24155 (2) APPLICANT TO FILL IN INFORMATION WITHIN RI:D LINES - USE BALL POINT PEN ONLY
Building Project PERMRTNO.
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Bplld jo 24155
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CITY OF CUPERTIN6DUILDING DIVISION
APPLICATION I PERMIT
Ar En ser BUILDINC-ELECTRICALPLIIMBING-MF-CHAMCAL CATEGORY CONTROL#
Lic.No:
ELECTRIC PER FEE BUILDING PERMIT INFO
re o ❑ ❑
PE4MfITISSUANCE
MLLH
LI ENS EDCONTRi.od,,CONTRACTOR'S DECLARATION
IhthSy o.7000atlam Bcm3.fthderpemand mCssions de,(ceand
APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Ing with S.tlollAgre of lelf"n3o(the Buelneeeand ProfemipnaCAde,and my %L01c0
licen.is In full dd(ed. #j PANES
Llcen km
Date Contrsdar '"�I 201 1000 AMPS e—
RCHITECTSDECLARATION
Ore 0X
]understand my plata stall be used as public records JOVER 1000 AMPS SQ.E7.FLOOR AREA f/SQ.FT.
6:Iz Licensed Professional SIGNSELECTRICAL
�6 OWNER-BUILDER DECLARATION SIPECIALCEtCUIT/#LSC
Ih
Z s., b erebyaffl.that l am exempt fromthe Contractor's License Law for the
following meson. 7RIL5,Business and Professions Code:Any city or
O HTEMP.METFRORI'OLE INST.
r� Countywhich rcqulreaa permit to Construct,alter,Improve,demolish,orrepalr
anyatmM.pdpmolt.W .ncqaisosequim.theappllantforsuchperndtt° POWER DEVICES
Q file a signed statement that he W licensed pursuant to the provi knees of the
ALED IN
µ0� Contacto/e License Lw(Chapter9(commencing with Section 7000)o(Divl- SWIMMING POOL ELECTRIC
sion3ofthe Buslnessend ProfewWmCp e)orthathekexemptthemfmmand TER
< the basis for the alleged exemption. Any violation of Section 7RI15 by any OUTLETS-SWITCHES FIXTURES .`i
Applicant fora penNt subjects the apphcanuo.civil penalty d not more than L
R flv^c-hundred doWn(f5(p). NEW RESIDENTIAL ELECTR FT.
�n LJ I,as Owner of the property,or my employees with wages as their mk TYP NSTRIKTION
t compensation,willd°the work,and theslmtture Is not intended or offered for
5 O sale(Sec 7004 Business and Prefenlmu Cade:The Contractor's License I..
f?j $ docs not apply t°mOwner ofproperty who build.orlmproeatthereoRand OCC.GROUP RES.UNITS
CC.• who dma.uchwork hintw1forthtwgh hlsownemployea,provided that such
Improvements arc not intended oroffered fwmle.It,however,thebuilding or TOTAL:
improvement Wield within one yearof completion,the owner-builderwlll have
t4LItrrden ofpmving that he did rpt build orimprove for purpoceofulo), Ql'Y, PLUMBING PERMIT FEE Wpp DONNE AIN
Lf L as Owner of the property,am exclusively contracting with licensed PERMIT LSSUANCE
Contractors to cenrtmd the project(Sec.7044,Business and Professions Code:
The Contractor'.License Law does not apply to an owner of property who ALTER-DRAIN VENT-WATER(FA)
Wilds or Impmvn thenen,and who contracts for such pSojeda with
cq➢�fado,(.)licensed punen,to the Cootoma'.Llan.law. BACK FLOW PROTECT.DEVICE FEE SUMMARY '
LJ I am exempt under Sec. B&P C for this reason
DRAINS FLOOR ROOF,AREA,COND. SANITARY - Y N—
. Owner Date gp�pyp#
WOR KMAN COMPENSATION DECLARATION FDCTURES-PER TRAP SCHOOL TAX Y N
❑I hereby affirm that I have o lmu ate of anent d pythemcf S a RECEIPT#
certlflLab of Worked Comperuatlpn lruuranaora artl(led apythereof(Sec. GAS.EA.SYSTEM-1 WG OUTLETS PARK FEE Y N
3#00,Lab CJ
Policy p BBCGAS EA.SYSTEM-OVER 6(FA) DING DI M
Ca������mpppCcn BUILDING DIVISION FEES
Certified Copy W heed with the
city GREASE/WDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy W flied with the city Inspecilon division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200bT. Date Recei f#
(This.ctlpnneed not be ENSATI Nthepormit SURA Wier one
hundred dollars
(4100)afy that
WATER HEATER W/VENT/ELFCTR ENERGY FEE Y N
(certify emptor Anyhe person
In an tmh.mannwmker
sof.As t beta eemt jest to heed, —
1 shall not employ any person In any manner n cue to beams subject to the
Workers Compensation laws of California. ATER SYSTEM/TREATING
. Date Pplp
O Z Applicant NEW RMIDENTIAL PLMB. FT. Date Recei IS
Z D should E70 esubjCANThe after making thWustion ateof Exemption,you _SQ
.FT.
beams sab)Mlothe Worken'Comperuatbn provblov ohhe Labor TOTAL:
W Code,you=9forthwith Comply withsuch provisions orthis permit shall be
W 7 deemed revoked.
BD -019
W
C CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there W a conatruction lending agency for the perform- TOTAL: ELECTRIC FEE
Z ane of the work for which this permit Is Issued(Sec.3097,Civ.C.)
V O Leader.Name PLUMBING FEE
LL h• Lender's Addres. QTY MECHANICAL PERMIT FEE MECHANICAL FEE
O W lartify that have read this application and nate that the above Information
Wcormet.l agrmto complywith allcity and county ordinances and pate laws I PERMIT ISSUANCE FEES PAID:
1
>. 0. relating to building roust ,and here by authorize representatives ofthis
Z city to enterupo ve- nttenat property for hupedlot purposes. ALTERORADOTOMECH. Date RCCCI !H
— (We)a Inde Ify an d kap harmless the City of Cupertino
again men ,aWsandexpen..whichr aylnanywsyattmAIR R HANDLING UNIT CTO 10,000 CFM) SUBTOTAL:
Aga t era of the granting of this Form I.
-
aw 'J AR HANDLING UNIT(OVER ULWO CFM) CONSTRUCTION TAX
rgn Can rador Date (/ IXHAUS'THOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building Occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) pBtC RCCCI !N
material A.defined by the Cupertino Municipal Code,Chapter 9.IZ and the - #.
Ifee lth and Safety Code Section 75532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: v
❑ YesNo
Wllltheappilcanl or turn building occupant use equlpment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which dolt hazardous aircontamWntsas defined bythe Bay Area Air pp�� p
Quality Management DWtrict7 BOILER-COMP OHP OR 10Q0(10 BTI) P A I D
Yes n No
have read the haza�aue materials requirements underChapler 6.95 of BOILER-COMP(OVER100,000 BTU) AUG
the California Health&Safety Code,Section 25505,25533 and 75534.1 ?T ^ 6 1892
understand that lithe building docs not currently have a tenant,that It is my NEW RESIDENTIAL MECFI. SQ.FT
responsibility to not lfy the aced pa nt of the mqu lmmm nts which must be met
prior to Wsua oce of a Certificate of Occupa ncy. CITY Ur lxUf Cfi MVV
Owner or authartud agent Date
TOTAL: I ISSUE-DRY. CL
OFFICE COPY,