24004 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES --USE BALL POINT PEN ONLY
Building Project Identification PIR.MIT NO.
Building Address:
24'004
n Poore
: -
N yy Q CITY OF CUPERTINO-BUILDINGDIVISION
Contractor a Ngrye_: - Lie.No: - APPLICATION / PERMIT
UI �- �•��
BLDING-ELFGTRICALG
PLUMBINMECHAMCAL CATEGORY , t CONTROL,F
-• D�NL UYV•(NAl V' 3
Architect/Fsgineer. ., Lic.No '
( ^ 1 ',;•BUILDINGPERMIT)INFO'
QTY '. I,• 'ELECTRIC PERM 111ITS 1 '..!��FEC ,fit - - i .�. . . ..
Add-3301 Y PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION LIJ
Ihereby affirentha l am licensed under provisions of Chapter 9(commenc APPLIANCES-RESIDENTIAL , JOB DESCRIPTION
Ingwlth Se fyooJJn7000)of Dlvision3oaf�the Bu//slnpe and ProfeaderaCede,and my - - -
lice^selClasg..' )0d cited.
I4 PANELS _
Dale Contractor
ARCHITECTS DECLARATION 2014000 AMPS
q�q�vu NO ZCOC I understand my plass shall be used as public records. OVER 1000 AMPS SQ.Fr.FLOOR AREA $/SQ.FF.
Fe X U Licensed Professional ( SIGNS ELECTRICAL -
dddd� e . OWNER-BUILDER DECLARATION SPECL1LCIiCNT/MLSC
7F' G I herebyafflrm that l am exempt fromthe Contractor's License Law for the
o county
a permit
Professions Code Anycityor
�yF� TEMP.METE(OR POLE INSF.
� county which requires construct,alter Improve,demolish;orrepalr -
gg anystructure prlorto its bsuance,also requires the applicant forsuch permit to POWER DEVICES
m
fib a signed statennt that he is licensed pursuant to the provisions of the
3 p,In Contractors Llcese Law(Chapter9(commencingwith Semm%700))of Dlvl- SWIMMING POOL ELECTRIC
H don3 ofthe Budoeuand PmNedoneCode)orthat hebex n;pttherefromand VALUATION
-
Yi_ the basis for the alleged exemption.-Any violation of Stolon 70315 by any OUTLETS-SWITCHES-FIXTURES
E755W[TCFIESE%TIJRFS
applicant fore permit subjects the applicant to a civil pealtyofne,morethan
live hundred dollars(S500). NEWRESIDENTIALELEC7R SQ.FT. STORIES TYPE CONSTRUCTION'
n 1,as owner of the property,or my employees with wages as their sole
�7¢ compeneatiogwilldo the wor"ed the structure b not intended or offered for
❑ sale(Sec.7064,Buslr,eu and Professors Code:The Contractors License Law '
does nm.pply to an owner of property who bidlds or Improves therme,and OCC.GROUP RFS.UNITS
whoduessuchwork himself orthrough hisownemplayew,provided thatsuch
Improvements are not Intended oroffered forsale.If,however,thebuiiding or - TOTAL:
Improvement bsold within omyearofcomplelioNtheowner-builderwdlhave .. '
t)e�unien of pmving that he did not build or improve for purpose ofule.). 67y,"' IPLUMBING PERMIT', tP• '"FEEFLODDIDNE APN
11 L as owner of the property,am exclusively contracting with Restated pptMlT ISSUANCE
contractors to construct the pouted(Sec.7044,Business and Professlom Code:
' The Contractor's License law does not apply to an owner of property who AL7174ARAIN&VENT-WATER(EA)
Wilds or Improves thereon, and who contracts for such in jells with. { n 'FEE SUMMARY, '
�q➢I(actor(s)licensed Pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
LII am exempt under Sec B&p C for this reason
OUTSIDE FEES
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Owner Date RECEIPT p.
