24281 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES- USE BALL POINT PEN ONLY
Building Protect Identification PERMIT NO
Buii(gpdd 24281
t T.�aarm: U er-F_/fi-5,O l hone: A A
N CITY OF CUPERTINO-BUILDING DIVISION
c °r'N' -- APPLICATION I PERMIT
"� BUR.DINC-ELECIMCAI MUMBINGMECHANICAL CATEGORY CONTROL
A r & No:
S� n QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Add.. 0 r r'�. PEIthgTI55UANCE �� ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l an licensed under provisions of Chapter9(rommenc- APPLIANCESRESIDEM7AL BDESCRIPTION
Ingwith5ettion7D010of Divislon3ofthe BuslnessandprofessionsCude,andmy n.�a,a�
license lain full force and effect. PANELS /y r-J13f`T,
License Class Grp
Date Contractor UP TO 2DO AMPS
\'
ARCHITECT'S DECLARATION 1014000 AMPS
q�q�vv re 2 I understand my plans shall be used as public records. OVER I OCO AMPS SQ.FT.FLODR AREA $/SQ.Fr.
Licensed Pr°fcmlmul SIGNS ELECTRICAL
<<¢ OWNER-BUILDER DECLARATION
7 p., Thereby affirm that lam from the Contractors License Law for the SPECIAL CRtCOr/M15C
Foo qq�y following masseur.(Section 7631 S,Business and Pro(esslons Code:My city or TEMP.METER OR POLE INS(.
z 7 wuntywhkhrequimapermlttoromtmct,alter,impmve,d..Wh,orrepalr
q°� 3 anyrtru mprlorto Beim.nee,aLsonquire.the.pph..tfonuchperMtt. POWER DEVICFS
F <� file a signed statement that he b licensed pursuant to the provisions of the
3µ Contractors License law(Chapter9(commencing with Section 7000)of Divi-sioSWIMMING IDOL dECIlIIC VALUAT/Q�>♦
O J the basis for the
esselle e d Professions Any)viothat lation is exempt th31.5 by rad � ev
fb�n the besot for the alleged exemption. Any t tolacivi of nacilon 761 cr by any OfSR.E75SWITCHESH%'1'URFS
<� appHcantfor a permit subjects the applicant too civil penalty door more than
five hundred dollars MM. NEW RESIDENTIAL ELECTR SQ,FT. STORIES TYPE CONSTRUCTION
❑I,as owner of the property,or my employees with wages as their sok
comperuedon,willdothe ori.andthestmn core notintended or offered for ,
5
510
sole(Sec.706q Busbuss and Prof....Code:Th.cmun dee.License law
2 does not apply to an owner of property who Wilds or Improves therem,and OCC.GROUIs RFS.UNITS
who doessuch work himself°rthrough hlsown employees,provided that such
Improvements are not intended orudered forsale.If,however,thebuilding or
Improvementissold withinone)Baro(cmnpleiomtheowner-budderwlll have -
this of proving that he did out build or improve for purpose of sale.). QTY, PLUMBING PERMIT FEE
1,as owner of the property,am exclusively contracting with licensed HADD ZONE APN
contractors to construct the project(Sec.7044,Business and Professions Code: PERMIT ISSUANCE
The Contractor's Llceme Law does not apply to an owner of property who ALTER-DRAIN kVENT-WATER(FA)
Wilds or Improves thereon,and who contracts fee such pipleets with a FEE SUMMARY
,�5!T-ctm(q H.ren d pursuant to the Contractor'.License Law. BAIX FLOW PR077iCT.DEVICE
c LJI am exempt under See. B A P C for this reason
.
OUTSIDE FEES
Owner DRAINS FLOOR ROOF,AREA GOND. SANITARY Y_ N—
Date RECFlIeC M
WORKMAN COMPENSATION DECLARATION FIXTIRtES PER TRAPS HWL TAX Y N
E31 hereby.dm orthat I have a certificate of consent to self-Insure,or a RECEIPT Y
certificateo(Workers•Comperuati°n Insurance ora credited copy therrof(See. GAS F.A.SYSTEM-1 INCAOUMETS PARK FEE Y N
PIlry 11 Tab C.) RECEIKM
P p CASTEM-OVER 4 LEA)
any S F.A.FA. BUILDING DIVISION FEES
er00ed copy is hereby furnished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
Certified copy Is filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASEIRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-SCORN EA.700FT. Date Recei t#
(Chissectionneednotbec°mpletdUth.pem tla(Dronehundreddollars
(SIM)mlessd ENERGYFEE Y N
I certlfy that on the performance work forwhich this permit is issued, WATERIIFATQt W/VENT/ELFGIR —
I shag not employ any person in any manner sa as to become subject to the WZt7FR SYSfFA1/TREATI
Workers'Compenstion la.vs of Callfomia.Date AID
O Z ApplicantyL, D Date Recei t#
Z O NOTICE TO APPLICANT;If,after making this Certificate of Exemption,you
should become subject to the Wurkan'Compensation provisions of the Labor ;� TOTAL: ft
N Cod,you rewat forthwith comply with such provisions or this permit shall be W I 1
deemed revoked.
CL F) CONSTRUCTION LENDING AGENCY (� jEj1SMIC FEE aZIherebyaffarmthetthe is corutructionlendingagenry for the pedorrn DA RIC FEE O
7 anceof the work(orwhich thla=t is,Ward(Sec.30W,Civ.C3
V C Lender's Name PLUMBING FEE
LL F Lender'.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW I.Aifythatl WvereadthiseppHcationanddatethattheaboveinf..tion
1 bcorrect.Iagreetocomply with all WY and county ordinanmand state laws PERMIT ISSUANCE FEES PAID:
>. W relatinglo bofWingconstruction,and hereby authorize representatives oftht,
F Z enterupont abo.mentlonecipropertyfor Wpidjon see. ALTERORADDTOMECH. Date Receipt#
e)a to ve,inde fy an d keep bar
the f Cu Ino
V a airs IHab toes pdgmer 'cortsaMexpenenwhkh ma yway arae AIR HANDLING UNIT(C010,OODCFM) SUBTOTAL:
bol C incon n this pe yn
I ( AIR HANDLING UNH(OVERIO,000CFM) CONSTRUCTION TAX
ren Applicant/Contractor Da t EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUSIALS DISCLOSURE
Will the applicant or bug ding occupant store or hand le havrdous HEATING UNIT(110 100,0D)BTI!) Date ReceI
material as defined by the Cupertino Municipal Code,Chapter 9.1 1,and the
Health and Safety Cade Section 25532(a)7 I IEATTNG UNIT(OVER 100,000 BTS)) TOT
I�I Yes r]No
Illthemt appRcausair contaminants
oaupandby equipment Area
device VENTILATION FAN l51NGLE RESID) ISSUANCE DATE
which eMtharomm adtiiet? antset defined by the Bay Area Alr
. Quality Mawgcrrcnt DlsMct7 BOILER-COMP OIR'OR 100,0(D BTI))
4Yes ❑1'"1 No ^
haii.a e.Ith&S' fbt materials underChapter Cbap534. I5 of BOILER-COMP(OVER 100,000 BTU) 1 N
the Uli(omla Health A Safety Code,Sectlosu 25505,25573 and 75536. I
understand that t(the building does not corrently have a tenant,that It 6 my NEW RESIDENTIAL MECH. SQ.Fr SEP 28
responsibility to notify the occupant d the requi mentswhkti must be met 1`
prior to isuanre d a Cent iflrateof Occupancy. CII t'
VC-4-:111,
Owner or authorised agent Data
TOTAL: ISSUE
OFFICE COPY