24397APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification
Building Addik nsa:
PERMIT NO.
24397
Wamc: one:
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BUILDING-E.FCMCA4PLUMBINGMPCIIAMCAL
Cuou. 'e Ni Lie•NO:
rchlted/Engineer.
ALic. No:
CATLGOAY
CONTROL M
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Address:
❑
PERMITISSUANCE —e
LICENSED CONTRACTOR'S DECLARATION
I herebySection hat I am sof Chapter9(te,and c
ing with Section force diedn3 afthe Bupneesand Pro(enionsCode,and my
limens Is Ins form and effett.
License Glen Con
Date Contnttor
ARCHITECT'S DECLARATION -
I understand my plansshallbe used as public records.
rds.
Licensed Professionalrm
OWNERULDER DECLARATION
I hereby affirm lisam exempt I axemp[!rom the Contractor's License LAW for the
tollowlegreason.(Senion7Q115, Businenand Prefssions Code: Any qtyor
muntywhich requiema permit tomrutruct, alter, Improve, demolbh,orrepair
anystmu mpeortoiUa mance,al m(uimstheappbmntforsuchperoutto
file a signed statement that he is Rcenaed pursuant to the provisions of the
Comment's License IoW (Chapter 9 (mmmenctng with Section 7000) of Divi.
slon3 otthe Buslnenand Profeaslore Code) nether he h exempt therefromand
the burnt fees pemeged jects the exemption. Any
the basis for the reneged exemption. Any violation olnMlon not
ation Penalty of not mo rel hon
re anyLic
five hundred dollars (SM.
nL as owner of the property, or my emptoyees With wages as their sole
compensation, will d o the work, and the structum is mat Intended or offend for
sale (Sec 7044, Bualneas and Proleselom Code: The Commerce, License Law
does not apply to an oweer of preperty who Wilds or improves thereon,and
donsuch work hlmavl or through hlaownemplayms, provided that such
improvement arc not intended oroffered forsale. If, however thebuilding or
improvement tsold within ane yea rofcomplellon, the owner-bullderwOl have
thW.kurden of proving that he did not build or improve for purpose of sale.).
U L as owner of the property, am exclusively contracting with licensed
contractors tocorutmctthe project(Sec.7044, Buslrmisand Profenlma Code:
The Contractor's License Law does not apply to an owner of property who
Wilds or Improves thereon, and who contracts for such p(njeets with a
m dor(s)licensed pursuant to the Contractor's Llmose Law.
U I am exempt under Sec. B so
& P C for this reanOUTSIDE
APPUANCFS ENTIAL
` Icxp,puycymrt
a ^ � '� �tlrra
`(�iia�rnw
PANES
'IOW AMTS
TWO
SQ. FT. FLOOR AREA
S/SQ.FT.
E CA
LC T/MLSC
p ETpt OR TOLE INST.
POWER DEVICES
'WB1tM1NC IA70L F2.ECTIEC
VALUATION
All
t�t O ��
7 1
UTLETSSWITCHFSFIXTURES 1
NEW RESIDENTIAL ELEC7R_SQ.I7,
STORIES
TYPE CONSTRUCTION
QTY. PLUMBING PERMIT FEE
OCC. GROUP
RFS. UNITS
PERMUISSUANCE
pLTEiDRAIN&VENT• WATER (FA)
FLODDZONE
APN
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
FEES
DRAINS. FLOOR ROOF, AREA, COND.
PER TRAP
SANITARY Y N _
RECEPI• Npp(•I.URM
Owner Date
WORKMAN COMPENSATION DECLARATION
❑I hereby ork that I have o l rt me of consent d apytheure, ora
MOO, Lab of Workers Compevallanlnuunnm ne certified ropy thereo!(Sec.
