24255 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pened identification 11.0PERMIT NQ,
Bufldfng Address: 24255
w3 F eJsmt-p R
nen hone:
CITY OF CUPERTING-BUILDING DIVISION /AP�
Lic'"n APPLICATION I PERMIT k'loasZ
BUILDINCELBCTRICALPLUMBING-MECHANICAL CATEGORY
Architect/ neer. Lie No: -
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: POWTISSUANCE ❑
LICENSED CONTRACTOR'S DECLARATION 01 S
fherebyefflrmthallamlicensed under provWansof Chapter9(comms APPLIANCFSRFSIDE OB DESCRE'ITON
Ingwith Sectitn7000)ofDivl.lon3afthe Bunlnessand Profmi.a.Codgand my y `
Ilicense le in full f and effect. PANELS !r1-'
rase Cis- LIC# 1G -7/ 'Y
ate Contractor O A
ARCHITECT'S DECLARATION MI-1000
nt0 2 1 understand my place shag be used as public recarda O 1 AMPS SQ.Fr.FLOOR AREA $/SQ.Fr.
mJmJ Z Licensed Profr.I..l - SI ELECTRICA
Q OWNER-BUILDER DECLARATION SPECIALCIPCI-kTAP
71.'2 I hereby at@m that I am exempt from the Contractor's License Law for the
(allowing....(Section 70115,Business and Professions Code:Any ctty or
Fcountywhichmquiresapert ttocomu cLalter,Unpmwdemalhh,orrepalr TEMP.M RPOLE INST
.� anyatmdum pdortoits lawaneq also requireslheapphuntforsuch permit to
file a signed statement that he Is licensed pursuant to the provisions of the POWER D
sta
�Owl Contractor's License Law(Chapter 9(commencing with Section 70W)ofDlvi-
0� sion3ofthe Bu.inesand Profe.I.r Code)orthathelsemmptthemfromand SWIMMING POOL ECTRIC VALUATION
the basis for the alleged exemption. Any violation of Section 7031.5 by any UTLETSS fiFSFIXTURES L + _ assess,
t
applicant fare permit aubjectathe applicant to a civil penalty of not more than 7`�!/l
q five hundred doll..(SM.
1,as owner of the roe NEW R ENTIAL ELECIR_,SQ.IT. STORIES TYPECON5MUCTION
co,open�n ❑ property,k,and
or he employees with wages r offered
dole
Q, ask&.704k
workfradm aCcala is not Intendedor /-
q vie(Sec apply Busbies and f property Code:The Contractors Llave law sess
�$ whododoes tapply torn owner ofp rough who nampluilds rimproovidedves that
�
who Improvement,
am notlmse dee or oraugh eleowne.11,ho es,provided ildi such
Improvement issold lnlendcdoroo(comffered arsale.theh ever,ihderwiling or IAL:
Improvement bdold wlthlnoneyearolcamplction,iheownervbu0derwill have
ttyrjxuien of proving that he did not build or Improve for purpose ofsale.). QTY. PLUMBING PERMIT FBE
Lf L as owner of the property,am exclusively contracting with licensed FLOOD7D"gqE
contractors to coneWct the project(Sm 70K Bushes and Professions Code: PERMIT ISSUANCE ATE lap
The Cont.ctors License Law don net apply to an owner of property who ALTER-DRAIN 4 VENT-WATER(FA)
builds or Improv.thereon,and who contracts for such p(ujecte,with
CgRtr+duds)Banvd pursuant to the Contractors License Law. OACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I ec am exempt under SB k P C for thin reason
•
OLD
DRAINS OF,AREA,CONTI.FLOOR ROOF, SANITARY Y N Owner Date - RECFdrI'M
WORK MAN COMPENSATION DECLARATION FIXTURES PER TRAP SCITOOL TAX Y N
❑I hereby affirm that pea t o lmumne of consent to opytneua,(Sa RECEIPT#
