24329 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Project Identification PERM1TNO.
Building Address: 24329
netsName: h hone: APPLICAT A A
CD D CITY OF CUPERTINO-BUILDING DIVISION
Contractor's Name: No: APPLICATION /PERMIT f �- 1 r
2�
+— �"' ` � �591§ � BUILDING-ELECnUCAL-MUMBING-MECHANICAL CATEGORY CONTROL N
Architect/Engineer. Lic.No
ELEEMTCTRIC PINFO
Address PERMIT ISSUANCE ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(opmrnenC APPLIANCES-RESIDENTIAL O$DESCRIPTION �f�C�
Ing with 9ecfulUtion 0eandeffect 3oftheBuslnessandProfessionaCode,andmy L s��� W _ I'
license is in fu and effect. 3 PANEIS
License Class w
Date 'd >i Contractor
ARCHITECT'S DECLARATI N 201'1000 AMPS -T
C4 O I understand my plans shalt be used as public records OVER 1000 AMPS �, P AR S/SQ.Ff.
.z i D
J .
6� Licensed Professional SIGNSELF�TRICAL OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MTSC P U T E
I hereby affirm that I am exempt from the Contractor a License Law for the
p�p following reason.(Section 7(bIS,Suainess and Profeasiona Code:Any city or
county which requites a permit toconstruct,alter,improve,demolish,or repair TEMP.METER OR POLE INST.
.aa any structure prior to its issuance,also requires the applicant for such permit to POWER DEVICES
file a signed statement that he is licensed pursuant to the provisions of the
rt,fg; Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC
'O d sion 3 of the Business and Professions Code)orthat he is exempt therefromand VALUATION
h Q 1 the basis for the alleged exemption. Any violation of Section 70315 by any OUTLEISSWITCHESFD(TURES �s OD ��/�/!
applicant for a permit subjects the applicant to a civil penalty of not trrore than C1 j
five hundred dollars(5500).
❑I,as owner of the ro or e 1 with wages as their sole NEW RESIDENTIAL ELECTR SQ'FT' STORIES TYPE CONSTRUCTION
P Perh% mY rnP oY� B
compensation,will do theworlr andthestructureisnotintendedoroffend(or
A sale(Sec.7044,Business and Professions Code:The Contractor's License Law
r�$ does not apply to an owner of property who builds or improves thereon.and OCC.
who does such work himself orthrough his own employees,provided that such GROUP RFS.UNITS
Improvements are not intended or offered for sale.If,however,the building or TOTAL: „oD
improvement issold within oneyearofcompletion,the owner-bullderwill have
the burden of proving that he did not build or improve for purpose of sale.). Y. PLUI�I$INCi PERMIT- EEE
LJ L as owner of the property; FLOOD ZONE APN
p peI - exclusively Business
contracting with licensed PERMIT ISSUANCE
mntnctors to construct the project(Sec..^044,Business and Professions Code:
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER CFAI
builds or improves thereon,and who contracts for such p{ojects with a
ce�ctor(s)licensed pursuant to the contractor's License Law. FEE SUMMARY
UI am exempt under Sec B&P C for this reason BACK FLOW PROTECT.DEVICE
_ DRAINS•FLOOR,ROOF,AREA,COND. SANITARY Y_ N_
ES
r Date
WORKMAN COMPENSATION DECLARATION RECEIPT#
1 hereby affirm that I have a certificate of consent to self-insure,or a QT S'PER TRAP SCHOOL TAX Y_ N_
certificate of Workers'Compensation Insurance or a certified copy thereof(Sec. RECEIPT#
3800,Lab CJ GAS EA.SYSTEM-1 INC.4 OUTLETS PARK FEE X N_
Policy# RECEIPT#
Com ny_ GAS-PA.SYM 14-OVER4(EA) BUILDING DIVISION FEES
Wertified copy is hereby furnished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
lCert�ed appy is filed with the city inspection division.
CERTIFICATE OF EXEMPrION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-SPORMEA.20pFf Date Recei t#
(This section need not be completed ifthe permit is for one hundred dollars
($100)or less.) WATERHEA,TERW/VFNT/ELECTR ENERGY FEE Y N
I certify that in the performance of the work for which this permit is issued, — —
I shall not employ any person in any manner so as to become subject to the WATER SYSTEM/TREATING
Workers Compensation Laws of California.Date PAID
AppliZ NOTICE
NEW RESIDENTIAL PLMB. SQ.Fr. Date Recei t#
0 NOTICE TO APPLICANT:If,abet making this Certificate of Exemption,
should become subject to the Workers'Compensation provisions of the Labor TOTAL:
Code,you must forthwith comply with such provisions or this permit shall be r Q
> deemed revoked. BUILDING FEE
SEISMIC FEE
G CONSTRUCTION LENDING AGENCY r
I hereby affirm that there is a construction lending agency for the perform-. TOTAL: ELECTRIC FEE
Z ance of the work for which this permit is issued(Sec.3097,Civ.C.)
L Lenders Narne ;, - PLUMBING FEE
F- Lender's Address QTY, MECSANI " FEE
IcertifythatIhave read this applicarionand state thattheabove information MECHANICAL FEE
W is correct.I agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
Coll
relating to building construction,and hereby authorize representatives of this
Z city to enter upon the above-mentioned property for inspection purposes. ALTER OR ADD TO MECH. Date Recei
(We)agree to save,indemnify an d keep harmless the City of Cupertino pt#
against liabilities,judgments,coats and uses which may in anyway accrue AIR HANDLING UNIT CrO 10,000 CFM) SUBTOTAL t
against ity -teerace granting oft mat.
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Sigfiature of Applicant/�OOUSactor Dae EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAMATERIALS DISCLOSURE
Will the applicant r building occupant store or handle hazardous HEATING UNIT CIO 100,000 BTU) Date Recei t#
material as defined y the Cupertino Municipal Code,Chapter 9.12,and the
Health and Safety Code Section 25532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑Yes M No 11_
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
Which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management District? BOILER-COMP C3HP OR 100,000 BTU)
[- s ❑No
read the hazardous materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTI)
the California Health&Safety Code,Sections 25505,75533 and 25534.I 1 [y
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.Fr OCT + Fr 1992
responsibility to notify the occupant of the requirements which must be met
prior to issuance of a Certificate of Occupancy.
Owner or authorized agent Date ISSUED BY: C
TOTAL:
OFFICE COPY