3800, Lb CJ
Policy tl
SCI-IOOL TAX Y N
RECEIPT N
GAS EA. SYSTFAf•11NC1OUTLETS
PARK TIE Y_ N_
T N
RECEGAS
[A. SYSTEM -OVER 4 (EA)
m y
nrtiflsd
DINC DIV]
BUILDING DI VISION FEES
copy h hereby te ty
Certified mpy h filed withh the city Inspection division..
CERTIFICATE OF MEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Th.r l..) n need eat be completed lithe permit t!aeons hundred dollars
(S10O)orfy that he any person an o to become permit is nosed,
Ill not employ in anf the worturner
I shall not employ any person In any manner ao u to become mbjett to the
Workers Applicant Compensation hove of California. Date
NOTICnt
atter makingthissation procate is Exemption, you
NOTICE become subject Compenasonprovhlm permits of salt be
Code, ou=r eubKwith co ply With
dermad you =at forthwith comply witheach provisions ortht permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby aftirmthat them is a construction lending agency for the perform
ance ofthe work for which this permit Is Issued (Sec 3097, Civ. C.)
Lender's Name
Lender'sAddress
1 mrtifythat I havercadthhappBntW. and pate thatthe above tfornution
hmrred. I agreeto comply with all city and county ordinances and pate laws
relating tobuieding mestructlon, and hereby authorize representatives of this
city to enter upon the ve-mentioned property for Inspection purposes,
(We) a to uvp 1 7 N j an d keep barmien the City of Cu Ermine
agams 11 ,jadg nt,mpa and expenses which may in anywayamrue
agaim In con (thegnndng of this Pertyy.
I/O CA
Igm o p tra r Date
HAZAR OUS ATERIALS DISCLOSURE
Will the applicant or to rebut ingoccupant store or handle hazardous
matertlasdefinedbythe a oMunicip.ICode,Ch.pter9,12,andtha
Ilealthand SafetyCode�+. Sedion25532U)?
Yes , N No
Will the applicant or future building occupant use equipment or devices
which rout hazardous air contaminants .,defined by the Bay Area Air
Quality Management District?
Yea No
e read the haze ous materials requirement underChapter 6.95 of
r eGlltomia Health&Safety Code,Ssdions25505,75533and25534.1
understand that if the building does not currently have a tenant, that it is my
rnpotoiIssuato notifytheoctsofotthenqulrerrcnt which must he and
prior to Issuance ole Ccrtiticatc o(Occvpanry. -
GREASE/INDUSIRL WASTE INTERCEPTOR
PLANCHECK FEE
PAID
Date Recel tN
GREASETRAP
SEWER -SANITARY -STORM FA. 200FT.
WATER HPATEt W/VENT/CLECTR
ENERGY FEB Y N
PAID
Date Rcmi tN
WATER SYSTEM/TREATING
NEW RES[ DENTIAL PLMB. SQJrf.
2
IOTA
BUILDING asp
SEISMIC FEE
TO?%.: ��
ELECTRIC FEE rs
``
QrY. MECHANICAL PERMIT FEE
PLUMBING FEE �.
MECHANICAL FBE
PERMIT ISSUANCE
FEES PAID:
Date Recei 1N
ALTERORADDTOMECH.
AIR HANDLING UNIT (TO 10,000CFM)
SUBTOTAL:
AIR HANDWNG UNIT (OVEt 10,000CIM)
CONSTRUCTIONT
IXHAUS'TIIOOD(W/DUCT)
CONSTRUCTION T X PX D:
Date Rec
HFATINGUMT(TO100,0001IM
_
HEATING UNIT(OVER 100,000 BTU
TOT L'
VIiNTILATIONPAN(SINGLERESID)
ISSUANCE DATE
reg p tl p
h� A p D
OCT
/�I/���/a�/y�1 /�
ISSU;D11Y:t�VTr�Y1
- �N-F:fVtr`—
BOILER -COMP OHP OR 100,000 BTU
BOILER-COMP(OVIB2100,000 BT U)
NIiWRES[DENITALMECil. SQ.PI'
Ownerorauthon.dagent r Date
'IOTA L:
OFFICE COPY