.l a deOmd by the Cupertino Municipal Code,Chapter 9.12,and the
Health and Safety Code Section 25532(.)7 HEATING UNIT(OVER 100,000 BTUI TOT
0 Yes UN.
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
which emit hazardous air contaminants as deBmd by the Bay Area Air
Quality Management tDistrict? BOILER-COMP DHPOR 100,IX17 BTU)
Yes ❑No Q p�
1 have read the harimicus materials requirements under Chapter 6.95 of BOILER-CO.MP(OVER 100,000 BTU) 6J
the Californu Health&Safety Code,SMiom 75505,25533 and 75534. I
understand that lithe building does nm currently have a tenant that it Is my NEWRESIDENTTALMECH. SQ.Ff. JULresponsibility to notify the occupant of the mquircmenta which must W net U 28 199,2
prior to Issuance of a Certificate of Occupancy, s
01 ur Mid
1.,,�
Owner or authorlud TOTAL:agent Date — ISSUED BY-.— V
OFFICE COPY