24334 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification - •' i PERMIT NQ,
Building Addre.s: :4334
CITY OF CUPERTINO-BUILDING DIVISION171
- 'I}"• '
Contractor',Name: LIc.No: APPLICATION) PERMIT' ' •'
( CATEGORY CONTROL#
{ BUILDINGELECTIUCAUPLUMBING MECHAMCAL
Architect/Ggineer Lk.Na t
- ,. "4'Tr't3t ;'i ELECTRIC PERMIT t (,i (fFEE` .=t'l'"` BUILDING-EERMITdNFO -) ;it'
Address
. PERMITISSUANCE ,-�' ,. ❑, ❑.
LICENSED CONTRACTOR'S DECLARATION - L.J•I _
[hereby affirm that l am licensed under pontsioes of Chapter9(comment. APPLIANCES-RESIDENTIAL " J08 DESCRR'CION
ingwith5ectlon7000)of Divislon3o(the Buslnessand PmfesslnnsCode,and my ' • I - p�a.�$�
• lice selsln full force and effect, PANELS .��` �� L a a, `
_ License Claes Llap t ' v ;` `••, J\
Date ' -- Contractor
„ARCHITECIPSDECLARATION'. 701-I01M AMPS
I understand my plars.hall be used as public mourde.' OVER 1000 AMPS FL P IN
$/SQ.FL
Licensed Professional . ' SIGNS ELECTRICALtat, eMPU I -
�¢.4 OWNER-BUILDER DECLARATION SPECIALCRCU[T/MISC • • �/ �
7i.., owing atfirmthat lamexempt fromthe Contractor.License Law fee the ° - -J�Irq l
pp 'following reason,(Section 7031.5,Business and Professions Code:Any city or. -
OZt;� TEMP. OR POLE INST. �• � E
countrumem requires.peuNtto cons trust;esthemprov nt fors usher mit I
NA
,,!8a any assigned statemenpirlorto ts that
he in aim licensed
pursuant to the forwch of permit POWER DEVICES y
0 te �Ble a signed statement[hal he E r 9(commencing
pursuant it the provisionso700) of the
�w Contract's License Law(Chapter ammendn with Section 7003 o(Divl-
In. Pt C B ) SWIv1hIN0 POOL ELECTRIC t'
sk basis for the alleged
Any violation
of exempt thercfromand _ VALUATI(][JC.
0 the basis far the permit
subjects
exemption. Any violation of Stolon net m re any v Q
applicantP le applicant penalty -OUTLETSBWITCHCSFIXTURFS
fora emN[sub'eta Neo besot too civil nal of more than _ . %• .^ „VI �.0� �+� • - ,
�G ive undreddolhrs(55,X0. L -
NEW RESIDENTIALELECTR'
,ate owner of the property,or m y employees with wages as their sole SQ'FT' . STOIIIES TYPE CONSTRUCTION
c nsation,willdothework,andtheatrudurei.notintendedor offeredfor
O k(Sec.7044,Business and Profession.Code:The Contractor.License Law _
does not apply to an owner of property who builds or improves thereon,and ,-OCC.GROUP : RFS.UNITS
who does such work himself or through his own employees,provided that such _
Improvemor
offered are not intended offered for sale.I(howevep lhebuildingor TOTAL:
improvement issold withinoneyearofcompletlon,theowner-buildereitll have ' • ,
the:iurdeo of propose
proving that he did net build or improve for purofeals.). OTy; .".4;' PLUMBING pERM/TI i';t;il'EE",", FLOOD ZONE
r APN
Lf L as Owner of the property;am exclusively contracting with licensed PERMIT ISSUANCE
contractors to conslmct the project(Sec.7044,Business and Profesalora Code: ..
The Contniiora License Law does not apply to an owner of property who ALTER-DRAIN&VENTWATER(EA)'.