WOR KMAN COMPENSATION DECLARATION FDOURES PER TRAP SCHOOLTAX � Y_
IZ1 hereby affirm that I have a certificate of consent to self-Insure,or a NRECENT M
mhifioteofWorkers'Compewtionlmuranmoramrtlfledmpythereof(Sec. GAS FA.SYSIFAf-i INCA OUTLETS PARK FEE Y N -
3800,IabC.) 9LL �a1
S ViDI NG
' Com env
GAS- • BUILDING DIVI SI ON FEES
�Certlled wry b hereby furnls�ed. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
ZCenUed ropy to Med with the city inspection dividon.
Je--' CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANI'ARY-STORM EA.200FT. Date Reoli ill
(rhbes
eien need not be completed If the permit b(orone hundred dollars
I
(E1orleaa.)cenl(ythat in the performance o(the work for which this permit la bWATER HEATER W/VFNT/ELECTR ENERGY FEE Y Nooed, -
I shall not employ any person In any manner so as to become subject to the WATER SYSTEM/TREATING
Workcre'Compenuuon Lewsof Callfornb. Date PAID
SQFL Date Remi tic
Applicant
ICE
ZZO Nould homers If,
after making
penCeion pro of Exemptionyou, NEW RESIUFNDALI'LMB.
should become subject to the Workers'such prwtfon provisions p of the Labor TOTAL:
LUW Code,youmust forthwith comply with such provbloss or this permitshall be BUILDING
IL j rimmed revoked.
4. CONSTRUCTION b;a ons LENDwc AGENCY SEISMIC FEE
I hereby w therebacomtis tion lending Issud(Sec.3 gency for.C.) perfornF TOTAL, ELECfRICFEE
O once of the workfor which this permit (Sec. Civ.CJ
V Lenders
Name - PLUMBING FEE _
LL t—
Lender's padreaa QTY. ',MECHANICAL PERMIT.', - FEE' MECHANICAL FEE
U I certllythatl haveread thbappllatlonand date thatthealove ln(ormatlon
O W iscormet.I agree to comply with all cityand county ordloancesand dalrelawn PERMIT ISSUANCE �� FEES PAID:
} G relating tobulldsng construction,and hereby authorize mpresentatives ofthli - -
F_ N city to enter upon the above-mentioned property for Inspection purpoxre. ALTER OR ADD TO MUCH. -
? (We)agree to save,Indemnify an d keep harmless the City of Cu pert loo Date Recelpttl
V a against liabilities,indgments,mks and expenses which may In any way seems AIR HANDLING UNIT CQ 10,000 CPM) SUBTOTAL:
against said City in consequence of the granting of this permit AIR HA NDLING UNIT(OVER 10,000 CFM) CONSTRUCTIONTAX
* Sigraturc of Applicant/Contractor - Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE '
Will the applicant or future building occupant store or ha fid le harardous ' HEATING UNIT(710 100,OW BTU) - Data Rec
nuterlaI as defined by the Cupertino Municipal Code,Chapter 9.12,and the
IJe lth and Safety Cod�dlon 25532(il2 �' - HEATING UNIT(OVER 100,000 BTU) TOT
❑ Yes No '
Will the applicant or future building occupant use equipment ordevlces VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hauMous air contaminantsas defined bythe Bay Area Air . • - .
Quality Management Didn't? BOILER-COMP PIN OR 100,0M BTU) '
S
Yet I�_�r�do'u$Ns' - 1 -
4havereadlheM1a�douamaterialaregnlrementavnderGhapter6.95 o! BOILER-COMP(OVER 100,000 B1TI)
the California I lealth&Safety Code,Sections 25505,25333
and 25536.I
'e
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECId. SQ.r--r
nsporeftnity tonotify the occupant of the requirements which at be mM
prior to Issuance of a Certificate of Occupancy, - : CL• y
21`12_ Cl�r
Owneror utthorizodagent Date \ ``
- TOTAL: �� OV ISSUED BY: ,
M
OFFICE COPY