24013 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address:b GAn St. SV�h s� Ga A 0
v t►" Li
on APPUCArMT99MMrTA=
.��� CITY OF CUPERTTN66UILDING DIVISION _^ n
conn 11.N?Nam< T a=.Nn: APPLICATION 1 PERMIT
�' a C y BUILDING-ELECTRICA4PLUMBINGMECHANICAL CATEGORY CONTROL M
Architect/Engineer. Lk.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE as' 1:1LICENSED CONTRACTOR'S DECLARATION
I herebyafflrmthet lamgcensed under provlsionsof Chapter9(mmmene. APPLIANCES-RESIDENTIAL JOB DESZRIPHON
Ingwith Scctt0r7000)ofDMvlsion3ofthe Busineuand Professions Code,and my' y
littnac le in full(e and cited. PANELS
Littnee Cla LION N+�
Data Contractor_ UP TO 200ANIPS
ARCHIl'ECTS CLARET nd. OVER00AMPS
p�u p❑O I uderstand m9'plass shell be used u public recoil.. OVER 1000 AMPS SQ.FT.FLOOR AREA §//�.FC.
6i� Licensed Professional SIGNS ELECTRICAL '�Lj/7 SI\J Via
<<�<611 OWNER-BUILDER DECLARATION SPFGIALCIRCUIT/ �% T
Ze„ ?; Ihereby affirm that l am exempt from the cmorsdorb License Law for the
following....(Section 70315,Business and Pmfessinns Code:My city or
�� countywhich requires a perrmt tomrotrud,alter,Improve,dernolish,urcepalr TEMP METER OR N
�e anystmdure prion,its issuance,alsorequlreatheappllcant forsuch permit to POWER DEVICES
file a signed statement that he ts licensed pursuant to the provisions of the
Contradore License Law(Chapter 9(commencing with Section 7000)of Divi. SWIMMING POOL ELECD*TE
SOS sion3oflhe Buslnessud Profeulom Code)orthat he is exemp"Iterefromand VALUATION
O F the basis for the alleged exemption. Any violation of Section 7031.5 by any ()7I,E.ISSWI.I.CI{FSHK.I.URES
applicant fora permit subjects iheapplicant to a civil penalty d more ore than V
$ five hundred dollars('SM. NEW RESIDENTIAL ELPLTR
L_jl,as owner of the property,or my employees with wages as their sole SQ'FT' STONIES TYPE CONSTRUCTION
C compensation,Mild.the workand thestmdure b not Intended or offered for
C1 ale(Sec.7044,Busineeaand Professions Code:The Comndore License law
does not apply to an owner of property who builds or improves thereon,and OCC.GROUP RFS.UNITS
oo.• whodoss such work himself or through his own employees,provided that such
Improvements are not Intended or offered for sale.If,however,the building or ror�
improvement issold within oneyearof completion,the owner-builder will have
theWdenofprovingthat he did rwtbuild or bnprove for purpose ofsakJ. QTY, PLUMBING PERMIT FEE
0 Las owner of the property,am exclusively contracting with licensed bT.00D TONE APN
contractors to construct the projed(Sec.7044,Business and ProfessionsCode: PERMIT ISSUANCE
The Contrsdor's License Lw does not apply to an owner of property who
Wilds or Improves thereon, and who contrada for such Explects with a ALTER-DRAW&VENT-WATER(EA)
c LJ
,p{[adue
or(e111censed pursuant to the Contradoes LiecLaw. FEE SUMMARY
I am exempt under Sm 0 Is P C for this mason BACK FLAW PROTECT.DEVICE OUTSIQF FEES
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Owner Date RECEIPT Y
WORKMAN COMPENSATION DECLARATION FD(TURES PER TRAP SCHOOLTAX Y N
❑I hereby affbm that I have o Insurance
of consent to copy
ora RECEIPT N
3800,Lte ab
Compeuatlonlnsunntt ora ttrtlfkd copythereof(Sec. GAS EA.SYSTEM-i INCA OUTLETS PARK FEE Y N
Policy
N C.) RECEPTN
Cc
N GAS EA.SYSTEM-OVER d(EA)
Cam any BUILDING DIV ION FEES
❑pCertlfied copy is hercbythMahed. GREASE/WDUSTRL WASTE INTERCEPTOR PLANC14ECKFEE sssa-a
❑Certified copy b filedhere with the city Inspection division. ` `/
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.700FI. Recei [#
CThlssedlon need net he completed tithe permit Is forone hundred dollars
(§l00)otifyth WATER HEATER W/VENT/ELECTR ENE N
I certify that ts the performance o(the work for which this permit is Wued,
I shall employ person In any manner sou ne ubll'eed to the WATER SYSTEM/TREATING
Workers omp�allc of orn ,JJatej,6 PA
OZ Appll
NOTICnt /,,N Y /rgi NEW RESIDENTIAL PLMB. SFT. Date Rewi t#
Z 0 NOTICE I e aft. mgt Cert a oBl [r1 ions o ftt a Labor
should Femmesubjecttothe Workers'suchCompensationprov4lonsrcthe Lab or TOTAL:
N Coded revoltfodhwithcomply with such provialenserthbpermit shall be
W F3 deemed revoked.
(L CONSTRUCTION LENDING AGENCY SEISMIC F
Ihercbyaffirmthetthem lasmmtmdlan lending agency 3W,Civ.
C.) perform- TOTAL: ELECTRIC E
7 O antt of the workforwhich this permit Is Wud(See.3097,Civ.C.)
tender'.Narrc PLUMBIN FEE
U H Lander.Addmaa QTY. MECHANICAL PERMIT FEE
O w I mdlfythat I have read this appliatlonand datethatthe above Information MECHA CAL FEE
OW
EL iscorred.]agree to eemplywltha0cityand countyodinancea and state laws PERMIT ISSUANCE FEES PAI
} N relafingloWildingconstmdion,ind herebyauthedze representativesofthi.
f Z city to enter upon the above-mentioned property for inspection purposes. ALTER OR ADD TO MECH. Date Recei t#
V — (We)agree to save,Indemnify an d keep harmless the City of Cupertino
against liabilities,pdgments,meta and expenses which may in any way same AIR HANDLING UNIT GO 10,000 CPM) SUBTOTAL:
against said City in consequence of the gaming of this permit CONSTRU ION TAX
AIR HANDLING UNIT(OVER 10,000 CFM)
Signature of Appliant/Contractor Date EXHAUST HOOD(W/DICT) CONSTRU ON TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfumre building occupant store or handle hazadous HEATING UNIT GO 100,000 BTU) Date RecOi
material as defined by the Cupertino Municipal Code,Chapter 9AZ and the
Ilealth and Safety Cede Stolon 75537(a)? HEATING UNIT(OVFR 100,000 BTU) OT
❑Yea NN.
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESIDE ISSUANCNATE
which emit haradous air contaminants as deflred by the gay Area Air B1
Quality Management District? BOILER-COMPOHPORIOLEXIMTU) 1� + N1
Yen No V
have JULread the haze ossa materials requirements under Chapter 6.95 of BOILPR-COMP IDJ,000 BTU[
the California Health&Safety Code,Sections 75505,25533 and 75534.1 v 99
understand that if the building does not currently have a tenant,that it B rriy, NEW RESIDENTIAL MECH. SQ.FT ws t7 19(1
responsibility/on a the rsteO Occup.requirements which must be met J
prior too lss nm/da Certiflate o/ofOmp�a `�' / I Vl" -
Qt5rcrorauthorimclaiftnt Date ISSUEDBY,�y"�\�
OFFICE COPY