3800,L�Afflleo(Worken'Comperwtlon lruurana ora artl(kd copythenwf(Sx. GAS EA.SYSTEM-1 INCA OUTLETS PARKFER Y N
Policy
N CJ
Com -y— GAS -OVRRt(EA) DING DrN
BUILDING DIV NFEES
Certified ropy Is sed with he ed.city GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHEC F �^ �o
❑Certified copy I.Bled with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GRFISETRAP P
COMPENSATION INSURANCE SEWER-SANITARY-STORM FA.200FT. Date Recei tri
(rhl.wedon need not becompleted lithe permit is furore hundred dollars
($100)orles) WATER HEATER W/VENT/ELECTR ENERGY FEE N
a
I rtify that In the performance of the work for which this permit Is"wed, _
I shall not employ any person In any manner an as to became subject to the WATER SYSTTM/TRFATING
Workers Compensation lawsof California.Data PAID
O Z Applicant NEW RESIDENTIAL PLMB, SO.IT. Date RCceI til
Z Q NOTICE TO APPLICANT.If,after making t his Certificate of Exemption,you
Fshould becomesubjectto the Workers'Compereatlon provisions ofthe Labor TOTAL:
CCN Code
Code,you must fortwlth camplywith such provlsloruor this permit 0.11 be —s
deemed revoked.' 13UILDING FEE
LU
C CONSTRUCTION LENDING AGENCY SEISMIC FEE _
Ihereby orkfo w there i e constmctfon lending agemy ior the perform ELECTRIC FEE
M Z once of the work which permit lsisered(Sec.3097,CIV.C.) TOTAL:
C.) 2 Leeder'.N.me PLUMBING FEE
LL Leader'.Addece. QTY, MECHANICAL PERMIT FEE MECHANICAL FEE /
OW Icertlfythat l haveread this application and statethatthe aboo,iefomutlon
fbcarrcct.IagreetocomplywlthaBcilyand auntyordinancesand Metalaws I PERMIT ISSUANCE FEES PAID:
} relating to building construction,and hereby authodea,representative ofthls
(— Z city to enter upon the abovoarcntloned property for Inspection purposes. Tk7tORADDTOMECH. Date Recei ted
U _ (We)agree to save,IndemNfy an d kap harn0ess the City of Cupertino P
against hab11ities,)Jdgments,coos.nd expenses which may In anywayacaue AIR HANDLING UNIT(TO 10,ODO CFM) SUBTOTAL:
against said City In consequence of the granting of this permit.
1_Z - ATR HANDLING UNIT(OVER IO,ODOCr•M) CONSTRUCTION TAX
Sig ture of Appllca t/Contractor Date EXHAU5TFIOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the appBantor futa.building occupant atareor handle havrdous HEATING UNIT(TO 10D,000 BTU)
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the Date e'
1 lealth and Safety Code Section 25532(x)7 HEATING UNIT(OVER 100,00)BTU)
❑ Yea No
Will the a pplleant or tum building occupant use trial parent or devices VENTILATION PAN(SINGLE RESIO) ISSUANCE DATE
which emit haeardous alrmntaMnantnan defined bythe Bay Arca Air BOtLFR
as lily Management Dlsirict7 COMPORT'OR 100,OW BTI. P A 6 Ry
I Yea n No 8,1
havemad the th& uyCode,alsrcons 255nbunderChapter 6.95 of BOILER-COMP(OVIR 100,000 M)
the California Health A Code,Sections Sly have 11—a tenant,
that. IunderDECryE jQeq
responsibility
to If the notifybuildingtheoccupant of
of to roquiyhavea tenant,thatb met NEW RESIDENTIAL MCCFi. SQ.Pr DIt7s�
rcaponelbfllty to notify the occupant of(he requlrcmenta which must be met
prior to Isuance of a Ctrtiflatc of Ottvpanry.
Owner or authorlred agent Data ISSUED 6Y:
TA .
OFFICE COPY