24401 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Protect Idemif tion Pti WTNO.
ealamg Address:
qg �twI L� �+T 24401
ra arR NMs1� one. CITY OF CUPERTINO-BUILDING DIVISION
• nc ~ Lk.Na APPLICATION / PERMIT
T BUILDINGELCCMCA4PLUMBING-MECHAMCAL G LORY CONTROL f
Arch / No
QTY ELECTRICPERMIT FEE , BUILDING PERMIT INFO
Add.
FQtnaTlssuANCE
LICENSED CONTRACTOR'S DECLARATION
reby dflnn that las ls.d under ofChapkr9(mmmenc APPLIANCES-RESIDENTIAL-RESIDENTIALppB
kmWr N
.$with SeRbn7000)ofDh•Won3oMeBuslrc,,sect FrofealoruCode,and ���,y
Ikene.bIn(u d dfet. PANELSUP TO 2DOAWS
`1
Date ro CoriTECTEI 7111-1000 AMPS
CHITS DECLARATIO
�
God Iunderetatdmy pbvahallbeuad aspultHemmrda OVERIWOAMPB SQ.FT.Fl)OOR AREA f/�.FT.
LkxruM Prolmbvl SIGNSELECTRICAL �D
2
OWNER-BUILDER DECLARATION SPECIALCIRCUITINHSC
Inamby.ffirm that l amexempt from the Comrator's Manse lAw fur the
o folbMng ream.fSecilm]mIS,Busbm and Pcolmbn.Cade:My city or 1.
Z TFAfP.METER OR POLE INS!.
i-
K� muntywhkh requireapemdt tomrutrvct,alter,bnprove,demoWM1,or repair
anyst =mpt wioimamc aborequ4 theeppBnmfmmapert to POWER DEVICES
O file a Jgned statement that he b lloensed pursuant to the proof the
Contractor's Lkerese IAw(Chapter 9(oomsencing with Secibn 7000)of DId-
F,3�1 sbn3oftheBuYnm.nal'rtdmbv Codc)ortM1at M1eberempttherrfmmarM NG POOL ELECTRIC VALUATION
�+Y the basis for the alleged..amption. My A.1alon of Se tion 7m15 by any �a� asa—
G� +pplantfora pemltsub"thoappBcaottaadW pevHy ofnat morethan UT=SWITCFIS-nXFURFS v
five hundred doll..($SOV.
?Sn ❑1,as owner of the property,or R7 employm wlh wages u their sole 1`RW RISDENTIAL I:LECIR SQ.F7. SIDMAN TYPE CONSTRUCTION
mmpensadm,wllldothe work,and thestructure As mt intended or offered for
,O sale 15ee 7DK Businm.rd Prdmbv Code.The Com.d.e.lJor.law `
S$ does net apply to an owner of property who build•or Improves thereon,and
who doessuchwork hlmselorthrough Msown employees,provided that such NI
improv rhaarenot Intendedproffered!¢safe.If,however,thebuildlogo
Improvem.ni beold within ovycarofmmplelbn,the vwnerbulderwW love
rdenofprovbgthm nadidiamb"dorknpmveforpurpo.eofsak.). QTY. PLUMBING'PERMIT RZ Las owner of the property,am ettWalvely contracting whh LicensedP ER
amtraet.to mnslrot the pro)ect(See 7094,BodnmaM Pro(mbv Code: PERMIT ISSUANCE2
The Comme or'•Lb Law does not apply to an owner of property who ALTER-DRAIN 4 VENT-WATER -
builds e ds or Improvthereon, and who mm.m for such MAam with . _ FEE SUMMARY
cgaWor(s)liaenaed pursuant to the Contractor'•Llrerue Law. BACK FLOW PROTEST.DEVICE
LJ I am exempt urdv Sec. B k P C for this reOUTSIDE FEES
ason DRAINS FLOOK ROOF,AREA,OOND. SANITARY Y_ N_'
Pvner Dale RECEIPT T
WORKMAN COMFIZNSATION DECLARATION pDCNRF_S I'FR.TRAP SCHOOL TAX Y_ N_
❑I hereby affirm that I have a certificate of cmrnt to sell-Iwo.,«. /a
JOate ofworke.•Compevatlonlvurance«a o tlfled copy therrofiSec. RECEII'T
m
39M,Lab C.) GAS IJCII.
