24290 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT Nq, 4 2 9 0
Building Address: Z
1 (9.21)_ Alt
neva .. Thai APPLICA I IUN 5UMMI I I AL VAIL
Q/)/ sc�A7 7cclll� CITY OF CUPERTINO-BUILDING DIVISION !
Q n
rintia"nr. ame: Lie.No: APPLICATION /PERMIT lr`JR4�`le 1
X%OhV234/6- BUILDINGELECTRICALPLUMBING-MFLFIAMCAL CATEGORY CON. OLX
Architect gtneer. Lie.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: PFRMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
Ihereby affirm ithSecion70thalamsiolicensed 3ofthe usineskalnnaof Chapter ssions9de,and c MPLIANCESRESIDENTIAL JOB DESCRIPTION
ingwlt I Senfon 9000)of DiWion 3ofthe Businnssand ProledslOna Code,and my
I
la In full fyape and effect. �2 3 ^ /G rANEIs
Lien Clan JJ Lm.X L!
Date . Contranor , UUiAT N
LIE 10 2W ANTS
ARCHITECFSOEC RATION 0AMI'S _
u07 lundentand my pbnsshaB be used as public remNOVER1
n. OVER 1000 AMT'S SQ.FT.FLOOR AREA E/BQ.FT.
Licensed Professional SIGNS ELECTRICAL + _
S OWNER-BUILDER DECLARATION SI'CCIAL CIRCUIT/MLSC ED 41 I N
]t- � owingr1 hereby asormthat I Sectio 7031exempt from the dProfctoraLicense Law for the 1� E R
4p p
following requires
permit t,Buafnea and,imponve, Code:Any dtyor /
countywhich requlrcaaperrNttoconstrod,alter improve,demolish,orrcpalr TFTIP.METFR ORIOLE INS7.
�gC anyatmeture pdorwits Issuance,alsorequirestheapplicint forsuch permit o POWER DEVICES / Q Q� RZ
O file o signed statement that he Is llansed pursuant to the provisions of the 1 I
�3On�
Contractor's License Law(Chapter 9(coma mencing with Section 9000)of Divi- SWIMMING IVOL ELECTRIC
aon3ofthe Busineaand PmtevlomCode)orthathebexem nd themfmmaON
the basis for the alleged exemption. Any violation of Section]011.5 by any
,p5J 65 applicant foraForm! is the applicants°a civil perulty of not mornthan OUTLETSSWITCHFSFIXTURFS
c. o five hundred dollars($SM.
I,is..at of the limperty,or my employees with wages as their sole NEW RESIDENTIAL ELECTR SQ.FI. STORETYPE CONSTRUCTION
compenatlon,Busio the ness
ess and work,and onahe tCode:
durc ucros not unactoetended or offered Law
O sale(Sec. ppy to anowand Professions Co Wilds Contractors thereon,
law
does not
who dinoisuch
tornowner ofpropertyhisonemporees,proted that such
�5^ whodocsuchworkhlmxlf or through hisown employees,prwidedthatsvch OCC.GROUP RFS.UNITS
Improvements am not Intended oroffered forsale.If,however,the building or TOTAL:
improvementisldwthnone)earofcompldion,theowner-WiMerw0lhave
th mMenofpmving that he did nabundorimproveforpurposcoftelc.). QTy. PLUMBING PERMIT FEE
LJ L as Owner of the FLOOD ZONE APN
Property, Se exclusively contracting with Banned PERMIT ISSUANCE
contractorsContct construct the project(Sec.7044 Business and Pf pro Ons Code:
The Contractor's Improves
License law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER ffN
bullda or Improves thereon,and who contracts for arch plojecta with a
co,Il[TadoK.)Bansed pursuant to the Contractor°License Law. FEE SUMMARY
BACK FLOW PROTECT.DEVICE
IJ I am exempt under Sec B&P C for this rcaaon
DRAINS FLOOR ROOF,AREA,GOND. SAMTARY Y— N_
Owner Date RECEIPT p
WORKMAN COMPENSATION DECLARATION
ON hereby affirm that I have a certificate of consent to aelf-insure,Or a FD�PER TRAP SCHOOL TAX Y— N—
anlllate Of Workers Compensce
ation Insurance ora rt04•d core
pytheof(Sec. RECEIPT X
3800,lab C. GAS EA.SYSI'EM-1 WC.40I17LE15 PARK FEE Y— N
Yolicyp �•'2[�
RECEEPT
GAS G.SYSILMAVER4(EA) p
Com acts ,A BUILDING DIVISION FEES certtred c° yl,heaby fumlahed.' GREASE/WDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certified ropy V filed with the my Wpection dlWslon.
