24056 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Protect Identification PF"T NQ 4 0 5 6
Building Address:
.1k. amn: one: p
ft CITY OF CUPERTINO�BUILDING DIVISION may
Co 1perora N. Lt.N. APPLICATION / PERMIT 7- me"
BUILDINGELECTRICAL-PLUMBINGMECHAM AL CATEGORY
�Arehlted/Engineer. LIC No:
QTY ELECTRIC PERMIT^ FEE BUILDING PERMIT INFO
Address: 44
h�"ap4 4jq,- - L 7'FRhRTI55UANCE •�� ❑ 1:1LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that tem lkmaed underprov/alens of Chapter9(mmmenc APPLIANCESRESIDE L If JOB DE EPIION
Ingwith Section 7000)of Dlvielon3ofthe BuslmmandPmfesstonsCode,and my '
lice..Is In full force and effect. PANELS T
License Class Lh,# Li' ,
Date Conbador
ARCHITECTS DECLARATION
00 rrn my pbm shall be used u public mmrds. V 1 I5 SQ.FF.FLOOR AREA $1SQ.FT.
�, A) IaI+COM ei a/QK 44 N 1RICAL
ceased esslaml
�< OWNER-BUILDER DECLARATION ULC UI
IherebyafOrm that l am exempt from the Contractors License L-awforthe ,
p lollowingreason.(S ap7 tto Bmtmd and Professions Cade:Anydtyor
TGiP.M R INST '
F� ouuntycture requlmaperMttommteuires the
applicant
forsuch,ormit tr
anya signed
statemeprior to nt
that
he is also Earned
pursuant t the In forsuchof It a POWER
O Ole a signed•cens eLa that he t r 9(me pursuant it the tion 70om of the
Contractors License Lw(Chapter 9(mm)orthag with Section hemi of Dlvl-
��OS sfon3ofthe Buelnmesnd ProfeslomCode)orthat he bexempt thercfromand SWIMMIN CTR1G VA TION and
6 S the basis for the alleged exemption. Any violation of Section 70315 by any UTLR }IESFIXE(IRFS 2 l..ke� I�a1 is
appllont fare permit subjectsthe appgcam toativll pemlty o(nd nnrethan /
Ree hundred dollars($500), NEW RESIDENTIAL ELECTR SQFf. STORIES TYPECONSTRUCTION
. z< M 1,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
sale(Sec.7044,Business and Professions Code:The Contactors Ltceme law does \VI
$
who
ooe apply torn owner ofproperty
rough who Wildnem oy mprovmdid!th Land �suchC
w Prower rats amwork himse Intended
orough Msowne.If,ho m,proer,the d tis Ing or R
ZAN
Improvementsarenot Intendedearofc for sake ILh er-gthebulilI hear
MprovemenUssokl wlthinomycaro(compldbn,theowner-bu0derw111 have ,
t"nice of proving that he did not build or improve for purpose of sale.). QTY, PLUMBING PERMIT E QAkftUZONR
Lj L as owner of the Property,am exclusively contracting with licnecd PERMITISSUANCE /
iz
coto construct the project(Sec46,70Business and PeresmioCode:
The Contactors License Law does net apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilds or improves thereon,and who contracts for such pkpj cu,.111,a
c�p�aelects)hcemed pursuant to the Contradors License Law. FEE SUMMARY
I_J I am exempt under Sec. B &P C for this reason BACK FLOW PROTECT.DEVICE
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Owner D Date RECEIVE p
WORKMAN COMPENSATION DECLARATION Ff1(TURF_SPFRTRAP SCI{COLI" Y_ N_
QI hereby.(flan that I have a I..ur.e of consentamAift d py there s . RECEIPT Y
MOO,neriab of Worker'Compeneatlonlnaurance on certified ropythereo((Sec. GAS EA,SYSTEd-1 INCE OUTLETS PARK FEE Y N
