24314 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
building Project Identification PEAMITNQ, 4314
Building Address aG)
`caner s. ams: one: inAL DATE
APPLICATION SUBM�JG� CITY OF CUPERTINO-BUILDING DIVISION
Ct dor'sName° Li=.No: APPLICATION /PERMIT
J BUILDINGILDCTIUCAT PLUMBING-MECIIAMCAL CATEGORY CONTROLN
Architect/Englncer. Lic.Na:
- Y QTY - ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: - � ,' L J i PHRMITISBUANCE 1:1 E:1 ❑
LICENSED CONTRACTOR'S DECLARATION
I Mreby.affirm that l am licensed under provisions of Chapter9(occomerc, APPLIANCESRESIDENTIAL JOB DESORPTION
Inense lasalon forceanDlvislon3ofthe BusinessGand ProfeWonsC-ode,and my
license lain full force and fee. O? PANELS
DateLkeCh , O
Date Contractor UP TO 2QO ANTS
ARCHI S :CLARATION 2041000 AMT'S
q�q�vuQO ]understand myplamshallMused aspublicrecords OVER 1000 AMPS SQ.FT.FLOOR AREA 5/SQ.FT.
1 Edd Licensed Professional SIGNSELECTRICAL z
t�,6 OtI.maBUILDER DECLARATIONIhxmSPECIALCIRCUIT/MLSC A LED I N
owing rason.CSatlamexemptfromthp Contraak Llcenseiawforthe
Zo followingreason.(Scctlpn7011to Businessand Ptofessions Code: h e or TER
FZI"'� cpuntywhich requlresa permittomnstmn,alter,lmprove,demolish.arrepalr TEMP.MEITR ORI'OLH INST.
anystmorme prlorm its bsuance,also requlrestheappHcent forsuch permit to POWER DEVICES
ry1 fih a signed statement that he is licensed pursuant to the provisions of the
Ou Contractors License low(Chapter 9(mmmenein"Ith Section 7000)of Dlvl- I
jog sion3ofthe0ueinessandPrpfessloruCode)orthathehexempttherefromand SWIMMING POOL DATE ON
y.'9
the basis for the alleged exemption. Any violation of Section 70115 by any OUTLETSSWITCFiE_SPIJ(I'URES
applicant fora permit mbjeeathe applicant to a civil penalty of act morethan
five hundred dollars(S500).
Sn ❑1,as owner of the ro oremployees with wa es as their sole NEW RESIDENTIAL ELECTR SQFT. STORIES TYPE CONSTRUCTION
e Pet,', my B
cole(Sm744,will do Business workand the rtroeurchnot Intended or offered for
O sale(See appy to an
Professions Code:The or improsi License law
$ docs not applyessuch torn owner ofprop"iswho bemplrlmprwndMreoryand OCCGROUP RFS.UMTS
who
ovesmchworkhimself a throughhisownemployees,provided that such
improvementsarenot Intended proffered forole,If,however,the ilder, ill have TOTAL:
Improvement h mid within one yearofcompictlon,lMowner-builder will have
(bbekurden of proving that M did not build or Improve for purpose of sale). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
LJ L as owner of the property,am exclusively contracting with licensed
matracton to mnstroct the project(Sec,7044L Business and Professions Code: PERMIT ISSUANCE
The Contractors License Law does act apply to an owner of property who ALTER-DRAIN AVENT-WATER(FA)
Wild.or lmproves thereon,and who contracts for such p7ujan,with a
ra4.tor(.)Bcenaed pursuant to the Contractors License Law. FEE SUMMARY
L-II am exempt under See B A P C for this reason BACK FLOW PROTECT.DEVICE OUTSI 13F FEES
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N_
Owner Date RECEHT N
WORKMAN COMPENSATION DECLARATION PER TRAP SCHOOLTAX Y N
❑1 hereby affm irthat I have•mrtifiate of consent to self-Inpp(71h(pg
mre,or RECEIPTNN
uniflrateo(Workers'Competuati°nlmuranmoramrife wpythere°f(Sec.
3800,Tab C.) CAS F.A.SYSTEM-1 INCA OUTLETS PARK FEE Y N
Policy N RECEIPT'
Com ny GAS G.SYSITT4-0VER4(EA) BUILDING DIVISION FEES
[]Certified copy lshdd with thehed. CRPASE/INDUSML WASTE INTERCEPTOR PLANCHECK FEE
Certllied copy ls(fled with IM sty Inspection divlelpn.
CERTIFICATE OF EXEMPTION FROM WORKERS' CREASETRAP PAID
COMPENSATION INSURANCE
RHon need no becompleted lithe permit h!scoe hundred dollars
SEWER-SANITARY-STORM EA mOFTDate Recei t#
0100).elaod
in WATER HEATER W/VENT/ELECM ENERGY FEE Y N
I certify thatothe person I. ofthe work so
o as
this permit to
o the
I Workers
nm employ any person In any manner aact m pecolre/�)ect toted WATER SYSTEM/TREATING
WorkereC�tensation lawn o(GIRpmI. nate a�� PAID
Z Applicant PLICAN17:1 aaer malkirg this Certificate of Exemption, _ NEW RESID=- AL PLMB. SQ.FT. Date Recei t#
2 em no,subject to the Workers'Compensat ion provisions of the Labor TOTAL:
jW Code,youmart forthwith comply with such provisions or this psmdt Shall be pUILDING FEE
deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 hereby affirm that there h a construction lending agency for the perform, ELEGTRIG FEE
rm
Z ance ofthe work for which this permit is Issued(Sec.3097,Ci¢Q TOTAL:
O Lenders Name PLUMBING FEE
t- Lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
WI certlfythatHave read thisappllodonand statethatthe above information
1 is correct.I agree to comply with all cttyand county mdinanoesand nate law. PERMITISSUANCE FEES PAID:
N relating to building construction,and hereby suthorlue representatives of this
Z city to enter upon the above-mentinned property for Wpectl°n pu rpose,. ALTFRORADDIOMECH.
— (We)agree to ave,Indemnify an d keep harmless the City of Cupertino
Date Recei t#
against Hab ,.d8rrcnts,.9...dexpenx.which mayinanywayacorue AIR HANDLING UNIT(TO 10,000CFM) SUBTOTAL'
.gal dCl inconsaryence
AIR HANDLING 11F1IT(OVER IO,000CFM) CONSTRUCTION TAX
sl
of Appllmnt/Contractort HKHAUST HOOD(WI DUCT) CONSTRUCTION TAX PAID:
HA7ARDOUS MATERIALS DISCLOSU
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date Re ' t#
material as defined by the Cupertino Municipal Code,Chapter 9.1$and the HealthandSafetyCode Section 25532(a)2 HEATING UNIT 100,000 BTU) TOTAL.
❑Yes No
Will the applicant or tore building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardcu.air contaminant.as defined by the Bay Area Air
Ilty Management DlsMct2 BOILER-COMP OHP OR 100,000 BTU) s'9 p
ID
uL�Yes ❑No
(have read the hazardous materials requirements u nder Chapter 6.95 of BOILER-COUP(OVER 100,000 BN) ®�
T
the California I lealth&Safety Code,Sections 25505,25533 and 25534.1
understand that if the building does not currently have a tenant,that it is my NEW RMDENTIAL MSCI I. SQ.FI' / y ry
responsibility to notify the occupant of the requirements which moat be met ^/ Y
-. prior.ioWuanmofaadificatoof Occupancy. V/r Vr
(at-ctyl
Owner or authorized agent Data
IDTAI.: ISSUEDBY:
OFFICE COPY