24411 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project idenfifica0on PERMIT NO
Building Address: PW re—P, 24411
Ow. �(5 �� CITYOFCUPERTINO-BUILDING DIVISION 11QQ A
ctor's Na c Lic.N : APPLICATION /PERMIT 16 ^�l�Z
tree- . e BUPLDING-aECTRICAL-PLUMBING-MECHANICAL CATEGORY CO
• Area/ gii er. LIc.No:
/ iBUILDING PERMIT INFO
QTY ELECTRIC PERMFF FEE
Address:
I'FRhBTISSUANCE
LICENSEDCONTRAROr pr DECLARATION - SON Y�
I hereby af(irm'hot ofDivJlc.3.fthnderptess.onsof ChArnesCde,and(commanc-
my APPLIANCESRF.SfDENTIAL JOB DP5CRR']70N
Ingwlth I.fu ill TOW)and affect.
8utlnessand Pro(esslonsCode,and my ����
u«nx ls m n,u Tures dna erren. PANELS
LI«nsc Clam Lic.x
Data Contractor
ARCHITECTS DECLARATION 201,1ODDAMPS
re02 I understand my plans shall be used as public records. OVERIOWAMTS s{j.Fr.FLOOR AREA $/SQ.Fr.
O
Licensed Professional SIGNS ELECTRICAL Ir
OWNER-BUILDER DECLARATION
f,i fqqi SPECIAL CIRCUIT/MISC es Code:Any city or 1
Z s,vl I hereby affirm that]followilog matter. n 7 31.5,Business lrom the d Predleado Llreve Lw for the 'VC
op t"'3 counlywhlch rcqulresapermittoconetruct,alter improve,demolhh,ormpalr TEMp'MEfFR ORIOLE INSf
anystructure priorlo its Issuance,also requirestheapp0cant forsuch permit to
file a signed statement that he IsWi
licensed pursuant to the proom of the (OWER DEVICES
Ow Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi- SWPSMING POOL ELECTRIC
ifiF,30 slon3oflhe Bueinn,and Pro(emlou Code)orthathelsexemptlherefromand VALUATION
6 the basis for the alleged exemption. Any violation or Section 7001.5 by any 1
applicant fora permit subjects the applicant to a civil penalty of not more than OUTLETS-SWITCHES-FIXTURES-SWITCHES-FIXTUREStV[ I68
Ove hundred dollars($500). NEWRBSIDFNTIALELECTR SQ.IT. STOWES TYI'ECSfRUCT'i .m
�n
F11,as owner of the property,or my employees with wages as their sole
a compensation,willdo the work and thestwchme is not Intended or offered for Loy
Me as Is(Sec.7044,Business and Professions Code The Contractors Limme Law
$ does not a pply to an owner of property who builds or lmprovea they er,and ` s OCC,GROUP RES.UNfrS
who doeesuchwork him.cif orlhrough Msown employees,provided that such O
improvements are not intended orofrcred forsale.If,however,Ihebuildingor
improvement ls sold within omyearofcompletioq the owner-bullder will have
tt�rdmor proving that he did not build or Improve for purpouof sale.). QTY. PLUMBING PERMIT FEE F(OODpONE APN
u L as owner of the property,am exclusively contracting with 1lcensed PERMIT ISSUANCE - '�11�
contracture to construct the project(Sec.7034•Business and Professions Code:
TheContracture License raw don not apply to an owner or property who
bullds or Improves thereon,and who contracts for such ptalects with a ALTER-DRAIN&VENT-WATER(E4
m,,IIIItt((,dor(9)licensed pursuant to the Contractor:License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
Ll I am exempt under Sec B& P C for this reconOUTSIDE EE
Owner
-Data DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y N_.
RECEIPT N
�
WORKMAN COMPENSATION DECLARATION ITl('IVRFS['FR TRAP SCHOOL VAX Y_ N 1 hereby affirm that I have a«rtlfi ate of consent to self-insure,ora RECEUT N
certificate or Workeri Compensation luuran«ora certified copy thereof(Sec.
3800,Lab C.) CAS EA,SYSTEM-1 WC.40U7LLT5 PARKFM Y - N
RECEI
Com an GAS EA.SYSTEM-OVER DING DI VI
l
y BUILI9ING DI VISION PEES
[fCerified copy ls hed with to city GREASE/INDUSTRL WASTE INTERCEPTOR PLANCI'IECKFEE I� X190
od
CertiOed copy ls filed with the city lupectlon division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID �sy,4 C
COMPENSATION INSURANCE SEWER-SANITARY-STORMEA.2(Xd7 Date Re t •I+
(Thi,section need not M completed if the permit is for one hundred dollars
($1I oddyh work WATER HEATER W/VENT/EI,ECTR ENERGYFEE Y N S
111 nor that emJet ploy
any er on in an thearmar.as to beta penult c lowed,
0 _ I shall not employ any person in any nunner w u to become subject to the WATER SYSTEM/TREATING
' Workcra'Compensallon laws of California.Data PAID �l
O Z Applicant NEW RESIDENTIAL PLMBDere
Z 0 NOTICE TO APPLICANT:If,after making thle .Certificate of Exemption,you SQ'T'
should become subject to the Workeri Compensation provisions of the Labor
ti
Code,you=at forthwith comply with such provisions orlhis permit shall be II IL Iasa^
LII > d«med revoked.
E3CONSTRUCPION LENDING AGENCY SETS E
a Z Thereby affirm that there is construction lending agency for the performMap; EL I FH
ante of the work for which this permit ls lswed(Sec.3097,Civ.C.)
V udame O La '.NaP G •E O
IL 1= Landers Address QTY. MECHANICAL PERMIT FEE ANI LFEE
I reddythatl have read this application and statethattheabove
O W lnformaUon
1 incorrect.I agree to comply with all city and county ordinances and date laws PERMIT ISSUANCE •EE AID:
relating to building construction,and hereby authorlu representatives of th:e
(_ U) city to enter upon the above to M property for Inspection purposes. ALTERORADDTOMFLH. Date Recei tq
_ (We em the City of Cu pertlno P
dg,ents, expenses which may In anywayaccom AIRHANDLING UNIT(1'010,W0CFM) SIT TOTAL•
enceof the ting of thlspermlL AIRHANDLING UNIT(OVER le,"CFM) CONSTRUCTIONT
gwtureo Dat_ E%HADS'I',HOOD(W/DUCT) CTNTA
HAZARDOUS MATERIALS DISCLOSURE
Wllltheapplicant«future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date Recei tN
material as defined by the Cupertino Municipal Code,Chapter 9.1Z and the
Health and Safety Code Section 25532(.)7 HEATING UNIT I W,WO BTU) TOTAL:
Yea , MN.
Ill the applicant«tutu re building occupant use equipment or d evices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air mntamleardn a,defined by the Bay Area Air
Quality Management District? BOILER-COMP Ohm OR 100,000 BTU)
Yes n❑No
i have read the hara .u.materials requirements u nder Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) `
the California Health&Safety Code,Sections 25505,25533 and 255534.I
understand that if lhebuilding does not currently have a tenant,that it is my NEW RESIDENTIAL MIiCHL SQ.FT P y � '
reap,maddlity to nal dy the ocmpart of the requirements which must be met
prior to issuance of a Certificate of Occupancy. 'r,
Owner or authorized agent Data ISSUED I QA
OFFICE COPY
�' �Y bbrrhlllyy