24358 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Prn'en identification I PERMIT N
Build ieg Address: 24358
lo3/, 5 an S Gia, � Ave,
w/n�ers ane: one: - 1 A A
l.:D 1 h i n S H —11 If CITY OF CUPERTINO-BUILDING DIVISION
Cm aRm'QN`ame: Lie.N.: APPLICATION /PERMIT
n W ma son PU aJ�I OrJ c„7 1 BUILDING-ELECTRICALPLUMBINC-MECHANICAL CATEGORY CONTROL p
Architect/Engineem Lie No: -
_/j Qct" ELECTRIC PERMIT PEE - BUILDING PERMIT-.INFO-
Address:�3 a^ Sj �I 5r PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION E- E_
.�
I hereby affirm that l am licensed under provisoes of Chapter9(comment- APPLIANCES-RESIDENTIAL JOB DESCRIPTEON
ingwlth Se ion7000)ofMAM.n3ofthe Businessandd ProfesslonsCxade,and my
license is In ful ores d affect. �j�yo35 1 PANELS
License CI�C.,p c_)'I
Date cnetnanr_��ne SJ M1f L� UP TO 2DO AWS
p1-10DOAMIS
ARCHITECTS DECLARATION J
Dl7 I understand my plane shall be used as public records. OVER1000AMPS - SQ.FT.FLOOR AREA E/ .FT.
DCC n pe (� IN
U Licensed Professional SIGNSELECTRICAL I 'I n, fl .
G cN. OWNER-BUILDER DECLARATION
I
y SPECWLCIRCNT/M15C �... „ ' I f � p^ p��
Fo�L [hercbyaffirm thatlam exemptlromthe Contractors License law(w the I Ih`� ,i.[l
p Z F following reason.(Section 7Q71.5,Business and Pro(essbns Code:Any tlty or T'W.. .I L
county which reclaims permit tomnetruct,alter,improve,demolish,orrepair TEMP METER OR POLE INSr.
g$F$E a anystm=mpdortoltst anceaboiequtrstheappBantlorsuchpem to POWER DEVICES DAT �/ •V
"s1 U file a signed statement that he is licensed pursuant to the provisions of the
83 Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL FLECTRIC
FmO� siou3cfthe Busteessand Profassunu Cods)orlhae heli exempt thc.fmmand VALUATION
the basis for the alleged exemption. Any violation of Section 70715 by any OUTLETSSWITCHESI•IXTURES sl aCO
appliamore ntfora permit subjectsthe applicant to a civil penalty of not than Ocai /
p:o five hundred dol6n(&S00). NEW RESIDENTIAL ELECTR SETT'.
((�5 M I,as owner of the property,or my employees with wages as their sole _ STORIESTYPE CONSTRUCTION
compensation,will do the work and the structure is not intended or offend for
sale(Sec.7044,Business and Prefesslons Code:The Contractor's License Law
S Q doe not apply to an owner of property who Wilds or improves thereon and OCC.GROUT' RFS.UNITS
does such work himself w through his own employees,provided that such
Improvements are not intended proffered for sale.If l oweveq thebuilding or TOTAL:
Improvement eased within oneyearofcompletion,the owner-bullderwill have
t1c.¢+rdenofpmvingthat he did not Wild orimprove for purpose ofsale.). QTY. - PLUMBING PERMIT FEE
LI L as owner of the property,am exclusively contracting with Ilaensed FLOOD TUNE APN
PERMIT ISSUANCE
centractore to construct the project(Sec.7044,Business and Profession Code:
The Contractors License Taw does not apply to an owner of property who
W
contracts Improves thenc n,and who contrafor ALTER-DRAIN&VENT-
such pmkces wuh a WATER(EA)
copp4actor(s)licensed Pursuant to the Conct
traors Limn.Law. OUTSIDE FFv1
FEE SUMMARY j_J I am exempt under Sec. 8&P C for thin reason BACK FLOW PROTECT.DEVICE
DRAINS,FLOOR.ROOF,AREA,COND. SANITARY Y N
• Owner Date re or RECEIPT N
KM