EA.SYSTEM-1 IOUEIS PARKFEE Y_ N_
Pdky l RM=
Com GAS EA.SYS O,4d OVER 4(EA) BUILDING DIVISION FEES
stifled copy b hereby th the city GREASE/WDUSTRI.WASTE INTERCEPTOR PLANCHECK FEE *70t'20
CetWed copy b(Bed with the city Ivpectbn division.
CERTIFICATE OF EXEMPTION FROM WORKERS GREASE TRAP PAID
COMPENSATION INSURANCE $EWER-SANITARYSTORM Fa NNOFT Date R., t#
(This section need not be completed I the pemdt b f«on hundred dollar P
($100)«lm') WATER HEATER W/VENT/EX= ENERGY FEE Y N
I¢tly tM1al brine petomw¢of the w«kforwMch rind.pemdt labsued, --
I shall eat empby any perm b any manner n u to beronr sub)ect to the WATER SYSTEM/TREATING
W«kera'CompevalnnlawsMGbfomb.Date PAID
O Z APPlant IGNEW RESIDENPIAL PLMB. SQFT. Date Remi t#
Z O NOTICE TO APPLM:If,after making this Certificate of Exemption,
should b.mme..byaad to the Workens'Compevatbn provisions of the Labor TOTAL
CC N Code,you morn forthwith comply with each pro isbv or this pemdt.hall be
W `J deemed revoked. BUILDING FEE te
CONSTRUCTION LENDING AGENCY - ISMIC FEE t
CL
Ihemby.ffirm that there As a moarutlon lerding agency for the perform, ELECTRIC FEE
n Z an¢ s
ofthe work for whkh this perlt Is blued(Sec,3097,CW.CJ L
U O
Lender's PLUMBWGFEE
LL ~ Iender'.Add. QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W I aaity Nat l have reed this.ppliotbnanci statethat theabove information1 bmrmct.I.gtee,to comply with all chy.td county oNlnanm and state laws PFRMTT ISSUANCE FEES PAID:
} N relating to building covtructim,and hereby authorize representative of tha
V
Z city to enter upon the abvvcmentbrcd property f«inspection purposes. ALTERORADDTOMECH. Date Recei t#Z (We)agree to save,Indemnify an d keepM
hare.the City of Cupertino
agaWt b,pdgme b,ma.am evnwhkh mayinanywayacaue ATR HANDLING UNIT(TO 10,000 CFW SUBTOTAL:
Id tyle ming of this pemdL ATRHANDUNG UNIT(OVER IVODOCFM) CONSTRUCTION TAX
p a /Cont « ate L EXHAUST HOOD(W/DUCT, CONSTRUCTION TAX
W"
WPAID:
HA�'ARI US MATE ALS DISCLOSURE
Will the applam«future building oceupamt store or hardk havrdw. HEATING UNIT(TO IOOXW BTU) Date R
material a deOrcd by the Cupertlrn Municipal Code,Chapter 9.17,and the
Hath and Safety Cade Seciim 75537 W7 HEATING UNIT(OVER 100,000 BTU) TOT
❑Ye M No
Will theappibm arfuture brldirgocapam use equlpmeet or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardo a alr mntamlvM•as defined by the Bay Area Air
• QualityMavgamem Dsrici7 BOILER-COMP DEIPOR 100,000 BTU)
4 .. r.� °
: °� H
have read then materials regnbemenb under Chapter 6.95 of BOIILfLCOMP(OVFR ID],000BM
the Ulfomb I Icalth A Safety Coda,Sections 75505,75533 and 25534.1 b o `
1!-
.Mentotdthatifthebuldingdanwtarrentlyhavc.tevntthatitbmy NEW RESIDENTIAL MECTi. SQ.FT /q
ioponsmlly to n.L"a oouTum of the mqul¢menb whhh most be rust 2/ Igo
Prix to bsuan¢o!a Certificate of Occupancy. CITY 0)r
V LIfi71,
owner or authoisd agent - Data 1SSUEDBY:
TOTAL:
OFFICE COPY