24147 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building project Identification 1 PERMIT NOO
IN Of Ing Add res.: • ( 2 4 1 4 7
"VIVI r-tT-e Lew voF P-D,
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u Nartn: � Q 'ItruI APPUCATION SUBMI ITAL DAM
�„ � lo CITY OF CUPERTINO-BUILDING DIVISION ^ � -
cm<ra car. eme: LIc.No: APPLICATION / PERMIT �f
- BUILDING-ELECTTUCAUI'LUMBINGMFGFAMCAL CATEGORY CQlf107%
Arehltect/[ngineer. Lk.No: l (( CCJJ �
I , BUILDING,PERMIT INFO
1'ELECTRfE P/ER/1X11 ,,�h FEE• 'I n,.w.
Address: PERMIT ISSUANCE ` , � 1 �� -�� sa! V
LICENSED CONTRACCOR'S DECLARATION __JJ�� LpY LFy'
I hereby affirm that l am licensed under provbions of Chapter 9(rommencl APPLIANCFSAjSTD�kl AL JOB DESCRIPTION
Ingwbh Section 7000).!DiV...3ofthe Basln.xruI Professl...Code,andmy CYO + ��\� I'
license 1.in full force and effect PA (�
Licenre Clam LIc.01 'l '
Date rr,eirsen, '
ARCHITECTS DECLARATION 1-10WA.MI'S -
q�+N 2 I understand my plans shaO be used a public remrdw OVER 1 - SQ.FT.FLOOR AREA $/SQ.Fr.
of Licensed Professional - SIGNS L CAL I � 141 .Gy
<�Q OWNER-BUILDER DECLARATION / S9[G(LA/L CIRCUIT _ I {/
7s• following (Seatlam01.5,B dresea Contractors License Lane for the ��
❑ foil.yw rem.n.(Seniors 7 tw Businem and Profemloe Code:Any city.r
F1"' counrywhlch requiresapemNtroconst sect,alter,lmprove,demoLLah,orrepair __P.ME77ROR POLE INST. -
q�5
�e ny.t=prior to its beuance,alsuregalrestheapplicant for such permuto POWER DEVICES
Ole a signed statement that he Is licensed pursuant to the provisions of the e
< Contractor'.License Law(Chapter9(commencing with Section7000)ofDivi-
O I"n SWIMMING POOL ELECTRIC
�J sLn 3.Rbe the alleged exemption. Any violation f Bump[therefrom any p VALUATION w
<; the bash for the alleged exemption. Any violation of Section 7031.5 by any 1 V OUTLETSSWITCH FIXTURES 7 '
'$g'y
applicant primal subjects the applicant to a civil penalty of not nnre than
o five ndred dollars($500), - SQFI. 1 v
(Qil asownerof[he property,or my employees with wages as their sole '�WXES[DFN77AL ELECTR SiOWFS Tl'1'E CONSTRUCTION
pensatlon,wOl dothew.rk and the structure boot intended or o((emd fool
le(Sec.7044,Business and Professions Code:The Contrac.e.License La +
GI $ does not apply to an owner of property who builds orimprwes thereon,and OCC,GROUP RES UNITS
who doessuchwork himselforthrwgh hisownemployee;Feseldedthatach -
Impr.vrmenberenot intendedorofferedforsals.If,however,thebullding oral �dI .LI 0-1
improvement bsold within oneyearo(completion,theowner-bullderwlll..
tl)e},mrden of proving that he d,d cam Wild or Improve for purpose olsaleJ. IQTY. , "i '' 'PLUMBINGPERMITt ,�^�I 't FEEt,1 FIA��T11 APN -- I
I,as owner of the property,am exclusively contracting with Ocensed 1 PERMIT ISSUANCE 1 'l.�I
mntracmn to c.nslmn the project(Sec.70K Businem and Professions Code:F � L ...)
