24287 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building project IdentlUation - ! PERhBTNQ
Address:Building Adda: /•f ny�a� _w Z
nee � • u ' /� ��� �.�r hone:
�i ,VWlrrs7Wr� CITY OF CUPERTIN0.6UILDINC DIVISION _� �
can a' SAPPLICA ION % RMIT
PM errs BUILDING-EIEC CALFL I HAMCAL CATEGORY CONTROL
f A Itc /Engineer. Lte,No:
QTY EL RIC PE FEE BUILDING PERMIT INFO
Address
PERFBTI ANTE ❑
LICENSED TRACTOR'S DECLARATION RESIDE L r
I hereby afflrmthat l licensed under provision of Chapter 9(rommen ! JOB DESCRIPTION
ingwlth Sect1on7000)o vltlon3oftheiltedssand ProfesslonsCode,andmy \ _�S
Ilanx la In full form rad effect. P
LkenseChsst `
Date Contractor
ARCHITECTS DECLARATION
a0 Z I understand my plans.hall be used as public records. ER 1 SQ.FT.FLOOR AREA S/SQ.Fr.
��° X540
Licensed Professional SIGNS EEE.. CA,
6 OWNER-BUILDER DECLARATION SPPLIALCB7C /MLSC '
Z F,�� IherebyafOrmthatlameaempt fromthe Cordralm'-llttnss lawfor the
qqq following ounce.(Section 7MLS,Business and Professions Code:0 or
Fs'ry county which requires a permit to construct alter,Improve,denrolish,orrepalr 7FMP.M ORPOLE INSC.
7 any structure prior to its Issuance,also requires the applicant for such permit to
Ole a signed statement that he is licensed pursuant to the provisions of the POWER DEVICES
) w Contractor's License law(Cha pter9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC
O sion3ofthe Businessand PmfessbmCode)orthat heh execepttimerformand VALUATION
f9 6 the basis for the alleged exemption. Any violation of Section 70315 by an UTLETSSWITCHFSHXTURFS I 1• \ �r
applicant fora permit subjects the applicant to a civil penalty offers room than �l JCO
Ove hundred dollars(SW. NEW RESIDENTIAL ELECTR_SQ.Ff. STORIES TYPECONSIRUCTION
7< ❑I,as owner of the property,or my employers with wages as their sole
compenuiion,wfildo the work andthe structure,h not Intended or offered for /
O assn.(Sec 7066,Buslr.e and Professloru Cade:The Contractor's Limnse Law
S$ does not apply to an owner of property who builds or improves thereon,and
-' who doem much work hoeselforthrough his own employees,provided that much
Improvements are not intended oroffered for"It.If,however,the building or
Improvement hsold within one yearafcompletion,the owner4milderw111 have 3
�`yOTk�' ^�p
t L olme of proving that be,did not build or improve for purpose ofmak.). QTY, PLUMBING PERMIT FEE TE V S�,
as owner of the property,am exclusively contracting with licensed -
contractontomnstrodthe project(Sec.7076,Bin
uaessaP
nd mfessions Code: PERMIT ISSUANCEpp' V
The Centrsdor'License Law dm not apply to an owner of property who ALTER-DRAIN 4 VENT-WATER(EA)
Wilds or Improves thereon,and who contracts for such ptojed -
a with a FEE SUMMARY
,➢Sr+ctor(O Banned pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
L-J I am excerpt a
pt under Sec. B&P C far thin ortors
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Owner Date RECEBrf M
WORK MAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOL TAX Y_ N
cerld
QI hereby aBirm that 1 have a t Imu'to of consent to copy
there,ora REC=a
MOD,ab of Workers CompensatianlnsuraaaQrattrtlfled copythereof(SecSm. , GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
MOD,Lab C.)
Poli RECEB'f a
CB�y GAS EA.SYSCEsf-0VER4(FA)
J BUILDING 4R�i
rtlfle pyhhe by rnIW d. CREASE/INDUSRL,WASTE INTERCEPTOR PLANCHECK FEE
Certifi copyh(11 with the city inspection division.
IL
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID _
COMPENSATION INSURANCE SEWER-SANITARY-S ORM EA.2(pFT, Date(Thiouctbnneed notWENSATI Bthepermit h(carom hundred dollars($100 winss.) WATER IffATFR W/VENT/FlECTRENERGY FEE Y
I.KUythatinthepedormanttafthewmkfarwhichthispermitisissued,I shall nm employ any person In any manner n as to become abject to the WATER SYSTEM/TREATINGWorkers'Compensation Le.of California. Date PAIDZ Z ApplicantNEW RESIDENTTAL PLMB._SQFT, Date
O NOTICEm APPLICt to
after nuking perationhis provisate of ions
of
Labor
Code,you ers,
abtMto the Work en'Campensistinprovhis per it s Labor TOTAL:
CC N Coda You o most forthwith comply with euchproWbns or this permit shall be U
devoted revoked.
LU , CONSTRUCTION LENDING AGENCY SEISMIC FEE
0. IherebyafBrm that there haconstadlon lending agency for the perform- ELECTRIC FEE �a
Z Len er.M. rk for which this permith Weed I'..3097,Civ.C.) TOTAL:
U O I<nder'.Name PLUMBING FEE
LL F Lender's Add.. QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
0:1.1 mer
OW I ced lfy that l have read this application and state that the above lnformatice - - i
6 hcormct.Iagreeto comply with all county ordinances and state laws PERMITISSIIANCE FEES PAID:
} relating to building construction,and herebyamholce repremnmtiva;ofthh
F Z city to enter upon the above,'dilFhamuccl property for Inspection purposes. ALTER OR ADD TO MECH. -
V — (We)agree to save,indemnify an d keep harmless the City of Cupertino Date Receipt#
agalnstlhbWties,pdgmenta,metsandr erases whlchmayleanywayaccom AIR HANDLING UNIT(TO 10,000CFM) SUBTOTAL
aga I Inc sena of tis o hu permit.
D AIR HANDLING UNIT(OVER 10,M0 CFM) CONSTRUCTION TAX
51 kof Appllca Corsa r Date FXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
A RDOUS MATERIALS DISCLOSURE
Will the apphant orfflum building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date Recel (#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Flcalth anciSafetyCode Section 25532(x)? HEATING UNIT(OVER 100,000 BTU) TOT
I—I Yes r]Na
Ill the applicant or Room Wilding occupant use equipment or devise VFNT1 LATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air rontaMrunts as defined by the Bay Area Air
Qua llity Management District? BORER-COMP(3HP OR 100,00()BTU)
Yes No pp
have read the requirementsossa materials requirements under Chap(er 6.95 of BOILER-COMP(OVER
W
VFIi 100,00D BTU) tl 8
the California Health&Safety Code,Sections 25505,75533 and 25534.1
understand that If the building does
a not currently have aienanq th
hat it NEW RESIDEMTAL METH. . SQ.FT
responsibility to notify the occupant of the requirements which most be met OCT 1$
prior to issuance of a Cedificate ofOccvpamy.
rr
Owner or authodud agent Date ISSUED BY:-.� 7>•
OFFICE COPY