Wilds or Improves thereon,and who contracts for such IrWiecte - -with a ="'i•^'':�l"FEE§UMMARY'•- ,
alfa actuarial lmnsed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE s""'
Lj I am exempt,under Sec. B &P C for this reason
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Owner v - -Date
}WORKMAN COMPENSATION DECLARATION RECEIPT#
�I �I hereby affirm that l have a certlBcate o(.conse t t el(-Insure,ora FIXTURES I'FR TRAP SCHOOL TAX Y N ,
RECEIPT— N p
certificate of Workers Compensation Insurance Ora rertl(Ied mre
pytFeof(Sec. GAS PA. INCA Y_OUTLETS, PARK FEE
'
Polity-p - - RECEIPT It
Com an •. GAS EA.SYSTGt-OVER4(EA)
Y BUILDING DIVISION FEES�Certlfied copy l9 hereby furnished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
FCemified copybflled with the city lrapectlon division..
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID -
COMPENSATION INSURANCE ^'SEINER SANHARY 5iORM EA 2(K)Fr. Data RCceI [If `
(This section need me be completed It the permit is intone hundred dollars -
($I00)mIns.), WATER HEATER W/VENC/ELECTS ENERGY FEE Y N
I certify that in the performance of the work for which this permit is stand, '
I shall not employ any person in any manner s0 ate to become subject to the WATER SYSTEM/TREATING - '
Workem'Compensatfon Lawaof Cehfmrnia.Date - PAID + -
.Q Z Applicant NEW RESIDENTIAL PLMB. SQ.Ff. Date " RCcei Ib
Z NOTICETO APPLICANT:If,after makingthis Cer/i(lcateof Exeception,you
should become subject to the Workers Compereation provislam;of the Labor TOTAL:
(A- Code,you must forthwith comply with such provisions or this permit shall be BUILDING
W j. deemed revoked.
CONSTRUCTION LENDING LENDING AGENCY-- _ SEISMIC FEE te
I herebyafflrmthat there is a coratmetlon lending agency for the perform, ELECTRIC FEE
7 Z once of the work for which this permit V Issued(Sec.3097,Civ,C.) TOTAL ,
'.0 O LOndereName . } ,b PLUMBING FEE: 4
IL FC— Leddl .Addeo. QTY. •_,t. MECHdNlCAL,PERINI7 t•7:FEE'„ MECHANICAL FEE
Q [00 I cnAllythatl have readthisapplicationand Mate thatthe above Information
d
is coma. agree to comply with a6 city and county ordinances and state laws PERMITISSUANCE FEES PAID:
relztingtobulldlegconstroctlon,and herebyauthomes,representatives ofthle - `
Z city to enter upon the aboveruntioned property for inspection purposes. ALTER OR ADD TO MECH. Date RCCCI t# ^
— (We)agree to save,indemnify and keep harmless the City of Cupertino p
against liabilities,judgments,corth and expenses which may In anyway ewe AIR HANDLING UNIT(TO 10,000 CFM) _ SUBTOTAL:
aga inst said I consequence of anting of this permit - '
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Sig tureot App nt/Contractor Date _ EXHAUSTHOOD(W/DUCT) CONSTRUCTION'TAX PAID:
c^ AZARDOUS MATERIALS DISCLOSURE '
Will thea cant orfumm building occupant store or handle hazardousHEATING UNIT(TO 100,000 BTU) Date RCCCI
material as defined by the Cupertino Municipal Code,Chapter 9.1$and the _
Health and Safety Code Section 25532(a)? - HEATING UNIT(OVER 100,wo BTU) IOTA
. Yes �]No
Will the applicant or furore building occupant use equip mentor devices VENTILATION FAN(SINGLE REBID) ISSUANCE DATE
whmheMt hazy Nous air contaminants as defined by the Bay Area Air
Quality Management District? BOILER-COMPOHPOR100,0WBTU)
MYea 1 FIN. c
rI have read the bazar ous materials requltements under Chapter 6.95 of BOILER-COME(OVER IW,D00 BTU) h
the Califernu health&Safety Code,Sections 25505,25533 and 25534.1 - -
understand thatlithe building does not currently have a tenant,that ltlamy NEW RESIDENTIAL MECH." SQ,Ff. - - '� '
responsibility to notify the occupant of the requirements which must be met - ` 0V 1 rv.r
prior to Issuance of a Certificate of Occupancy. 1
Owner or autbodzed agent - Date„ ISSUEIJ BY.
JrCfl l li$V
IOTAL:
OFFICE'COPY