24283 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
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Buildini Protect Identification PERMIT N24'283
. 4 2 8 3 '
Building Address: us-Nal Z
APPLICATION bUBMI I I AL DA 1h
hen� ) tpS3-' CITY OF CUPERTINO-BUILDING DIVISION ANIL 61 �
tra rm
aNae: PWAJ�A Lie.No: APPLICATION / PERMIT
BUILDING-ELECTRICALPLUMBINGMECHANICAL CATEGORY CONTROL N
Archllect En nae Llc.No: -
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addeeu: PERMITISSUANCE El EJ 1:1LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions o(Chapmr 9(comment, APPLIANCES-RESIDENTIAL ]OB DESCRIPTION
Ingwith Sedion7000)of Divl.i.3ofthe Bu.inemand ProfessionsCode,and
linnet l � q . t PANELS
e.XLicense Cm
(V �il(!'Jam.\" )/^✓+A,(r
Date Contractor_
ARCHITECT'S DECLARATION I 201-10DO AMPS
pkp�vu MZ I understand my plana shall be used as public records. - OVER1000AMPS SQ.FT.FLOOR AREA 5/SQ.FT.
k Licensed Professional SIGNSELECTRICAL
<< OWNER-BUILDER DECLARATION
�n aIz SPECIAL C)RCNT/MISC 1,
Thereby ezempt(romthe ConlractaALlcenm law(erthe
following reason.(Section 70)15,Business and Professions Code:Any city or
02 TEMP.METER ORPOLE[NSC.
county anystmhmph orlreaapermitroroom4qu ter,bnphantfmoilsh,orrcpao
< anyetvctum prtorta ib Wuance,alsorequbeathe appdont for such pemNtto POWER DEVICES
U file a signed statement that he it inseed pursuant to ted provisions of the
Cmdeacto/.License Lw(Chapter 9(commencing whh Section 7000)of DIA- S N L
slon3ofihe Buslnuaand Prof.ub Code)orthathabe¢mptthenfromand VALUATION
the basis for the alleged exemption. Any violation of Stolon 70)13 by any 01
ETS' TCFiFSITJEN{t rm
applicant for a permit subjects the applicant to a civil penalty of not mom than -
F five hundred della.($.500). V
❑I,as owner o(the property,or my employees wit h wage aelheir Bale NEW AI.SLHC '� STORIES TYPECONSIRUCTION
compensation,willelothe work and thestmentre Isnot Intended or offered for Q
Orole(Sec.7004,Bualnsu and Professions Code:TheContractors License Law
$ don not apply to an owner of property who builds or Improves thereon,and _ _ _- — -OCC.GROUP RES.UNITS
whodoessuchwork himself orlhrough hisown employees,provided that seen
Improvements are not intended muttered ferule.If,however,thebullding or TOTAL;
Improvement issold withinomyearofcomplet en,the owner-budderwill have
t"mien of proving that he did not build or Improve for purpose ofuls.). QTY,I PLUMBING PERMIT FEE FLOOD ZONE APN
u 1,as owner of the property,am exclusively contracting with licensed PERMITISSUANCE
contnato.to cons0uct the project(Sec.70/4,Business and Professions Code:
The Contractor's License law dm net apply to an owner of property who pLTER•DRAINA VENT'-WATER(EN
builds or Improves therms, and who contracts for such projects with a
cgIl[�actor(s)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec. B A,P C for this.aeon
OUTSIDE FE
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Owner Date
WORKMAN COMPENSATION DECLARATION RECEIPT X
rt mo afllrm that I have n certificate of content el apytnsure,or FIXTURES'PFR TRAP SCIiODL TAX Y N
3800,Lx a of Workers'Compensation I......rs certified copythereof(Sec. RECEIPT N
PoLab C.) GAS EA.SYSTEM-1 INC.4OUTLETS PARK FEE Y_ N
PolicyX ' ' GAS EA.SYSITEM.OVER 4(EA) RECIDr'IX
Ca��mppanv BUILD[ DIVISI FEES
�Inedeopy er by oma etl' GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK 'EE
ertledcopy ls(ikd with ted city inspection division. //��
CERTIFICATE OF EXIiM PTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORMEA.2WFf. [ YR1oeI'Dt#
(This.ectlon ne11)
ed na[he completed 1(the permit ls serene hundred dolls.
(5100)orlemJ WATER HFATERW/VENT/ELECTR E Y 'E N
perperformanceIcertlfy that In the performance o(thework lorwhlchthb permit Is Wued,
[shall not employ any person in any manner so u to become subket to ted WATER SYSTEM/TREATING
Workers'Compensation law.of Callfomla.Date PAID_
ZZ Applicant NEW RESIDENTIAL PLMB. SOFT. DR Recti f#
O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
Fshould became subject to the Workers'Competent has provisions of the Labor - TOTAL:
CCN Code,you moat forthwith comply with such provisions or this permit a hall be
deemed revoked. BUILDING '
CL Ihercbyal0
CLC eemCONSTRUCTION LENDING AGE CY SEISMIC FE'
rm that them isaconstruction lending agency for the perform ELECTRICP'E
Z assn of the work which this permit la inued(Sec.3097,Civ.C.) TOTAL: _
L) C Lenders No
PLUMBING 'E
IL = Le.cim'.Addon. CITY, MECHANICAL PERMIT FEE MECHANICA FEE
OW I certlfythat I havereadthisapplicationand nate that the above Information
IL To comet.I agree to comply withal cityand county ordinances and nate laws PERMIT ISSUANCE APAID
} N relating to building construction,and hereby authorize representatives of this
Z city to enter upon the above-mentioned property for Inspection purposes. ALTER ORADDTO MECH. cef [MZ (We)agree to save,Indemnify an d keep hamaess the City of Cupertinoagainst llaMlles,judgments,rods and expenses which may la anywayaccrue AIR HANDLING UNIT(TO 10,0)0 CFM) OTAL'i areal Ch mouiseqen of the grantipg of this permit..3-' AIR HANDLING UNIT(OVER IO,000CFM) XS ra p !/ est a Data EXHAUSTHOOD(W/DUCT) X DDO A ISCtoSUITE
Will the appilcanl orfuture bas llding occupant store or hand To hazardous HEATING UNIT(TO 100,000 BTU)material as deft tied by ted Cuperfou Mu ndpal Code,Chapter 9.12,and theC 1I lealth and Safely Cod,le SSelection 25532(a)2 I[EATING UNIT(OVER 100,000 BTU) ONO
❑all the a pplicant or future building ompant use equipment or devices VENIATION FAN(SINGLE RESID) E DA ,
which emit Imiandous it contaminants..de0ned by the Bay Area Air I
Qua lity Ma nogement DislrictT BOILER-COMP OHP OR 100,IX0 BTU)
Yes nrl��J1 No
law read the haaeZ..materials requircommsunderChapter6.95 of BOILER-COMP(OVER 100,00)BTU) A
199
the California health k Safety Code,Sections 25505,25533 and 25534.I �Y
understand that if the building does not currently have a tenant,that It is my NEW REST DENTIAL MSCI L SQFSEP T 1 s7 Fe-/
responsibility to notify the occupant of the requirements which must be met
prior to issuance of a Certificate of Occupancy. t d17Y Ur uurtFiIINO
Owner or authorized agent Date ISSUED BY
TOTAL;
OFFICE COPY