24070 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NQ 0 O
Building Add.,: Z
//'/v Sf F Or,
wners amc: one: AIIUN SUUMI I IALA
CITY OF CUPERTINO-BUILDING DIVISION �}as
Co d,4dorsN me: LIc.N.- APPLICATION / PERMIT ! -1
I^0 �""' 'Z 9a BUILDINGELFM
CTWCALPL HINGMECHANICAL CATEGORY CONTROL N
Archil /Engineer. Le.No:
QTY ELECTRICPERMFF FEE BUILDING PERMIT INFO
Address:
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION PERFITISSUANCE
IhthSy on7OW)Olam Bm3ofheBug rwandPmfehaptar9(comm. APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Inensei in fon force
effect.
elthe Budne.and Pro(esslonsC.ode,and
license is in full lora and steer. PONTIS
License Class LION
Date Contractor f1
ARCHITECTS DECLARATION 701-10)DA.MPS
90use
Z I understand my plana shall bed.public amnia. OVER 1000 AMP$ SQ.Fr.FLOOR AREA E/SQ.Ff.
Licensed Professional SIGNS ELECTRICAL p
f•,,.' A'
®
<� OWNER-BUILDER DECLARATION SI'FGULCIRCUIT/MLSC 'V
L., Z Ihereby affirmthat I am exempt fromthe Contractor's License Law for the
Z O -' following reason.(Section 7031.5,Business and Professions Code:An cityor '•- J (1—
OZF y TEMP.METER OR POLE INST. �" e
FMe� county regWma pemdtroroomquialter,Iaprove,derrsuch,orrutto
a anystronure tatepriotentshathiCIsalcensed rcrsuanttothe provisions
t e POWER DEVICES DATE—
Rle a actors statement that he la licensed(com pursuant it the provision of the
F�OO Contrictor'sLeenseLaw(Clupter9(mmmenthathehmmpthemfmSection 70M) fDWI- SWIMMING POOL ELECTRIC
< sian3of theeualnevand ProfeaonCode)erthat helaeumptthercfromand VALUATION
•.t the basis for the alleged exemption. Any violation of Section 7031.5 by any
appliantfor a permit subjects the applicant to a civil penalty a net mon,than
OUTLETSSWITCHESFIXTURES
m five hundred dollars(SM.
�n ❑I a owner of the NEW RESIDENTIAL ELECTRSQ.FT,
, s property,or my employees with wage as there dole S70WF5 TYPE CONSTRUCTION
74
compensation, dotalworkand the I Code:
Vnot Intended orofferedfor
5 F O sae(Sec.apply
to ainow and f property Code:The or impnora License Law
�j5R does not apply loan owner or through hiswho nWilds
mpornmprwnthereogand OCC.GROUP RF UNITS
who
ovdoes
ments am nut malt or edoroughed ownemIf,ho employees,provided that such
improvementsarenotintended profferedfor aide.If,hx,mor- the erildnngve TOTAL:
improvement is sold within one yearofcomplMlon,the owner-W BderwWhave
t1iLkuden of proving that he did not bis Rd or improve for purpose of axle.). QTy. PLUMBING PERMIT FEE F10p z NNE ApN
LI L as owner of the property,am exclusively contracting with Ilanand P LL ISSUANCE
mmach s to constrlln the project(Sec.7014,Business and Profession Code: i",
The Contractor's License Law does nut apply to an or of property who ALM-DRAIN k VENT-WATER
Wilds or Improv.thereon, and who contract, for such fr,jens with a (FA)
�gnt(ador(s)Bcensed pursuanttothe Contractor'sLicenseLaw. BACK ITAWPROTFGT.DEVICE FEE SUMMARY
I_J I am exempt under Sec. B k P C for this reason
DRAINS FLOOR ROOF,AREA,GOND. NITARY Y SAN—
Owner Date
WORKMAN COMPENSATION DECLARATION RECEIPT N
Ell hereby affirm that 1 have a certNate of consent to del!-Insure,ora FU('IURF_S PER TRAP SGTOOL TAX Y N
adifioteof Workers'Compenstiminsur moraartlfedmpythenrof(Sec. RECEIPT#
38M Lab C.) GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
Policy N RFGEI'f p
GAS EA.SYSTEM-OVER 4(EA)
°y BUILDING DI V ISI ON FEES
CeKilled copy is hereby thcid. GREASE/WDUSTRL WASTE INTERCEPTOR PLANC14ECK FEE
Certified copy V blind withhthe city Inpmian division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-MRM EA 2]OFT Date Rccei t#
(D)mInse.) need nitWcompleted Bthe permit V(Drone hundred dollars
(8100)orf.h) WATER HFATERWECENERGY FEE Y N
IaMeW
ify that the pedormsnce of thework forwhich this permit is lesaM, /VENT/F1TR —
I shall not employ any person In any manner so as to become sub)ect to the
Workers'Compensation Laws of California.Date WATER SYSTEM/TREA7IN'G PAID
O Z Applicant
Z O NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you NEW RESIDENTIAL PLMB. SQFT. Date Recel t#
Fshould becomesubject to the Workeri Compensation provislon n of the Labor TDTAL:
N
Code,you=at forthwith comply with such provisioor this permit shall be
W > deemed revoked. BUILDING FEE
CL C CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z
I hereby alarm co
that there is a nstructioe
n nding agency for the perform- ELECTRIC FEE
shoe of the work for which this permit is issued(Sec.3097,Civ,C.)
U O 1e"de`a Nd111e ------------
PLUMBING FEE
LL r Lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Icertlfythatl love readthb appBatlonand atatethauheabove ln(omation
0. larorren.I agree to comply with all city and county ordinances and Mate laws PERMIT ISSUANCE FEESPAID,
W relating to building mntnction,and herebyauthorim representatives ofthia
F Z city to enter upon the above-mentioned property for inspection purposes. ALTER ORADDTOMECH.
— (We)agree to save,Indemnify an d keep harMess the City of Cupertino Date Receipt#
against liabilities,judgmPts,costsand expenses which may In anywayaceme AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
agal axis en he gra ng a this permit.
AIR HANDLING[JNTf(OVER IO,DJOCFM) CONSTRUCTION
'Ig® TAppli.ht/Ccmr nor C JDate EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAIZARDOUS MATERIALS DISCLOSURE
Will thesppBant or future building occupant store or handle hacadous HEATING UNIT(TO 100,000 BTU) Date RCCCi t#
tergal as defined by the Cupertino Municipal Code,Chapter 9.17,and the
I ealth and Safety Code Section 75537(a)? HEATING UNIT(OVER 100,000 BTU) TOTA
❑Ys LnNo
Will the applicant orfuture building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air rontamiwnts as defined by the Bay Area Air qq B
Quality management District? BOILRR-COMP OHP OR 100,000 BTU) a'Y
Y. he 1'�No
have bt tealth&rRam materials rcqus 25505, 5533underand 25534.1
of BOILER-CDM 100,000 B7 U) (rrl�
the
erstandt it if the b Safety Code, Steen currently
have
stand,thatii %V - 199
understandyton hebulldingdoes not the
eroh, hich that it .art NEW RESIDENTIAL METH. SQ.FT _ gal
r.poto issuarmna Corti occto of Occupancy.mryircments which rwsl W met G�
prior to Lssuanoe old Certificate of Occupancy. b I `fr- LVrt
rrrnYv
Owner or authorized agent Dale
TOTAL: ISSUED BY:
OFFICE COPY