24153 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building ProjerI Identification PERMITNO.
Building Address:
24153
J O _ d O.fK✓/�L� I/E.
P one: A A
�rilN9ES /\ _iiGC ZS--7-`� -754 CITYOFCUPERTINO-BUILDING DIVISION _ Z
Contractors Name: Uc.No: -APPLICATION If PERMIT
BUILDING-ELECIRICALPLU.MBING-MECHAMCAL CATEGORY CONTROL#
Architect/Engine,. Lax.No:
_ QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMITIS5UANCE . ❑ ❑ ❑
`LICENSED CONTRACTOR'S DECLARATION
I hereactionn)(X) lam Bcenseduederprosancl of Cssions9(conunm APPEANCFSRESIDENTIAL JOB DESCRIPTION
inense i SecHan force of DiWslon3o(tM1e Buslnevand ProfessionaCode,and my x
liana Is In .fora and sited. PANELS f SQ
Warta Class LION - p12 IQ 200 AMPS . (C 0
Date - GHITTCT` � MI1000 AMPS It
ARCHITECTSDECLARATION OVERl"AMPS - SQ.FT,FLOOR AREA $/SQ.lr.
�Z I underttand my p6rs shall be used ss public records )
q.+ CO
< tj Licensed Professional ELECTRICAL
lonal -
< -, OWNER-HUILDER DECLARATION SPECIALCIRCUIT/MISC
s„ I herebyaffirmthatl amexempt fromthec otractore Llcena Lawforthe ,
KgG following reason.(Seelon 70315,Buainem and Professlona Cede:Anydtyor TEMP METERORPOLE INST. .
county which requires a permit to comtruct,alter,improve,demolish,orrepalr
¢11.�55Q 'anystructure prior to its Issuance,alsorequlreatheappilcant for such permit to POWERDEVICES
5 y 6 V file a signed statement that he 6lksnsed pursuant to the provisions of the
23m� CuntradoraLicense Law(Chapter 9(commencing with SM1on7000)ofDWI. SWIMMING POOL ELECTRIC VALUATION
O sion3ofthe Buslnevand ProfmioroCode)orthe he6esempttherefmmand
I`Sn 5 the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETS-SWITCHESEXTURES
<S app0cantfor.psnotsubjecle the applicant to a civil pemlly of not room than
five hundred dolls.($500). NEW RESIDENTIAL ELECTR SQ.F. SI'OWLS- TYPECONSTRUCTION
7 211,as owner of the property,or my employees with wages as their sole
compematlon,will do the work,and the structure 6 not intended or offered for
Osale(Sec.7044,Busleea and Ptofevloro Code:The Contractors Eceme law _
g does not apply to an owner of property who builds or improves thereon,and
a$^ whodassuchworkbiresew
lforthtgh hisewnemploym,provided that such
OCC.GROUT' RES.I1N[FS
Improvements arenot intended oroffered fe rsals.If,however,the building or TOTAL:
Improvement 6sold withinoneyearofcompleion,theowner-WBderwlll have
thrcien of proving that he did not build or improve for purpose ofsals.). QTY, PLUMBING PERMIT FEEn FLODDZONE APN
I,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE _OD
contractors to corstruetthe projed(Sec,70K Business and Pndessiors Cci c:
The Contndor'a License Law does not apply to an owner of property who
Wilda or improve thereon, and who contram for such.ptojecs with a ALTIILDRAIN&VENT-WATER(EA)
JJll1t(TctoKs)licensed pursuant to the Contractor.Liana Law.
Law. - FEE SUMMARY
u I am exempt under Sec. B&P C for this reason RACKFLOW PROTECT.DEVICE
OUTSIDE FEES
DRAINS MOOR ROOF,AREA,COND. SANITARY Y_ N—
Owner Dae RECEIPT p
WO KMANC P 1 NDECLARATI FIXTURES IT TRAPr SCHOOL TAX Y_ N
❑I hereby affirm that I have a adiBcete of consent to self-insure,ora r RECEIPT#
certificate m Workers Compevatton Insurance m a certified copy thersof(Sec. GAS P.A.SYSTEM-1 GC U7LL7 :j n 1 _' -PARKS� Y- N
3800,Lab C.) I
# ll\ RECEIPT#
Gom
�Can CAS FA.SYSTEM-OVER (EA) BUILDING DIVISION FEES
ertlRed copy ishereby!smashed. CRrASE/INDUSTRq WASTE INTERCO TOR L,J ;PLANCJ•1 CK FEE -
❑Candied ropy 6 filed with the city inspection division. 1
CERTIFICATE OF EXEM PTION FROM WOR KERS• GREASE TRAP /91�' PACJ3
Date Recei t#
(THaxdWn need not be completed If the perry t leforune hundred dollart COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 200FT
($100)or leas.) WATER FIFATFR W/VEM'/E.FCTR ENERGYFEE Y— N_
1 certify that U the periamunaaf the work forwhich this permit b Wued,
1 shall not employ any person in any manner so as to become subject to the WATER SYSTEM/TREATINGPND
Workers Compensation laws of California. Date
O Z Applicant NEW RESIDENTIAL PLMB. SQ}T. Date ReceI t#
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
should became subject to the Wori,ars'Compensation provisions of the Labor TOTAL:
W Code,you most fort hwith comply with such proiom or this permit shall be —.13UILDING FEE
W Wj clamed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL I hereby afflrmthat there 6 a construction lending agency for the perform- IMAI:
ELECTRIC FEE
D Z soca of the work for which this permit is Issued(Sec.3097,Civ.C.)
U O Lends.Name PLUMBING FEE p 0
U. Lender.Aadreas QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
Icertlfythatl have read thisapp0otionand statethattheaboveinformation
O W
a oconect.Iagreetocomplywith allcityand countyordbotecesand state laws PERMIT ISSUANCE FEES PAID:
>- relating to building meatrudion,and hereby authorbn representatives of this .
(— Z city to enter upon the above-mentlmud property for Wpedbn pu rposes. ALTER OR ADD TO MECH. Date RCCCIPt#
_ (We)agree to save,indemnify an d kap harmless the City of Cupertino AIR FTANDIdNG UMT(TO 10,11(10 CEM)
against liabilities,judgments,costsand expenses which may In anyway accrue SUBTOTAL:
against said City in consequenceof the'giiegf this permit CONSTRUCTION TAX
AIR HANDLING UNR(OVER.0,000 CFM)
5lgnatureof�Acpp cant/Contrattor 11ate IXHAUS'T HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle haurdous HEATING UMT(TO 100,000 BM Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Flealth and Safety Code Section25532(a)? HEATING UNIT(OVER 100,000 BTU) - TOTAL:
❑ Yes M No
Willtheapplicant or future building occupant use equipment or devices VENILATIONFAN(SINGLERESID) ISSUANCE DATE
which emit havrdous air conlamivas an defined by the Bay Area Air T A 1 V
• Quality Management Mind? BOILER COMPPFR'OR 100,IXD BTU)
Yo No
have readthehaza o materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) A�LI �La
the Glifernla I Icalth&Safety Code,Sections 25505,75533 and 25534. 1 V {,x '
understand that if the building does not currently have a tenant,that it 6 my NEW RY91DI=AL MECH. SQ.FF
'rmpomibll Ity to nMify then pant of the requirements which mwst be met
priorm Lssmnce ofa CertlOcateofOavpaney.' C,IIY Vi- vVI-L'N IIVV
x
Owner or authodaed agent Data TOTAL: - ISSUED BY:_ 4 Lle e
OFFICE COPY