24135 (2) i APIP�ICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
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Building Project ldemi(IaRon G Phxwi
N24135
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q,4,aaaJ .�DrGL CITY OF CUPERTINO-BUILDING DIVISION /y
Contractor'.Name: Lie. APPLICATION I PERMIT ^ `[ 2
• l«' 1 fa JF BUILDINGELECTRICA4MUMBING-MECHAMCAL CATEGORY CONTROL N
' Architect/En neer. Lk.No:
/�/ ��.f y "� QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address/�J7 W I,GF /ry G- S
PERMIT ISSUANCE �s 1:1 El E:1LICENSEDC TRACTOR'S DECLARATION I—17
I hereby affirm that amiv licensed under ick.isidPm Cha pier Cd,anden APPLIANCESRERDENITAL JOB DESCRIPTION
Ingwah Section7000)o(DivisiLic,on 3althe Buslnevand Profeulonal:,owe,and my
it
Ed
Y and effect. PANELS
Cont y��9� 7
Contractor
ARCHITECTS DECLARATION I 201-10D0 AMPS
q�q�uu�70. myplam shall be used as public records. OVERIIIODAMPS S11 Q.Yr.FLOOR AREA S/SQ.FT.
Licensed Professional SIGNS ELECTRICAL '
<6 OWNER-BUILDER DECLARATION A
z G a Y SPECIALCIRCUIT/ML9C ( v
of Ihereb affirm that l amexem from the Contractor's License hw for the
� ��qqq followingreason.(Section 7031.5,Business and Professions Code:Any city or N�
rountywhichrequlmapermRrocmutmcLatter,impmve,demolbh,orrepair TEMP'METER OR POLE INST.
anystructure prlorto Its hareance,alsorequlresthe appllcantforsuch permitto
F TNG file a signed statement that he et licensed pursuant to the provisions of the POWER DEVICES
Ow Contracrori License lsw(Chapter 9(commencing with Section 7000)of Divi-sioG•••
SWIMMING POOL ELECTRIC
the basis fo thele d Pemption.Any
f Section
therefrom and V LUATIfl[J�
the Walt for the permit
alleged exemption. Any vio.crel oBsatlon not room
by any ^ � �X►
<Y appRantfor a perMtsubj<ab theeppllcant toativil penalty of not more than 01177'ET'SWI7'CFfrSA%TUBE' C
e. five hundred dollars(¢500). .
�j NEW RESIDENTIAL ELFLTR
�n ❑ensaownwll do
che work,ahe property,dr my empuyeowit hended r offir ered
for �� SfOWFS M'E GDNSIRDGTIGN
compensation,BegintWworkfmalo structure Isnot Intended orrcenseLfor
O sale(Sec.apply
Business and Profession Code:The or Impdols License Law
$$ whoa not apply to an owner of property who.Wilds empor improvvi therehM and OCC.GROUP RIS.UMTS
who does ntsach ork intedf orough hlsowle.ILyces,provided,thebthatsuch —gor
Improvements arcnot Intended earofco Torsion.If,howevep Llder Ili have TOTAL:
Improvementb.old withinoneyearo(complet�n,tW owner-bullderwill have
thLkurdenof proving that he did not bulldorimprove forpurposeofsale.). QTY. PLUMBING PERMIT FEE fD7oNE APN
L j 4 as owner of the property,am exclusively contracting with licensed pptMlT ISSUANCE
contractors to constthe project(Sec.7044,Business and Professions Code:
The Contractors License law does not apply to an owner of property who ALTTR.DRAIN&VENT-WATER(EA)
Wilds or Improves thereon,and who contracts for such pto)eds with a
cg0.t(ad°r(s)Ilcenxdpumuaat to the CoMrset.'.Llceme Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ 1 am exempt under See. B& P C for this meant,
DRAINS FLOOR ROOT,AREA,COND. SANITARY Y_ N
Owner Date RECEIPT N
WORKMAN COMPENSATION DECLARATION FI(TVRFSPERTRAP SCHOOLTAX Y_ N
❑I hereby aflirrn that I have o certificate of consent to copy
ora Rmarnr N
cemflateolWorke.'Compematloninsurance oracertified copy thereof(Sec. GAS EA.SYSTEM-1 INCAOUTLEFS
Poli lab C.) PARK FEE Y— N
CH. p RDCEGAS F.A.SYSTEM.OVER 4(FA) DING Of VIS
Com any BUILDING DI VISION FE ES
ECertmedcopy mhereby ththecity CREASEANDUSIRLWASIEINTERCEPTOR PLANCHECKFEE.