/' CERTIFICATE OF )fEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SAMTARY-STORM FA."FT. Date RC i t#
(Ihlsadion need not be completed if the M
pert b for one hundred dollars
(El W)orle aJ WATERHFATERW/VENT/ELECTR ENERGY FEE Y N
Ira- thatin oy say
person nce
thework so
rwto become
Permit is issued, 1 —
1 shall not employ any person f any rm as to bemrrc subje t to the WAT7ERSYSI.EM/TRrA.UNG
Workers'Compenation laws of California.mia.Dae PAID
O Z Applicant NEIN RESIDENTIAL PLMB. SQFT. Date Recei t#
Z NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you
should beconn soli to the Workers'Compensation provisions of the Labor TOTAL:
P: f/) Code,you most forthwith comply with such provisions or this permit shall be
LU > deemed revoked.
BUILDIN FEE PaOaa
LU
C
CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there R a ronatructfon lending agency for the perform- ELECTRIC FEE
ante of the work for which this permit V LcwN(Sec.309],Civ,C) E
TOTAL: ELECTRIC EEE
0 lender'.Name
LL I- Lendera Adareas QTY. MECHANICAL PERMIT FEE MECHANICALFEE
O W I artifythat l have mad thisapplialionand state thatthe above information
iacorm<.I agree to comply withal]cityand county ordinances and state laws PERMITISSUANCE FEES PAID:
} N relating to building construction,and hereby authode repmsentatives ofthis -
Z city to enter upon the abovementioned property for bwpaction purposes. ALTER OR ADD TO MECH.
(We)agree to ave,Indemnify an Of keep harvdess the City or Cu ped in° Date Receipt#
V against liabilities,judgment.,costs arad expensed which may In any wayaaroe AIR HANDLING UNIT 8010,000 CFM)
against said in consequence of the granting of this permit. SUBTOTAL:
�/ AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
A /ia i Q-29'9 _
Signa A Bcan DOLISor Date EXE1AU57 HOOD(W/DUC'D CONSTRUCTION TAX PAID:
NAZA RDOUS MATERIALS UISCL or hand
Will ia the .fined by or
urebuilding oicipan ode,storhapten 9.1
.le h and
HEATING UMT(TO 100,000 B'!U) Data Recel t#
material as defined by the Cupertino Municipal Code,Chapter 9.12 and the - _
Health dna Sandy cad ction 25532(a)I HG77NC UNIT(OVER to0,000BTU) TOTAL• COK
Ya ur
WIIHhe 3pplrantorr cont building as defined
ndby the Bay Area devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit havrdous air contaminants as defined by the Bay Arca Air
lity Management DjnT BOILER-COMP(3FIP OR 100,IX0 BTU)
Yrs No pp�� p p�
have read the has ou maerials requ lrements under Chapter 6.95 Of BOILER COMP(OVER 100,000 BT U) P A y
the Calfiornto health&Safety Code,Sections 25505,25533 and 255M.I
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH SQ.Fr.
responsibility to notify the occupant of the rcqu imments which most be met SEP 29 t o�
priotuyy�uance of a Ccri ifiate of 0ccupa racy.
�/rr�
G • IsnM1v
thonud agent Data TOTAL: ISSUED BY:
OFFICE COPY