24293 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE SALL POINT PEN ONLY
Building Project Identification - PERMIT NO.
Building Address: rl'E� RPO 24293
where \ Tff-
r one: CITY OF CUPERTINO-BUILDING DIVISION
Aqq A
Con - 's Name: 1, No:
APPLICATION /PERMIT " L 2
R S O BUILDING-ELECTMCAL-PLUMBING-MECI-IAMCAL CATEGORY CONTIL njq
'ArcMtect/Eng[ er. Lie.No:
QTY{ ECECTRIG RERMIT + 'u=FEE = BUILDING PERMIT INFO
-
Address: PERMITISSUANCE ^
LICENSED CONTRACTOR'S DECLARATION
I hereby affinnthat l am licensed under provbi....i Chapter9(mmmenc- APPLIANCES-RESIDENTIAL OB RI'T10N
1ngwehinion7 'viied:. ftheBu�teinnsan/d�PIro(esslonaCade,and my /��/'\�]D cel
Or
licensebin fu8 d k.#. 3'9e�/Uy PANELS Prot)
'LpVR
LI se Class LM.# \ � -
ate Contractor lUP TO 2DO ANTS L
ARCHITECTS DECLARATION 701-1000 AMPS
r<p2p I understand my plans shall be used as public records. OVER 1000 AMPS SQ.Fr,FLOOR AVA $/SQ.Fr.
00
(� Licensed Professional SIGNS ELECTRICAL
Q OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC VVV
73I hereby a((I mthatlam exemptfromthe Contractors License Law for the
F
following reason.(Buell.7(31.5,Business and Predications feations Code:Acity or TEMP.METER ORPOLE INST.
O ccvntywhim requiresa permit
e,mnstruutreathe improve,amforsch,orrepair
netto
g any structure prior o its entthat he Is,
req pursuant
ttothe provisions
the POWER DEVICES
L5 file a signed statement that he(Chapter 9(coed pursuant to the proWions of the
Cantraf Ile License tawProfessions
orthag with eisexection mpttheW)om and
��OQ 'eton3of the Busineeaend Profeaions Code)orthat hebexempttherefromand SWIMMINGPOOL ELECTRIC 1 ^ VALUAT[O �(�U
O.•,]] the basLs!or the alleged exemption. Any violation of Section 7(31.5 by any OUTLETSSWITCHESOXTURFS 1 / �2 2, VV
applicant for a permit subjects the applicant to a civil penalty of not more than 111 a� J
R five hundred dollars($500). NEW RESIDENTTALELECTR Fr. STORIES TYPE CONSTRUCTION
�n ❑L as owner of the property,or my employees with wages as their sole
compensation will do the work,and the structure Is not intended or offered for
O sal.Z,,7044,Bu.incss and Pmfeasivns Code:The Contreciots License Law
does not apply to an owner of property who builds or improves thereoM and RO IS
who does suchwork himself orthrough his own employees,provided that such
improver unda are not Intended oroffered forwle.If,however,thebulldleg re 1
improvement bsold Mthinoneyearofcompletio4theowner-WEderwW have ,
ttekurden of proving that he did not build orlmprove for purpose ofsak) Qry. "-' ,;..,FLUIVtBING PERMIT, 'FEE,•' FLOODZONE WN
Li L as owner of the property,am exclusively contracting with Ilrensed PERMIT ISSUANCE
matractors to construct the project(Sec."014 Businessand Protea,. Code:
The Contractors License law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilds or Improves thereon, and who contracts for such pt jects with a
c actor(q licensed pursuant to the Contractor.License law. BACK FLOW PROTECT.DEVICE 'EEE 6LiMMARY.
LJ I am exempt under Sec. B&P C for this rcuonOUTS]DE FErS_
Owner Data - DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_
WORKMAN COMPENSATION DECLARATION RECEI'f#
M
❑I hereby affirm that I have a rertiBcam of consent to self-Insure,or a TURES PER TRAP ��r SCHOOLTAX Y N_
3801,IcatevfWorkeri Comperuationlreurance oracertlfled copy thereRECEPT#
o((Sec.
3800,Lab CJ GAS F.A.SYSTEM-]WCAOUTLETS PARK FEE Y N
REC
Policy N GAS F.A.SYSTEM-OVER 4 MA) DING Ur p
y BUILUINGD ISION FEES
Certified copy is hercbytumecityi GREASE/INDUSTRL WASTE INTERCEPTOR PLANC EC �. 2
-❑ OUied copy b(fled with the city Inspection division. t 1
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID • � 1_+
COMPENSATION INSURANCE SEWER-SANRARY-STORM EA.2(IOFT. DR Re [
(Thl..cet on readout bs completed if the permit bforone hundred dollars
($100)mhss.) WATER HEATER W/VENT/ELECTR ENE GY E Y N'_
Icerifythat In the performance ofthework furwhlchthis permit is boned, —� , ��
I shall not employ any person in any manner so as to become subject to the WATER SYSTEM/TREATING
Worlu re Compensation Law.of California.Date PAID
Applicant la$
Z Q NOTICE TO APPLICANT;If,aher ma king this Ceitifleate,of Exemption,you NEW RESIDENTIAL PLMB. 5QFr. Date
Hshould become subject to the Workers'Compensation provisions of the Labor TO A
W Code,you most forthwith comply with such provisions orthb permit shall be VOO
W j deemed revoked. ;FEE
DINCONSTRUCTION LINDINC AGENCY MIC PEEa" Iherebyaffirtnthat there is a construction lending agency for the perform CTRIC FE
7 Z armoftheworkforwhichthls permit is Lcsued(Sec.3097,Civ.CJ
V O Ixndere Name - MBIN
LL F- Lenders Address - QTY, .'i` MECHANICAL PERMIT ;l' FEE' FEE
OW Icertlfythatl have mixithisapplicatlonand slatethatlhe above information
fU is correct.I agree to complywith all cityand county ordinances and state laws PERMIT ISSUANCE A
} W relating tobullding constructionnd herebyauthmom repreaentative.ofthb'city to enter upont eabove-mentioned property for inspection purposes. ALTERORADDTOMICH. ReCel f#
(We)a to ve,Indemnify a d keep armless the City of Cupertino Pagainat8 it ics dgmenis,co hichmayinanywayacems AIRHANDLINGUNrr(TO10,000CFM) UBTOTAL'
ago at ea consnquen fthe ng o(thls permitAIR HANDLING UNIT(OVER 10,(30 CIM) STRUCTIO TAX
C gnahim of pplican nIrarrEXHAUBT HOOD(W/DUCT) STRUCTION AX PAID:
HA UOUSMATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle huardous HEATING UNIT(TO I M,000 BTU) Date R
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the
Health and Safety Code Section 25532(a)? HEATING UNIT(OVER 100,000 BTU) T
❑Yes MN.
Will the applicant orfuture building occupant use equipment or devises VENRLATION FAN(SINGLE RESID) ]S$U �']3' TE
which emit hazardous air contaminants as defined by the Bay Area AU
Quality Management District? - BOILER-COMP QHPOR 100,000 BTU)
4Yes �❑]No
hive read the hazardous materials mqulrcmentsunder Chspw,6.95 of BOILER-COMP(OVER I(3,000 BTU) MAR 1993
the California Health&Safety Code,Sections 75505,25533 and 25534.I
understa ed thatif the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. �.Fr
responsibility to notify the occupant of the requirements which most be met CITY UI• //VI'CriiI IIVV
prior to issuance of a Certificate of Orropancy. .
Owner or authorized agent Date - ISSUEDBY:
OFFICE COPY