❑CertQied copy V Wed with the city W pection division.
CERTIFICATE OF EXEMPT ION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORMEA,200PT. Date Remit#
(This swish.need nht W completed If the permit V forom hundred doll..
(5100)mcot'.) WATER HEATIR W/VFNT/ELECTR ENERGYFEE Y N
Illnot thatothe peroninaoftheworkfo as tobthis penultctimed, —
1 or II not employ any person f any mannerso m to become subject to the WATIR SY5rEM/TREA']TNG
Workers Compensation Lawsof California.Date PAID
O Z Applicant Date Recei t# '
Z NOTICE TO APPLICANT:If,after asking this Certificate of Exemption,you NEW RESIDENTIAL PLMB. SQ.FT.
Pshould become subject to the WOrken'Compematlon provlelom°(the Labor .TOTAL:
It W Code,you must forthwith comply with such provisions orthis permit shall be
j deemed revoked. -BUIL ING FEE--L
W a CONSTRUCTION LENDING AGENCY SEISMIC FEE
d Ihc.byaffirmthat there is a construction lending agency for the perform- ELECTRIC FEE
� O arm of the work(or which this permit b Issued 3097,Civ.Q TOTAL: PLUMBINGLL
V Lender's Name
U. F Lender's Addma. QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W I certifythat l have read this application and state thattheabove Information
a ismrrect.I agree to comply with all city and county ordinances and statelaws PERMIT ISSUANCE P$E$PAID:
} N relating to building construction,and hereby authodae representatives of this
1" Z city to enter upon the above-mentioned property for Inspection purposes. ALTER OR ADD TO MECH.
_ (We)agree to save,IndemNfy an d keep harmless the City Of Cupertino Da[e Receipt#
against llabNtim,judgments,mets ende.pensa which may inanywayaccue AIR HANDLING UNIT(TO to,"CFM) SUBTOTAL:
.gaimt.ld Ityl n enceo hegrantle of Ispermi_&A4,04-1
tt L�yyy���,�yyy AIR HANDLING UNIT(OVER l0,0D0 CFM) CONSTRUCTION TAX
.gm P nt/Cont re f rDmAusr HOOD(W/DUCT) CONSTRUCTION TAX PAID:
AZARDOUS MATERIALS DISCLOSUR
Wlllthca llant or future building occupant store or handle hanrdous HEATING UNIT(TO 100,000 BTU)
material as defined by the Cupertino Municipal Code,Chapler9.17,and the Date Reeel t#
I leallh and Safety Code Section 25532(x)? HEATING UNIT(OVER 100,000 BTU) TOTAL:4,171—
❑Y. IJ No 1
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE MID) I$$U l'L•�DATE
which emit havrd...air contaminants as defined by the Bay Area Air
Quality Management District? BOILER-COMP OHP OR 100,000 BTU) //�
4 Yes 2ND l/ 18 /g��
hav¢read the haza us mrleriab rcqulrcments under Chapter 6.95 of BOILER-COMP(OVQt 100,000 BTU) w
the Glifornia Health&Safety Code,Sen loco 2550.5,25513 and 75534.1 Cl r�.ur
understandlhat if the building does not currently have a tenant,that It b my NEW RERDENHAL MECH. SQ.FT Vhf/-CIT J71
responsibility ce notify the Certificate cote of cf the requirements which moat be ret V�/
prior to issuanceo f ti ytheoc u of Occupancy.
coq
Ow nerve authorized agent are
ISSUFDBY:
TOTAL: —�-�—�
OFFICE COPY