24277 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification 7 PERMITNO
Building Address: Z
4277
a24 . PIES ' PL
neve a one: p p
C'() S3 CITY OF CUPERTINO-BUILDING DIVISION _ ��c� Z
• Contract°:•Name: Lic.N.: APPLICATION I PERMIT �T
BUILDING-aBCTMCAL-PLUMBING-MECFtANICAL CATEGORY CONTROL If
Architect/Engineer. Lic, o:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add. / PERMITISSUANCE _ ❑ El
❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter 9(comencn APPLIANCE4RESIDENTTAL JOB DESCRIPTION
Ingwith Sedion7000)Of Dlvisim3ofthe Busiauand ProfessionsCode,and my
license Is In full form and died. PANELS
Linnse Class e' Lk.# /.?/
Data Contractor
ARCHITECT'S DECLARATION 201-1000 AMPS
AsZ Iunderstand my pbu «
shallbe used as publicoords, OVER1000AMPS SQ.Fr.FLOOR AREA $/SQ.Fr.
O
ULicensed Professional SIGNSELECTRICAL i I -1. lig ® ' A
6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC v `n { C� l(✓ (_• +rte I�V
zH�& 1herebyaffiren that famexemptfromtheContractor's License Law for the UT
oo q (allowing reason.(Section 7071.5,Business and Professions Code:My city or
FZ Iy county which rcyuecia permktoroutrud,alter,Improve,demolish,orcepair TEMP.ME ER OR POLE INS[. /�
qld 7 aeystudure priorto It.issuance,also requlrestheappLunt for such permit to POWER DEVICES ATE ID
15 fik a signed statement that he Is harassed pursuant to the provisions of the
3 u.� Of
C.Medoe.License Law(Chapter9(mmmendng with Section 7000)of Divi- SWB.IMING POOL ELECTRIC VALUATION
SOS skm3ofthe Busba.lolProfesskns Code)mthat bels exempt therefromand
<5 the basis for the alleged exemption. Any violation of Section 7MIS by any OUTLETSSWITCHFSFIXTURES
apphnnt fora permit subjects the applicant to a civil penalty of not rrore than
five hundred dollars($500). NEW RESIDENTIAL ELECTR SQk7.
�n ❑I,a owner of the property,or my employees with wages as their sole STORIES TYPECONSTRUCTION
compensation,will dothe workand thestrudum is not intended or offered for
q sale(Sec.7044,Businessand Professka Code;TheContradoes Limme Law
$ does not apply to in owner of property who builds or improve thereon.and OCC.GROIJT' RIS.UNITS
who doesuch work himself or through Msown employee,provided that such
Improvements are or Intended oroffmxi for sale.If,however,the building or TOTAL:.Z(&,0 0
Improvement issald wlthlnoneyearofcompletme,the owner-builderwill have
H(q_Lme,knof proving that he did not build or Improve for purpose of sale.). QTY. PLUMBING PERMIT FEE
LI L as owner of the property,am exclusively contacting with licensed FLOOD ZONE APN
contractom to coatmet the project(Sm.7044,Business and Pro(eadea Cade: PERMIT ISSUANCE
The Contractor's Limese Law don not apply to an owner M property who ALTER-DRAIN&VEN'C-WATER(EA)
Wilda or Improve thereon,and who contracts for such p(ojects with• FEE SUMMARY
aff,tors)licensed pursuant to the Contractor's License Law. BACK p(pIV PROTECT.DEVICE
LI I am exempt under Sec. B&P C for this reason
Owner DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N_
. Date RFGmT#
WORK MAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOLTAX Y N
❑I hereby•!Oran that I have a certificate of consent to op thereof G a RECEIPT#
cedifirab of Workeri CompensaHontruurance ar•certified ropy thereof(Sec.
' 3500,lab CJ CAS EA.SYSIEM-1 WC.40U7LETS PARK FEE Y_ N_
Policy# RECEIPT#
Com any GAS FA.SYSTQd-OVER 4(EA) BUILDING DIVISION FEES
[�Creifled copy Is hereby filed
the city GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
❑CertRied copy Is flied with the city inspection division.
CERTIHCATE OF EXEMPT ION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARYEA 300Fr Date Recti t#
RMssectlon need rad be completed i(tM pemdt V(or oat hundred dollars
(sl0gorless) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
Ill.mythat p Inthe pe.o In nof y work for which this pemNt is Issued,the
I shall nor employ any person In pray manner ro u to be me cit to the WATER SYS.T.EM/TIZEA.DNG ,
worken'cam udonl spl Gyimmia. s��°ZQPAID
O Z Applicant dl'i4 15 P. NEW RESID=N AL PLMB. SQFr. Date Remi t#
Z O NOTICE TO AP ANT:If,after maklagt Is Certif to of Exemption,you
F0 should bemire subject to the Workers'Compensation provisions of the Leber TOTAL:
Vi
— Code,you meat forthwith comply with such provisions orthis permit shall be 6 'E
W
> deemed revoked.
CL c CONSTRUCTION LENDING AGENCY SEISMIC FEE
IhembyafRnnthat there lsacoatmction kndlegagenry,forthe perform TOTAL: ELECTRIC FEE _p0
O once of the worklor which this permit Is Issued 3097,Civ.CJ
Lander'.Name PLUMBING FEE
LL !- Lead.ex Acidrea QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW Icedlfythatlhavereadthieappliutlonandmatethattheaboveinlorratlon
G Ismrrect.I agreeto comply with all city and county ordinance and pate laws PERMIT ISSUANCE FEES PAID:
} relating to building construction,and hereby authmbut representatives ofthis
(_ Z city to enter upon the above-mentioned property fee Inspection purposes. ALTERORADDTOMECH.
_ (We)agree to save,Indemnify as d keep harMea the City of Cupertino Date Receipt#
against llabWties,judgments,"sand expenses which may In anywayacerue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
against Id Cityln nsaxprenm of the rating of this pemdt.
AIR HANDLING UNIT(OVER]O,lAOCFM) CONSTRUCTION TAX
Slg..�OKof Appilnnt/Contractor DjAc EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCL SURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU)
mDale Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the
Health and Safety Cade Stolon 25532(P)? HEATING UNIT(OVER 100,00)BTU) TOTAL: .U-CU
❑Yes No
Will the applican or furore building occupant use equipment or devices VENTILATION FAN(SINGLE RESLD) ISSUANCE DATE
which rout hazardous air contaminants as defined by the Bay Area Air sm(� pp p
Quality Management District? BOILFR-COMP DHPOR 100,000 BTU) Y A I D
[?have
FF��No
4havereadthe huar`Trous materials requirements under Chapter 6.95 of BOILER.COMP(OVER 100,000 BTU)
the California Health&Safety Code,Sections 75505,25533 and 25534. 1 SEP �S 1992
understand that if the building does net currently have a tenant that it h my NEWRFSIDENIIALMECH. FT
SQ.
rexpoalbllity to notify the occupant of the requirements which must be met
prior to issuance ofa Certificate of Occupancy. ys,,,Y I� VIJr'E;T11ti4V
FF(!l1�11 ��((T 1, t
Owner or authorized agent Date ISSUEDBY: k QED /
TOTAL: IL
OFFICE COPY