Policy
0 C.) 1
Policy p �-:.1 IV O S ftEGEIPI A
Cam an GAS EA.SYSTEM-OVER4 CEA)
,.�Y Y (IJl/xl /. Q1FLQt 4 ECKFNCDIVIBION FEES
Certified copy s hereby Pomle city CREASE/INDUSIRI,WASTE IN'T'ERCEPTOR PLANCHECIC FEE -w�
OCertRled copy V filed with the tlty inspection divlelon.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-R SANfI.ARY 510RM F.A.lWFI, Recel
(This section need rhes plied ifthepermit bforomhundred dollarax
(f10Wofyth WATER HEATER W/VENT/ELECTR EN Y EE Y N O�
Icertl(y that In aPedo nceo(thewark(arwhlch this permit lsbeed, —/1 ,
I shall not empl any pe In any manner n u to become ebfm m the WATER SYSIFAf/17tEATING aGi++
Workers Com - sfton lJ sof Californl ate PAID
ZZ Appllant NEW RESIDENTIAL PLMB. SQ.FT. Date Retel f#
O NOTICE TO ICA after ma his Certificate of Exemption,you
F should become subject to the Worker' pmeatlonpeavblomofthe Labor TOL:
(n Code,you moat forthwith to wit uch proWioru or this permit shall be BD G
W7 deemed revoked.
d G CONSTRUCTION LENDING AGENCY SEISMIC FEE61
I herebyaffirmtiut there b a construction lending agency for the perform- ELECTRIC '
M Z ance ofthe work for which this pe rmitbbsued(Sec.3097,CIv.C.)
O O Lenders Name PLUMBIN
IL h Leedcea Addma QTY. MECHANICAL PERMIT FEE MECH E
O W I mrtlfythal l have read thbappltcatlon and statethattheabovelnfomation a�
is mrred.I agree to comply wtthall city.ed county ordinance and pate laws ` PFRMITISSUANCE F
fl relating tobulldingro tructlon,and hereby authorize repreenrvm tlof this
F N thytoenter upon t above- honed property for inspection Purposes. ALTERORADDTOMECH.
Z (We)agrm to e,Inde Ity an d keep harcrdes the City of Cupertino Date RCCei to
V agalmtllabilltloe,' dgmenot s and expenses which may In any way amus AIR HANDLING UNIT(170 10,000 CFM) SUBTOTAL:
.9 net ssid Ci nen of the granting of this permit. AIR HA NDLING UNIT(OVER 10,000 CFM) CONSTRU ION TAX
IgnatureofA p n or Qat FJ(FIAUST HOOD(WI DUCT)
CONSTRU ION TAX PAID:
HAZAR GUS MATER SOISCLOSURE
Will the applicant or futurebullding panbtoreor handle hazardous HEATING UMT(10100,0110 BTU) Da[e Recel to
malarbi as defined by the Cupertino Municipal Code,Chapter 9AZ and the
Hc.Ith and Safety Code Sedton 2632(.)? HEATING UMT(OVER 100,000 BTU) OTAL:
n Yea I/_—_,1 No
Will the applicant Rome building occupant use ctul preent or devices VENTILATION FAN(SINGLE RFSID) ISSUANCNATE
which omit hamrdous air comaminan4 as defined by the Bay Area Air
Quality Management District? BOILER-COMP(3HP OR 100,000 BTU) PAID n
Ym ❑n No P Y9 B
have read the 1,..9 us materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BE U)
the California Health&Safety Code,Sections 25505,2533 and 25534.1 Crn
underta rad that lithe building does not currently hive atenant,that it is my NEW RESIDENTIAL MECH. SQFr �tl6r g(1 1p�r�
rmpomibllity to nollty the oavpant of the requlrcments which must be met SE 29 y L
prior to Issuance of a Certificate of Occupancy.
u t i
Owner or authorized agent - Date ISSUED BW
TOT \
OFFICE COPY
C