24187 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT-PEN ONLY
Building Project Identification PERMIT NO.
BuildingAddress:'Ir �� . � 24187
'
w er one: A C1-
� A A
CITY OF CUPERTINO-BUILDING DIVISION C1 Ct 01
n a - 'ane: Llo No: APPLICATION / PERMIT V._1
BUILDING-ELECTRICA4PLUMBINGMECHANTCAL CATEGORY CONTROL M
A111cl/Engineer. Lk.Nee
TJ 6.S N SR/t�C4 C.C�L BUILDING PERMIT INFO
QTY ELECTRIC PERMIT FEE
Address: G � PERMITISSUANCE �� ❑ El ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter 9(commene. APPLIANCFSRESIDENIAL JUB DESCRIPTIO
Ingwlth 5e tlo^7000)of Divbdcxn 3ofthe Businessand Professions Code,and my
license is in full fo and offee. p PANELS
License Class Lk.# 02��7/!5
Date Conhaci:
ARCHITECPS DECLARATION 201-IOOOAMPS
pQ�al
77 I understand my place shall be used as public records. OVER IWO AMPS SQ.Fr.FLOOR AREA E/SQ.Fr.
06
E d 5 Licensed Prolesslovl - SIGNS ELECTRICAL
<�<Lu OWNER-BUILDER DECLARATION
.6 SPECL3LCItCUIT/M1SC
f, 1herebyafRrm that l am exempt fromct
the Contraors Llre"se Law for the
following reason.(Section 7071.5,Business and Professions Code:Any city or �..�
•rQ, =ntywhlchrequ4 apert ttommtmn,alter, pmve,demolbh,ormpalr TEMP METER ORPOLE!NSI. -
<g`' a anystmcrom pdorto its ismance,also requlmthe appBmnt for such permit to POWER DEVICES
C y V Ole a signed statement that he is licensed pursuant to the proWlons of the
�3O rte Comeac or's License Law IC pter9(commencing with Section 7000)pf Divi- SWIMMING POOL ELECTRIC
0r son3oftheBustrivandProfevlomCode)orthathe6exem therefmmand VALUATON
the basisfor the allegedexemption. Any violation of Section 70315 by any OUTLETSSW(TCIiESFIXT[IRFS
applicant fora permit subjects the applicant to a civil penalty of not more than
five puns ed owner of
(e
pm NEW RESIDENTIAL ELECTR SQ.Fr. STOWPS TYPE CONSTRUCTION
j] ❑Lasownwo(othe
work,and
myyemture isswithwage as tWredfo
C < compensation,lion,Business
ldessand kandthestrode:Th extintendedorofferedLaw
Sd sale(Sec.apply Business and f pr esskns Code:The Contractors License Law
docs noroessuch toanowner ofthroug hisonemplds oym,prn<edthathriven,and OCC.GROUP ITBUNIT5
L0.• impwho d es ntsa nrffite dedor ffemd ow le.If b wever thebuihatsvch
improvementsarenot Incendedprofferedpleioe.theonerq Hder illhgvr
improverrcnt b Bold within one ycaro(completlory the owner-W Bderwlll have
At den ofpmving that he did net build or improve for purpose otsale.). QTY. PLUMBING PERMIT FEE Ffppp ppm ApN
I/}v,as owner of the propeny,am exclusively contracting with licensedtractom to construct the project(Sec.7060 Business and Professions Code: PERMIT ISSUANCE
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN&VEM-WATER(EN
Wilds or Improves thereon, and who contracts for such piojects with a
�gIIttacme(.)hemsed pursuant to the Contractors License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec B k P C for this release,
Owner Date DRAINS FLOOR,ROD$AREA,COND. SANITARY Y_ N
WORILHAN COMPENSATION DECLARATION RECEIPT M
91 hereby affirm that 1 have•certificate of consent to sell-insorc,or FIXTURES PER]RAP SCHOOL TAX Y N
ceniflrneof Workm'CompevatlonImeuranmoracertifiedwpythercof(Sec. RECEI N
3800.Lab C.).— (a� ,A� pC� GAS FA.SYSTEM-1 INC60UILE15 PARK FEE Y_ N_
Policy M J , ' S LJY1 S koo�3"1. RECEB'T M
Company�' GAS FA.SYSITM.OVER d(EA) BUILDINGCENT a DIVISION FEES
,ILS$-1TCenified copy is he d with the
cit. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
CenlOed copy V filed with the city lopection division.
CERTIFICATE OF E)(EMFTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE
(rhissectlon need not becempleted tithe permit laforone hundred dollars SEWTR-SANITARY-STORM EA."FT. Date Recei tilt
(5100)oeless.) WATERHEATERW/VENT/ELFCTR ENERGYFEE Y N
!lenity thatmthe emarmperson in
nuhe wnekso as tobthispenult is Ito the
I shall not employ any person In any manner n ns to become subject to the WATER SYSTEM/TREATING
wodicant PAID
pensauon Lawa o(Glifornia.Date
O Z Applicant
_Z O NOTICE TO APPLICANT:If,after moving this Certificate of Exemption,you NEW RESIDENTIAL PLMB. SQ.FT. Date ReCei t#
~
should become subject to the Worker'Compensation provision of the Labor N Code,you nest forthwith comply with such provisions or this permit shallbe TOTAL:
W > deemed revoked. BUILDING ELF
d E CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there is a construction lending agency for the perform
O . ance ofthe work for which this permit b Weed(Sec.3097Tornl: ELECTRIC FEE,CIv.C.)
U _ Lender.Name
IL I— Lenders Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
O W Icenifythat l have read thisappemtlon and statethatthe above Information MECHANICAL FEE
0. bcorrect.l agreeto comply with all city and county ordinances and sate law. PERMIT ISSUANCE FEE-PAID:
r Nexisting to building construction,and hereby authorize representatives ofthis
Z city to enter upon the aWve-mentlonel pmpeety for inspection purposes. ALTFRORADDTOMECH.
(We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Receipt#
against liabilities,judgments,costs and expenses which may In any wayaomir AIR HANDLING UNIT ITO 10,000 CFM)
aga lot said City In consequence of the granting of this permit. SUBTOTAL:
AIR HA NDLING UNTr(OVER 1 qm0 CEM) CONSTRUCTION TAX
Signature of Appllant/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAlEA R DOLS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or hand le hazardous HEATING UNIT CFO I 00,000 BTU)
material as defined by the Cupertino Municipal Code,Chapter 9.1 2,and the _ Date RCCCI
He�all ..d Safety CedYes go
Sectlon25532(a)2 HEATING UNIT(OVER IM000 BTU) TOTA .
Will the applicant or❑❑future Wilding occupant use equipment or devicesM(OVER
(SINGLERFSID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management D❑lstnct7 OR 100,000 BTU)
4 Yes rd No
have read the laza pus materials requirements under Chapter 6.95 ofCOMP 1W,000 BTU)thqCalifornia Health kSafety Code,Sections 25505,25533 and 25536.un erstandthatlithebuildingdoesnotcorrectlyhaveatenant,thatitismyMECH. SQ.Frm exibllity to notify the occupant of the requirements which must be met
rloLssu ceotaCcnIEcateofOccupancy. _ irte ort or� Bt Dateqrn 7 e
TOTAL: ISSUED BY:_
OFFICE COPY Gay jr wl r,