24043 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address: 24043
lh�c-L-
wn rs ° : A A A
a¢ y
CITY OF CUPERTINO-B I DING DIVISI
Lie.No: APPLICATI I�I / PE MI
�—IL icor iFCARY
Archmect/En n r BUILDINGE,FCTRI AG BING_ MCAL
gl fie. Lic.No:
QTY E CT ICPE BUILDING PERMIT INFO
Address: PFRMI I -� IT xe1 ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby afflrmthat l xm Bcenaed under provisions ofChapmr9(mmmenc NCESRESI E JOBD RII'ITON
ingwith Section 7000)of Divislon3ofthe Businessand Pro a. e,andm
licenseClsu8 tone and t.#
Class
License Class Lic# 1 aMV`t✓1
Date Contractor
ARCHITECTS DECLARATION 201-1
pO+a0 O I understand my plan shall be used as public records OVER PS SQ.Fr.FLOOR AREA 5/SQ.FT.
s E �j Licensed Professional 9CN5 ]RICA I 'I n R�I�� ,(�,J�i �Q
fn 6 OWNER-BUILDER DECLARATION w �5']✓ Q
SPECIALCIRC /MLSC
7 Ihereby affirmthatlam exempt fromthe Contractor's License Law fort e
"ppa following reason.(Section 7001.5,Business and Professions Code:An d or K
K �"'W ceuntywhichmquaesapert ttococotmd,alter,knpro ,demlish,orrepalr 7FMP.M OR POLE INST. ITER
••
�E d< anystmmmpdortoibbsuance,aboryuimtheappBnntforsuchperMtto Poww6m� �/ �O//��
CMV file a signed statement that he is(kens d pursuant to the provisions of the /
OQ� Contractor.License law(Chapter9(ce—roirgwithSectam7000)ofDWI-
3 sion3ofthe Bus .,.dProfessionsCode)°,that heis exempt therefromand SW;MMlNG IDOL ELECTRIC VAC ON
y3 S the basis for the alleged exemption. Any violation of Section 7031.5 by any f^� _ 1 ���4
�O rom
pplicant for as�t subjects theapplicet to a civil peraltyof not mm, v �-En�TCHFSFIXTURFS `
( )' NEW RESIDENTIAL ELFCTR FT.
mer of�he property,or my employee with wages as reds,sok SIEIIOES TYPECONSTRUCTION
Pon ,will doth work and thestmcture is not intended or offered for
o 0 Business and Professions Code:The Contractors Lice.Law
y to an ownerof property who Wilds or improvesthemon,and OCC.GROIIPRIS.UNRS
h work himself or through his°wn employees,provided that such
Improvements arenot Wended oroffered forsale.If,howevegthebulldingor T
Improvement issold within one yea rof completion,the owner-W Oderwlll have
(he,c.p�rdenofprm,mgthat he did not build mimproem for peuposeofsak.). QTY, PLUMBING PERMIT FEE FLOOD ZONE ppN
LJ L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec 7044,Business and Professions Code:
The Contractor'.License law does not apply to an owner of property who ALTER-DRAIN 4a VENT-WATER(EA)
Wilda or Improves thereon,and who contracts for such pRojects with a
,,C�Ht[[actor(a)licensed pursuant to the Contractors License Law.
I am exempt under Sec. B k P C for this reason BACKFLOW PROTECT.DEVICE FEE SUMMARY
OUTS!�LLS
Owner pate DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
WORKMAN COMPENSATION DECLARATION RRCEPT«
[-]Im 1 hereby affirthat I have a certificate of consent to self-insure,or a FDCrURES PER TRAP SCHOOL TAX Y N
certificate of Workers'Compensation Insurance ora certified copy thereof(Sec. RECEIPT#
3800,Iab C.) GAS EA.SYSTEM-1 INC.4 OUTLETS PARKFEE Y N
Policy# RECEIPT M
Co any GAS EA.SYSTEM-OVER4(EA) Fees
[Certified copy is hereby famished. BUILOMGDI VISION
❑CenNed copy is filed with the city Inspection division. GREASE/WDUS-ML WASTE INTERCEPTOR PLANCHECK FEE /
SETRAP
VQ
CERTIFICATE EXEMPTION FROM WORKERS' GREAPAID
COMPENSATION INSURANCE
(This section need not hcompleted lithe permit is(orone hundred dollars SEWER-SANITARY-STORM EA.200Ff. Date RC s,'
(Sl ro)orlWATER HEENERGY FEE Y N_
I certifyy that In the performance of thewwk forwNPermit ch this peit. ATER W/VENT,/ELECTR
issued, —
1 shall not employ any person in any manner so as to become subject to the
Workers Compensation Lawn of Calffomia.Date WATER SYSTEM/TREATING PAID
ZCr Z Applicant NEW RESIDENTIAL PLMB. FT. Date Remi t#
O h.ldb TO MPLICttothe after orkers'Comaking er cation ateofon,oftior,you _SQ
Code benne forth tothe Workers'such provisions
porthiorormit s Lab be TOTAL:
LU N Cumordr must forthwith comply with such provislov orchis permit shall be
W > deemed revoked. BUILDIN FE --+
a p CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirmthatthere this
ammit constructionlendingagency for ted perform. ELECTRIC FEE
0
arm,ofthe work for whkhthispermitisbsued($ec.3097,Cie.C.) TOTAL:
U _ ]order.Name PLUMBING FEE
U. Lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O IL IcertifythatIhaveroad this appliationand statethattheabove Information —�
1 is correct.I agreeto comply with a8 city and county ordinances and state laws PERMIT ISSUANCE FEE$PAID:
N relating to building construction,and hereby authorize representatives ofthis
H Z city to enter upon the aboveaxeatlored property for Wpe Hon purpoxn. ALTERORADDTOMECH.
(We)agree to save, emnify an d keep harmless the City of Cupertino Date Receipt#
agabuthabllitieq' g nb, d expenses which may in anywayaceme AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
ag.lrem.aid ty the granting oft permit.
ATRHANDLINGUNIT(OVFR10,0WCIM) CONSTRUCTION TAX
Sig a (Appllant t cur Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HA FifATER1AL5 DISCLOSURE
Will the applicant mfuture building occupant store or handle hazardous HEATING UNIT(TO 103,ODO BTU)
tcrial as defined by ted Cu pertino Municipal Code,Chapter 9.12 and the _ Date RBCCIpt#
EF1 and Safety Coder�Section 25532(a)t HEATING UNIT(OVER IW,000 BTU) TOTAL:
❑ Yee u No
Will the applicant or future building occupant useequipment ordevices VFNDLATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardousnt
air conDedcants a.deed by the Bay Area Air
Quality Management District? BOILER-COMP OEE'DR100,000 BTU)
Ye No
cove readmeharar�do,materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU)
the California Health h Safety Code,Sections 25505,25533 and 25534.I
understand that ifthe building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.I7 AUG
19g;0
nsporeibility to notify the occupant of the requirements which must be met
prior to bsus nm of a Certificate of Occupancy. Gil Y Ut-
V laUYtd�'
Ownerm.whodred agent Date A /
ISSUED BY: � /�__ _
OFFICE COPY