24001 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
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24001
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nems aces: one:
rov W C CITY OF CUPERTINO-BUILDING DIVISION ^ 1
Contractors Narre: fS. APPLICATION I PERMIT NZ
BUILDING-ELECTRICAL PLUMBINGMFOIIAMCAL CATEGORY CONTROL If
Arch)a t/Englneer. Lie No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address:
PERMITISSIIANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
Thereby afflrmthat lai lk.e3.fthdur ..slonso(C.,i..r9(rommenc- APPLIANCES-RESIDENTIAL `gDESVON
�
Ing with am ny.fil7000)of amlic nsed under
n BuGnsmands ofC a pter9 de,and my
limn.Is In fun form and effect. PANELS
laoonn
s
Date C
Datem Coer
ARCHITECTS DECLARATION 701-1000 AMPS
9 CCZO I understand my plans OAR be used as public records. OVERIODOAMPS SQ.Fr.FLOOR AREA $/SQ.FT.
Llcenxd Profemlovl SIGNSELECTRICAL
OWNER-BUILDER DECLARATION SPECULCIRCUIT/MLSC
1hembya(firmthat I am exempt from the Contractor's License Law for the
Q following reason.(Section 7031.5,Business and Professions Code:An d or
FCil county whlch requires a permnrocunsUuct,alter,improve,demollsh,or repair TEMP METER OR POLE INST.
anystmu mpr wiro lseuamc ab m-qul theappRonlfmauchperrrdtto
file a signed statement that he V licensed pursuant to the provisions of the POWER DEVICES
pµ Contractor's Lkmve Law(Chapler9(m.rcling with Settbn 7000)0(Divi- VALUA�(l�a
slon3ofthe Businessand ProfemloaCode)orthat helaexempttherefromand SWIMMING TOOL ELECTRIC �CJJ(J
S the baste for the alleged exemption. Any violation a(Setlon 70115 by any O O
applicant fora permit subjects theappllcant toa civil penalty of nor rtnre than OUTLETSSWITCHESFIXfURES ,
?fqdred dollars($500). �' NEW RES[DENTTAL ELECTR O TYPECDNSUtUCT10N
owner of the property,or my employees with wages as their soletlon,wRldothe wmk.and the stature is not intended or offered for(Sec 7014,Busims and Professions Code:The Contractors License law no[apply to w owner of property who builds or Improves thereon,and RFS.UNITB
whod c suchwork himselforthrough hlsownemployees,provided that such
Improvernenb are not intended orofferad forests.If,however,the buildingor TOTAL-
improvement
OTAL
improvement osold Mthinoneyearofcompltlogtheowner-budderwill have
t rden of proving that he did not build or Improve for purpose ofsaleJ. QTY. PLUMBING PERM FLOOD ZONE APN
Lj L as owner of the property,am exclusively contracting with licensed
re.h.ors to construct the Project(Be.7061,Business and Profess me,Code: PERMIT ISSUANCE
The Corde tore License Law does not apply to an owner of property who ALTER-DRAIN&VENT WATER(EA)
bunds or Improves therson,and who contracts for much pipets with a FEE SUMMARY
cglLI�aturts)licensed pursuant to the Contractor's License Law. BAIX FLOW PROTECT.DEVICE
LJ 1 am exempt under Sec B&P C for this maven
Owner Date -
DRAINS. AREA.COND.ROOF, SANITARYRECEIPT M—
WORKMAN COMPENSATIONDECLARATION
E31 hereby afit.that I have a mrtl0cate p(concent to self-Insure,m a FIXTURES PER TRAP SCHOOL TAX Y N
RECEIPT e
mhificateo(Workers'Compematlonlns mnmoramnifWmpythemof(Sec.
3800,Lab C.7 CAS EA.SYSITM-1 INCA OUTLETS PARK FEE Y N
Policy GAS EA.SYSTEM-OVER 4(EA) RECEIPT11
Com ray BUILDING DIVIS NFEE
Certified copy is hereby furnished.
CeGREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy Ice(lied wltA the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GRFASETRAP
PAID
COMPENSATION INSURANCE SEVER-SANITARY-STORM EA 700Ff Date Rccei t#
Oh Hass.) need rat bemmplted little permit V(Drone hundred dollare
($1I metilem.) WATER HEATER W/VENT/ELDM ENERGYFE 0 N
I mrtifythat fo the performance of the work forwldch this permit Is Weed,
I shall not employ any Penson In any manner w as to become subject to the WATER SYSTEbT/TR ATING
Worker'Compensation laws of California.0 mms
Z Applicant NEW RESIDENTIAL PLMB. SQ}T. a Recei til
Z dl
Z NOTICE TO APPLICANT:If,sPerraWng this CertBlrate of Excerption,you
should become sub)ect to the Workeri Comperaation provisions of the Labor TOTAL:
W Code,you mu at forthwith amply with much provisions or this permit shall be
131JIMING FEE 9n.
W rimmed revoked SEISMIC FEE
(L CONSTRUCTION LENDING AGENCY
I hereby affirm that there a construction ding agency for the petprm ELECTRIC FEED Z arm of the work for which this peroMtbissued(Sec.
3097,Civ.CJ TOTAL:
V O L0ldera N.. PLUMBING FEE
LL f Lenders AddressQTY. MECHANICAL PERMIT FEE MECHANICAL E
OW I mM1ifythat l have read this application and tatethattheaboveluformidon
6 ismrmt.Iagreeto complywithall city and county ordlnanmaand Gate laws PERMITISSUANCE FEES PAID:
>. Nrelating to building construction,and hereby authorize representatives of this
F Z city to enter upon the above-mentioned property for Inspection purposes. ALTERORADDTOMECH.
(We)agree to save,indemnify an d keep harmlem the City of Cu pertlno Date Receipt#
V against liabilities,judgennots,mss and expenses which may In anywayacvue AIR HANDLING UNIT(to 10,000CFM) S BTOTAL:
against mid City in mnmryence of the granting of this permit. AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTIONVAX
S�gyw lent/Contra
Data EXHAUST HOOD(W/DUCT) CONSTRUCTION AX PAID:
HAZARIATF.RIALS DISCLOSURE
WIIl the applkant or future buliding pccvpantstoreorhandle hazardous HEATING UMTOD 100,00011TO
material as dented by the Cupertino Municipal Code,Chapter 9.1 7,and the _ Dale ` 1 _
Hearth and Safety Cade Section 2S537(a)7 HEATING UNIT(OVER 100,000 BTT3) T
❑Ym ,L+,—,J,No a, VPNIILATION FAN
Will the appncantorfu rotaroildingodefine mythe By Are.devices (SINGLE RESID) ISSUANCE DATE
which e. hazamdous air mntaManb as deflad by the Bay Area Air
Quality Management
DisWttl BOILER-COMP p}IPDR]W,IXD BTU) � p 1
❑ Yee ❑No K 7
J*
(have readthehazardouamterialerequie...taundcrChapter1.95 of BOILER-COMP(OVER 100,000 BTU) ��
the C7100 mat Health&Safety Code,Set Ions 25505,75533 and 25534.I �j�
understand thatn notihe fy
the ing doesoccupant net mrtennymhave s which that RBmy NEW RESIDENTIAL MECH. SQ.FT �/ 199,
responsibility to Issuance
of a Certificate
of the requirements which must be met CI
prior to Wuancn pia CertilkatcplOcmpanry. V
Owner or authorized agent Data ISSUED BY:
TOTAL:
j OFFICE COPY