24392 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pr.'ed IdentificationiPFR.WT NlQ/7
Building Address: 2 4 3 9 2
o l2'b Q I.. -LI 3(;I( L one. A
ft</J aG�P y. -i CITY OF CUPERTINO-BUILDING DIVISION
c.rtrad.r.Namr: LIC.Ne: APPLICATION / PERM T IG'
✓�Gs U 's BUILDINGELECTRICALPLUMBING-MriCEIA CAL CATEGORY CONTROLN
Architect/�Engineer. Lic.No:
T
-- a 'r I&e !/�/N f S, C2Q 3_9_3 Q, .ELE T C PER FEE BUILDING PERMIT INFO
Address: 2 d _l 5.41C-
I'FRhllTI lec
�s r�
LICF.NSEDCONTRA OR'SDECLARATION
I hereby affirm that l am licensed under provislonso(Chapter9(cvmmmc APPIIANC DENTIAL OB DESCRII'ION
Ingwith SecUon7000)0(Divtslon3o(the Buslvssand Prolnsi.naCode,cend my
license Is in full fora and died. AEm
License Class Lic.N / �L \��
Date Comrade
ARCHITECTS DECLARATION 301.1 M
�Z I understand my plans shall be used m public mends OV 1 SQ.FT.FLOOR AREA S/SQ.Fr.
O ,^
d� Licensed Professional9 SE CAL ' �V�
as
6 OWNER-BUILDER DECLARATION S CIRCUIT/MISC
i.., Iherebffi
yarmthat I am exempt from the Contractor's License Lew orthe
F O t✓ following reason.(Sect7TTd ion 70715,Business and Professions Code:Any city or M OR POLE INST.
county which requbesa permit to construct,alter,Improve,demolish,or rep air
any structure prior to as issuance,also requires the applicant for such permit to POWER DEVICES
I file a signed statement that he is licensed pursuant to the provisions of the
3 w Contractor's License Law(Chapter 9(commendog with Section 7000)of Divi- SWIMMING POOL ELECTRIC VALUATION
O< sion3 ofthe Buslnessand Professions Code)orthat he 13 exem there(romand
b ^t the basis for the alleged exemption. Any violation of Section 70315 by anyCyr-
UTIICU
_
G .ETSSWITCHESFIXTUItES ICU
appBant for a permit subjMsthe applicant a dull penalty o(nd moa than 1 •�C�V
F. five hundred dollars(S5010). NEW RESIDENTIAL ELECTR
6 ❑1,as owner of the property,or my employees with wages as their sole 9Q'FT. STORIES TYPE CONSTRUCTION
c
ompereation,willdothe work and thestrudua is not Intended or offered for
❑ sak:(Sec.70K Business and Professions Code:The Contradoes License Law
does not apply to an owner of property who Wilds or Improves thereon,and OCC.GROUP RIS.UNITS
EE who does such work himself or through his own employees,provided that such
Improvements arc not Intended oroffered forsals.If,however,thebuilding or TA
Improverrcnt bsold wiNin one ycarof completiaq the owner-W Bderwlll have
tI�*+rden of proving that he did not build or Improve for purpose ofsale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
L L as owner of the property,am exclusively=trading with licensed PERMITISSUANCE
contactors to construct the project m94,(S .70Business."ProfessionsCode:
The Contractors License Law does not apply to an owner a property who ALTER-DRAIN&VENTWATER(FA)
Wilda or Improves thereon,and who contracts - -for such pWjeds with a
cgtLI[ador(a)licensed pursuant to the Contractor's Lt...Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LII am exempt under Sec. B&P C for this reason
DRAINS R
FLOO
Owner Date ROOF,AREA,COND. SANITARY RFGFlPf N
WORKMAN COMPENSATION DECLARATION `� SCHOOLTAX Y_ N_
❑I hereby affirm that 1 have a certificate of consent to selLlnsorc, RECFR'T N
certificate of Workers'Compensation insurance or a certified copy thereof IBCA PARK FEE Y_ N_
38OQ lab C.)
Poliryp RIiCER'Tp
any BUILDING DIVISION FEES
m Certified copy is hereby furnished. t•�
Certified copy b filed with the city inspection dividon. GREAs L A iQtCEI' PLANCI-IECK FEE
1 J�
CERTIFICATE OF LXEM PTION FROM WORKERS' GREASE 77W' PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.300E7. Date I ReCM
(Thlssedion need not be completed if the permit Is for one hundred dollars
($100).rl.ss.) WATER HEATER W/VENT/ELECTR ENERGYFEE Y_ _
1 certlfythat In the performance of the work for which tFls permit b[ossa,
I shall cot employ any person In any manner so as to become subject to the WATER SYSTEM/TREATING PAID \
Workers Compensation Laws of California,Date
Z Z NOTICE TO APPLICANT:If, making this Certificate of Exemption,you NEW RESIDENTIAL PLMB. SQRT.lican Date Recd tf(
O should becomeaubject to the Workers Compensation provisions of the Labor TOTAL:
A Code,you=at forthwith complywlth such provisions orthis permitshall be BUILDING EE •�- ��
2 j deemed revoked.W — CONSTRUCTION LENDING AGENCY SEISMIC FEE _
O. a Ihercbyalfirmthat therebaconstmction lending agenry for the perform- ELECTRIC FEE
Z ance of the workfor which this permit ix issued(Sea 3097,Civ.C.)
U O Lenders Name PLUMBING FBE t
LL H Lender's Address QTY. MECHANICAL PERMIT FEB MECHANICAL FEE
O W losttifythatl havereadthisappllatlonand statethattheabovelnformation
Is correct.l agree to comply with all city and county next..ncnsand state laws PERMIT ISSUANCE S FEES PAID:
} IL relating to building construction,and hereby authortu representatives of this
(_
in
city to enter a Pon the abovcmentloned pmperty for inspection purposes. ALTERORADDTOMECH. Date ReceiPlp
(We)agree to save,indemnify an d keep harmless the City of Cu portio V AIR FfANDLING IMI7(TO 10,000 CFM)agaWt liabilities,pdgmentgmiss and expenses which may In any way accrue SUBTOTAL:
againstsald City in cons erre of the granting of this permit.
�iw�� AI
l R HANDLING UNIT(OVER IO,ODOCFM) CONSTRUCTION TAX
SigM�tun,of Applicant/Contractor r Date Da OD
TAUS How CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the a ppllant or future building eau pant store or hand le haeardous HEATING UNIT ITO l 00,OD0 BTU) Date Recei tN
materinl as defined by the Cupertino Municipal Code,Chapter 9.1 3,and the
Plea lth and Safety Cade�-Section 25532(a)7 HEATING UNIT(OVER IM"BTU) TOTAL:
r-1YeaM No
Witltheappticant or futon,building occupant use equipment ordevices VENTILATIONFAN(SINGLERESID) ISSUANCE DATE
which emit lurardous aireantaMeants as defined by the Bay Area Air
. Quality Marugcment District? BOILER-COMPOHPOR 100,IXU BTU)
Yes 1�No `y d.✓
thavereadtheM1 . materials requlrcmentsunder Chapter&95of BOILER COMP(OVER 100.000 BTU) (No
the California Health&Safety Code,Sections 75505,35533 and 75534. I !P y'9
understand that if the building docs not currently have a tenant,that it Ls my NEW RESIDENTIAL MECH. SQ.FT. U /1
responsibility l.ndify the occupant of the requirements which must be met 6`,/�, 9/ ,{
prior to Issuance of a Certificate.(Occupancy. 1-/p
T UyCc Y/
Owner or authorlud agent Date - ISSUED
T ZY
OFFICE COPY