24129 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Protect Identification PERMIT NO.
Building Address: . - 24129
a
ams: one:
1 -
neva ^C CITY OF CUPERTINO-BUILDING DIVISION
on°selfie N': �J APPLICATION /'PERMIT
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De Nre BULDINGELECTRICALPLUMBING-MECHANICAL CATEGORY CONTROL p
Architect/Engineer. Lac.No:
,QTY - ELECTRIC PERMITFEE' BUILDING PERMIT INFO :
Address: S:fIa^^ PERFRTISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby aHmm that am licensed under provWonsof Chapter 9(commena APPLIANCESRESIDENTIAL OB DF$C
Ingwlth Sectlon7OW)of Divisim3ofthe Busueaand ProfeulansCode,and my � � ^
limnm a in full rce d effect. o $9 PANELS . - `
License( m Lica
Data Contractor UP TO 2DO AMS
ARCHITECTSDECLARATION 201-1000 AMPS -
,Z I understand my plana shall be used a public records. OVERIOJOAMPS SQ.FT.FLOOR AREA $M.FT.
k Licensed Professional - SIGNSELECTRICAI:
<�6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MLSC ' ®_
to., � Ihereby affirm that am exempt from the Contractor's License Law for the _ p I Z'
ZO Z qq following mum.(Section 7031,5,Business and Professions Code:My city or \ I\��I D �
P Ip"' countywhichrequmesaper wcoru cr alter,lmpmvgdemollah,orrepalr TpMP'METEROR POLE MST. . 6 J- ..✓
�5 anystmc mpr WiftbwancgalsorequimatheappRl ntforeuchperMtto POWER DEVICES
J b����Z
qw file a signed statement that he is licensed pursuant to the provisions of the O Coatmear§License Law(Chapter9(commencingwithSection7000)ofDivi- D J
slot,3°flhe Business and Professions Code)orthat he Is exempt therefrom and SWIMMING POOL ELECTRIC VALUATION
the basis far the alleged exemption. Any violation of Section 7031.5 by any OU LETSSWITCI ES-FIXTURES
applicant for a permit subjects the applicant to a civil penalty of not more than
five hundred dollars($500). NEW RESIDENTTAL ELECTR
❑I,as owner of the property,or my employees with wages a their sale SQFT' STORIES TYPE CONSTRUCTION
compensation,wi ldo the work.and the structure Isnot Intended or offered for
' O isle(Sec.7094,Buelnea and'Professions Code:The Contractoe.License Law
does not apply to an owner of property who Wilder improv.thereat,,and - OCC.CROUP RES UM75
CC.. who dousucle work himself°rthrough Ms own employees,provided that such
improvements are not intended or offered for ale.If,however,the building be TOTAL:
Improvementusoldwithnoneyearofcompletio4theowner-W OderwOlhave "
tlF-,L sof proving that he did not Wild or improve for purpose ofsakJ. QTY, PLUMBING PERMIT FEE FLOODTDNE APN
LJ I,ae owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
rontrachas m coulruct the project(Sec.7044,Business ami Professions Cade:
The Contractor's License law don cot apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
WEds or Improves thereon,and who contra for such pRojecu with a FEE SUMMARY
or tjactor(s)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
LJ I am exempt under Sec. B&P C for this reason
RB
DRAINSFLOOK ROOF,AREA,CONI. SANITARY Y N
Owner Dm RECEIPT p
WORKMAN COMPENSATION DECLARATION FIX.NRF-PER TRAP SCHOOLTAX. Y_ N_-
❑I hereby ork that I have o cent a c of consent to copy thereof
ora _ RECEFf 8
3800,abte ofWorken'Compensatlonlnsurance oracertilled ropythereo((Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y_ N_
3800.Leis C.) / l/ RECER'TM
Pollry Byf�(/J�y{G��{��_.Qy. [/ T GAS EA.SYSTEM-OVER4 BIM BUILDING DIVISION FE ES
Com an fy
�eURica copy s hereby turn a city GREASE/INDUSTRL WA5IE INTERCEPTOR PLANCHECK FEE
ertBied copy Is(fled with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM P.A.200FT Date Recei tN
(Thlssecron need not be completed If the permit Is for one hundred doll..
(81 Wl or les°') WATER HEATER W/VENT/ELECTA ENERGY FEE Y N
I nertifythat in the performance of thework forwhich this permit I.Issued,
I shall not employ any person in any manner so as to became subject to the WATER SYSTEM/TREATING
WmIc..'Compen.firm Laws of California.Date' PAID
Z Z Applicant NEW RESIDENTIAL PLMB. SQ.Fr.' Date Remi t#
NOTICE TO APPLICANT.If,after making this Certificate of Exemptlon,you
should became subject to the Worker'Compensation provisions of the Labor TOT
y Code,you at forthwith comply with such provisions orthis permit shall be BUILDING FEE
W 9 deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
Il I hereby affirm that there las construction leading agency for the perform ELEC'T'RIC FEE
M Z an.of the work forwhich this permit is Issued(Sec.3097,Civ.C.) TOTAL:
C) O lender'.Name PLUMBING FEE
F Lenders Address - QTY. MECHANICAL PERMIT FEE
O W Icerhave readthie applicationand stauthattheabove Information MECHANICAL FEE
UfythatI
Iemrrect.I agreeto comply with all city and county ordinances and nate laws PERMIT ISSUANCE FEES PAID:
). C' relatingto Wilding construction,and herebyauthorlu reprearmativeso(this '
N cityto entero n the above-mentioned a for inspection purposes. ALTERORADDTOMECH.
~ ? (We)agree ave,Indemnify an d'keep property
the(City of Cupertino Date Receipt#
V against liabilities,judgments,costsand expenses which may In anyway accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
aga{mt said( in c nee of c�R granting of fle permit.
/�//-,,,,_ AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
(SlgnaLmmofA ant/Contrto ate pHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARD0 S ATERIALS SCLOSURE f�
Will the appllant or Inure building occupant store or handle hazardous, HEATING UNIT(TO 100,000 BTU) Date Recei
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health and Safety Code Section 25532(1)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑Yea r]No
Will the applicant or tutum building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air conuMnants as defined by the Bay Area Air '
lily Management District? BOI(.ER-COMP PFR'OR 100,000 BTU PAID
Yea No
have read the huar[ous materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU)
the California Health&Safety Code,Sections 25505,25533 and 25534. I' Sip 4](1 ���
understand that lfthe building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. - SQFr m P J V
responsibility to notify the occupant of the requirements which must be met ^
prior to Issuance of a Certificate of Occupancy. "CITY ser.VUr.:T y 4
Owner or authorized agent - - Date TOTAL: ISSUED BY: 1
OFFICE COPY