24095 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMTNO.
Building Add nR�)06eT le q'� 24095
wed'/rs lime: f - one: - p
2SS• CITY OF CUPERTINO-BUILDING DIVISION
Conlra5ypr'a N1 lime: LIc.Nee APPLICATION I PERMIT
6�� BUILDINGQ,ECTRICALPLUMBING-MECHANICAL CATEGORY CONTROL
Architect/Engineer: Lie.No:
QTY
ELECTRIC PERMTTE BUILDING PERMIT INFO
Address: I'FRhBTI55UANCE L� U�i PLUMB MELD
❑ ❑ � ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby afffrmthat l am licensed under provisions of Chapter9(commenc- APPLIANCES-RESIDENTIAL ]OB DESCRIPTION
ingwesInfun7000)ofd affeon3o(lhegusineseand Profroelon.Code,and my
Incense fe In fun force and effect.• PANELS '
License Clam Lk.# -
Data Contractor UP TO 200 ANTS
ARCHITECTS DECLARATION 701-1000 AMPS
ceOZp Iunderstand my plans shall be used as public records. OV IOpO, �_ SQ.FT.FLOOR AREA 1/SQ.FT.
�C —.
(3 Licensed Professional SIG SELE[[CTRICAL_
�¢ OWNER-BUILDER DECLARATION - 51
IALq,ItCUIT/MISG
X0
1.,Scuff' Ihereby affirm thatlamexempt from the Contractor's License Lawforthe
following reason:(Section 70315,Business and Profession.Code:Any city or T�P.MEff( Z.
F cauntywhichmqu4 sapermfttommt c,alter, pm ,de=llsh,ormpalr 'E[i,QRPOLE IN
uu
anystructu ,prlorto its Issuance,also requirestheappbcantfor such permit to
Kis ale a signed statement that he Is licensed pursuant to the pnevbloru of the ]OWER DEVICES
3 w[• Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING IDOL ELECTRIC
L., O slop 3 ofthe Business and Profeselons Code)orthet he is exempt therefrom and VALUATION
O the basis for the alleged exemption. Any violation o(Sedi=70115 by any OUTLE1SSWITCHESFD(TURI15
applicant fora permit subj cathe applicant to a civil penalty of not more than
1q five hundred dollars 11500). SQ.FT. STORIES -TYPE CONSTRUCTION
❑I,as owner of the roe NEW RESIDENTIAL ELFGTR
property,rty,or my employees wlih wages lie ibetr sole
compensation,will do the work,and the structure Is not Intended or offered for
Dsale(Sec.7044,Business and Professions Code:The Contractors License Law
does not apply to an owner of property who builds or improves therms,and _ OCC.GROUP RES.UNITS
who doessuchworkhimself orthrough hlsawnemployees,provldedthat such
Improvements are not intended or offered for sale.If,however,the building or 'TOTAL:
improvementbaoldwfthinoneyearofcompletlon,lheowner-bunderwRil ve -
thrrden of proving that he did not build or Improve for purpose ofsale). PLUMBING PERMIT FEE FLOOD ZONE APN
Ll;pI,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractsconsumerconsumerorconthe Fueled(Sec.7014,Business and Professions Code:
The Contractor's Licenae Law does not apply to an owner of property who ALTER-DRAW kVENT-WATER(EA)
band.or Improves thereon,and who contracts for such pwjecta with a FEE SUMMARY
cgB -mu(s)licensed pursuant to the Contractors License Law. BACK FLOW PROTECT.DEVICE
LJ I am exempt under Sec. B k P C for this reawn
OwDRAINS A,GOND.FLOOR ROOF,ARESANITARY Y_ N
Date
ner AECEI Np
WORKMAN COMPENSATION DECLARATION FIXTURES.PER TRAP SCHOOL TAX Y N
Of
hereby affirm that I have a I rtcone of as diff d spy theure,ora RECEIPT M
certificate o(Worken'Compeneatlonlwurance oracertl(kd copy thereof(Sec. GAS EA.SYSTEM-[INCA OUTLET PARK FEE Y N
3800,Lab C.I
PO a �4 CAS EA.SYSTEM-OVER DING DIV
Com any BUILDING DIVISION FEES copy b he d with t le city GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
❑
Certified copy V(fled with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 100F1' Date ReCei t#
(Thlssedion need not be completed lithe permit la forone hundred dollars
($1°°)orlem') WATER HEATER W/VENT'/ELECTR ENERGY FEE Y N
[certify that the performanceof the work an se as tocb thio permit L owed,
I shall not employ
n y any person In any manner m become subject to the WATER SYSTEM/TREATING
Workera'Compeneation Laws of California. Date PAID
Z Z NOplicant
TICE TO APPLICANT.If,after making this Certificate of Exemption,you NEB`'RESIDENTIAL PLMB. SQ.FT. Date Recel t#
0 should become subject to the Workem'Compensation provisions of the Labor :'TOTAL:
O) Code,you must forthwith comply with such provisions or this permit shall be
W y deemed revoked. BUILDING FEE
a c CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there la a mnstruction lending agency for the perform- ELECTRIC FEE
Z ance ofthe work(orwhlch this permit is issued(Sec.3097,Civ.C.) O
U O Lenders No. PLUMBING FEE
IL Lender.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW Icerti/ylhat I have readthisapplicattonand statethal theabovelnformation
M ismrrect.I agreeto comply with all cityand county ordinances and state laws PERMIT ISSUANCE FEES PAID:
>- W relating to building corkructlun,and hereby authorize representatives oflhls -
I.. Z city to enter upon the above-mentioned property for inspection purposes. ALTERORADDTOMECH. Date Rl t#
— (We)agree to save,Indemnify an d keep harmless the City of Cu pert Inca eCeF
against liabilities,ju dgments,mks and expenses which may In any way accrue AIR HANDLING UNIT 0010,000 CFM) SUBTOTAL:
a City in consequence of the grant Ing of this permit.
39.7.. AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Nre of Applicant/Contractor V Data EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the a pplica rat or future building occupant store or hand to hazardous HEATING UNIT 00100,000 BTU) Date Recei t#
material as donned by the Cupertino Municipal Code,Chapter 9.1$and the - _
Flealth and SafetyCadc/�Sedlon 25537(a)? HEATING UNIT(OVER 100,000 BTU) TOTA
❑ Yee , u No
Will the applicant or future building oempant use equipment or devices VENDLATION FAN(SINGLE RESID) ISSUwAN9 DATE
which emit hazardous air contaminants as defined by the Bay Area Air t 'BD
.Quality Management District? BOILER-COMP OEIP OR 100,DM BTU)
tC� Yee r,No ... .. 1
r / have read the baaMous materials requirements under Chapter 6.95 of BOILER-CO MP(OVFRI00,0000TU) AUG ^" 1992
tthe C.11furnW Health k SafetyCode,Bediona 25505,25533 and 75534.I
understand that lithe building does not currently have a tenant,that It is my NEW RESIDENTIAL MECH. EQ.Frrespo .
priors issuance
of a Certificate
to ant ofOcfthe requirements which must be met rr' CRY Ur 1Ourtrt kWLs'
prior ns Issuance of i Certificate of Ompa reqs
Owner or authorlaed agent Date - ISSUED BYE-A
TOTAL:
OFFICE COPY