WORAN COMPENSATION DECLARATION FIXTURES-PER TRAP SCHOOL TAX Y N
f-11 hereby affirm that I have a certiBate of consent to.B-inw RECER'r N
certificate ofWorkers'Corepensatlon Insurance or a rertBied copy themnf(Set. GAS FA.SYSTEM-1 INCA OUTLETS PARK FEE Y N_
ADD » DING N
GAS FA.SYSTEM-OVER 4(EA)
Com any BDILDING DI VISION FE ES
[Certified copy is hercbytumcity ty CREASE/iNDUSTRLWASTEINTERCE'TOR PLANCHECK FEE
QQlrtified ropy 6 filed with the tlinspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP -PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 200Ff Date Recei t#
(fhb section need na le completed](the permit 6(Drone hundred do8an
(Stall or less.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N_
I certify that in the performance of the work forwhich this permit is issued,
I shall not employ any perwn in any manner so as to become subject to the WATER SYSTEM/TREATING
Workers'Compensation laws of California.Date PAID
-
Z Z Applicant NEW RESIDENTIAL PLMB. SQ.FT. Date Recei t#
Z O NOTICE TO APPLICANT:If,after meki ng this Certificate of Exempt ion,you
Fshould become subject to the Workers'Compensation provisions of the Labor TOTA
N Code,you most forthwith comply with such provisions orth6 permit shall be
CC j seemed revoked. Py P Pe BUILDING --E
W — CONSTRUCTION LENDING AGENCY SEISMIC FEE
d Ihcreby.firmthattham bamnswction lending agency for the perform- TOTAL: ELECTRIC FEE
Z anceoftheworkforwMchthiapamdt L txxuad(Sec.3 ,CIv.C.)
V O Lenders Name PLUMBING FEE
f- Lenders Address QTY. MECHANICAL PERMIT FEE
W 1 nifythat l havereadthisappliationand setethatthe above information MECHANICAL FEE
O
1 is l agree to comply with all city and county ordinances and gate laws PERMIT ISSUANCE FEES PAID:
>_ W relating to Wilding construction,and hereby authorize representatives of this _
F city to enterupon the above-oentioned property for inspection purposes. - ALTER OR ADD TO MECH.
Z_ Date lie[ci t#
(We)agree o save,indemnify on d keep harmless the City of Cupertino P
V against liabilities,Lodgments,coseand expenses which may In anywayaccrue AIR HANDLING UNIT CTO 10,ODO CFM) SUBTOTAL:
against said City In consequence t granting oft is permit
- /A471
a>Z � AIR HANDLING UNIT(OVER ho,Doocr•M) CONSTRUCTION TAX .
Signature of Applicant/Contr o Date EXHAUST HOOD(W/D1xn CONSTRUCTION TAX PAID:
HAZARDOUS r ATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BN) Date Re[e
metrial as defined by the Cupertino Municipal Code,Chapter 9.1Z and the
11
Health and Safety Code Section 75532(a)7 HEATING UNIT(OVER 100,000 BTU) TOT
❑Yes M No
Will the applicant or future building occupant use equlprrent ordevims VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
xiilY Mawgemcnt�907 . BOILER-COMP PFfPOR 100,000 g"r)
QIj--rllhavc readthehaza materia6requirc,rcntsunderChapler6.95of BOILER-COMP(OVERIM,0008TV) dp "' 1
the Glifomu Health&Safety Code,Sections 25505,SS33 and 25534. I DP
f%
that if the building does not correctly have a tenant,that it is my NENRESIDFNIIALMECH. SOFT. A �jQ
responsibility to notify the occupant of the requirements which must be net G w /
prior to issuance of a Certificate of Oompancy. Cu s r y
Owner or authorized agent Dale- Terni: 155UFDBY: V�W'F,aC4jl aafsV
OFFICE COPY