/ The Contractor's License law does n.t apply to an owner d property who ALTER-DRAIN k VENT-WATER(EA) .c....
bulldis or 1'prove thereon, and who contracts for such p(opm w11h a I '°"' SUMMARY
mkt acior(slice sd pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
`( LJ I am exempt under Sec. B k P C for this reason I - f QUTSIJJI I;FI%
' Owner Dad DRAINS-FLOOR ROOF,AREA,MIND. f I SA RY V lY� NN
F-11 byORmthat COMPENSATIONDECLsent to N 1IV(TURESPERTRAI' Id ' SC1iOO R� Y'�N_
here affirm that I have a certificate of consent m opytnmre,ar a / �R
rtl,Lals o(Worke''C.mpensatlon Ivurance or a certified ropythereof!Sec, N
3800,Lab CJ GAS EA.SYSEFM-]ING40UTLETS I �PAAK FFP Y N_
Policy 1. GAS EA.SYSTD.1-0VER4 MAI I I BUILDING Coco any BUILDING DIVISION FEES
ECMfird copy is hereby famished. CREASE/INDUSIRL WASTE INTERCEPTOR I PLANCHECICF�
n Certified copy b filed with the city inspection divides. • f
CERTICICATE OF ID(EMPTION FROM WORKERS' GREASE TRAP I PAID K.
COMPENSATION INSURANCE �%.V V
(Ihi.section need not becompleted lithe permit bf.rone hundrcddollan SEWER-SANITARY-S ORMEA'700F I' /Receipt
($]00)orlem.) { IT—,.,R.Ap /I ENE Tj ENER �•E Y NL
shall that inchnpertnrs,inan thencerans to Do the 1 A^`9t`R4'lr d 1'°' tlr7
I shall not employ any prawn in any manner m m Io become abject to the I SYS17EMI TREATING _
' Workera'Compeneation[awe of California. Dat^ I IT I f- PAID
O Z Appllcanr RIr9DLNTfAl9[MB.`" Date �,Recelpt#
Z p NOTICE TO APPLICANT:[Laf ter nuking this Certificate of Exemption,you i
F W should become aubjen 1.the W.rken'C.mpewtlon pmvislons of the labor a TOTAL'
Code,you must forthwith comply with such provbio+u or this perms shall W I DA I n r
W > dremed revoked. , I BUILDING FEE _
CONSTRUCnON LENDING AGENCY SEISMIC FEE _
0. 0 once of the ihat there L+aronstmctlon londingagenry forthe perform ELECTRIC FEE
O arse¢ofthework locwhIchthi,permit is bound(Sec.3097,CN.C.)
U a der'.Na I ``' y PLUMBING FEE
IyH Lenders Addremm _ - [QTY. . MECHANICAL PERMIT FEE, �MECHANICAL FEE /--�
OW b Ice,tlfythAl have read thbappOcadon and mate thattheabove Informatl.n aste�.. _
1 conent.Iagree to comply wlthaO etyand duntyordinanms and I,telawal t' (PERMIT ISSUANCE I •i�l ��' FEES PAID:
Cl) relating to building construction,and herebyauthoris a representativesofthl.
F Z atyt he above-mentioned property forinspenlon purpose, `, ALTER OR ADD 7b MECH. a^� Date Recei ITT
_ e)agrc t vr,ledFrpnl an d keep harMem the City of Cupertino P
a Iretllabi111 ,' dgmenb,cwb ode ees which may In an wayamme MRHANDLING UNIT(TO 10,000CFM) I SUBTOTAL:
a sine[saldC conssryence t file permit' AIR HANDLING UNIT(OVER I0,000C17,M) CONSTRUCTION TAX
as
C!� � �
S O' t/ o 'nor EXHAUST HOOD(W/DIJCTT CONSTRUCTION TAX PAID:
RI OUS MATERIALS DISCLOSURE
Will the applicant future building ocopantstoreor handle haranious HFATINGUMT(TOIOQOWBTU) Date Receipt#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
health and Safety Code Section 2M32(a)i HEATING UMT(OVER[00,000 BTU) I TOTAL: I
❑Yes M No
Will the applicant or future budding occupant use equipment or device I VENTILATION FAN(SINGLE RESID) I ISSUANCE DATE -
whichcor thauMoustlr contaMmnbas defined by the Bay Area Air
*q�mBOILER-COMP pHPOR 100,IXDBMhenals requirrments under Chapter 6.95 u( BOILER-CAMP(OVIR If10,000 BTU) Oh �4 0 eae,Senlons]55115,25533 and 75534.1 P pq I D
,(the buildingdoes no,currently have atrmnq that it].my NEW RESIDENHAI.MECH. SQ I"f
reponsibs Issuance dy the ocupast of the requirements which mual be met NOV 17
prior to lmuance ufaCerti(icate of Occupancy.
Owner or authonaed agent Date 91 LIlII� I)SSOED11
lD YMT1 a�I'f-+rur>
OFFICE COPY