24047 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building.Project Identification ' Z� PERMITNO
BuOding Addmss:
- 24047
weer. .. - -
ate. one, CITY OF CUPERTINO-BUILDING DIVISION ' 1
con or'eN O1� LIc.Nm APPLICATION / PERMIT r� Z
��yy�♦� �9 D BUILDING-ELECTRICALPLUMBING-MF- NICAL CATEGORY C
• Architect/Engineer, /9 t �l CJLIc.No:
QTY' ELECTRIC PERMIT FEE BUILUING PERMIT INFO.
Address:
PERMITISSUANCE '
LICF,NSEDCONTRACTOR'S DECLARATION
I hereby af(Irmthat l am Bcemaximder p. bdoh.ol Chapter9(rommene APPIJANCES E OB DESCRIPTION
tngwith Se on7000)of Dlvlsion3ofthe BuMneuandlarofuslonsCode,andmy S PT- #ate
license ie In full force and died. PANELS liVb��lT
Llomxa Gla Le.p 00
Date_ Contractor
ARCHITECTS DECLARATION 701-IODDAM
yqqp!!rc0 0 l underst.ed m plem ah it be..d u pubH,m rd. OVER 1000 SQ.FT.FLOOR AREA $/SQ.FT.
Ft� Licensed Professional SIGNS ELECTRICAL ,
<< kCUu OWNER-BUILDER DECLARATION
5PLCIALCRiCU1T/M(5C
yt. ,7a Iherebyafflrmthat Tem exemptfromthe Contndor's License Lwforthe - -
pp fallowing O� reason.(Section 70315,Business and Prefeulone Code:Any city or Z TEMP.MECIR OR['OLE I
rou
a� ntywhlch requbesapemNtrororutrud,alte.,lmprovq dem.Wh,.rrcpalr
IKO anyetrocture prbrto ita iseuance,eborequirotheappllcent(..such permit to )OWER DEVICES
isle a signed statement that he is licensed pursuant to the provisions of the
^� Commune,License law(Chapter9(rommencingwithSection7000)ofDlvl-
Q 3 res SWIMMING POOL d RIC
Ijja, slon3ofthe Buelnessend ProfeulauCode)orthat hebexemp[therofromend VALUATION
�) the basis far the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWITC FIXTURES
j 65 appllont lots permit subject.theappBcantoa civil penalty elect morethan "
t five hundred dollars(SM.
pro NEW RESIDENTIAL ELECTR SQFT. STORIES TYPECONSIRI)CTION
I,asownerll theproperty,orhe employees Inwithwagd ea their sole
rompS..7044,Business work fes ionsC durc V not Intended or offered for
sae IS..7044,Business adProfessions
property Cade:The ori Contractor's License
eram law
' $$ don nor apply/oen owner ofproperty who n emporimprovestbercoryand - GROUP RFS.UNITS
who does such work Hmsel(wthmugF his ownemployee.,provided that such
improvement$are not Intended oroffered forsale.If,howeem,the bulldingor TOTAL:
Improvement lasold withlnoneyearofcwnplmiomtheowner-buOder MiI have
t-""len of proving that he did nat build or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD APN
u I,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to ronstrud 94,the project(Sec.70Businessand Profe aloro Code:
The Contractor's License Lew does out apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
builds or Improves thereon,and who contracts for such pkajects with a _
e tjactor(s)licensed pursuant to the Contractor's LlcemeLaw. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sea B&P C for this mason
OUTSI UP FEES
Owner Date
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y -N
WORKMAN COMPENSATION DECLRECE W ItARATION FDIURpS PER TRAP SCHOOLTAX Y - N
711 hereby d(Irm that I have a certificate o!consent to sal(-Insure,ora RECEIPT M
3ROQ38W Lateab C.)o(Workers'Compewtloulrouranmwecertlfed ropythercof(Sec. GAS EA.5YSTEM-1INCA OUTLETS PARK FEE Y N
L
Policy Jr � . — RIiCEIPT N
Com ray GAS EA.SYSTEM-OVER 4(EA) B U ILDING DI VISION FE ES
CertiBed ropy Is hereby f.ant bed.
F-1Cer iOed ropy is filed with the city Iropettion division. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
16QB0
'
CERTIFICATE OFIO([MI'TION FROM WORKERS' GREASE TRAP PAID .
.COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.2WFT. Date Recd t#
(Thissectlon need not be eomplded If the permit b fororo hundred dollars
(5100)orlessJ -ed, WATER HEATFRW/VENT/ELECTR ENERGYFEE Y N—
I
thato anyphe person
In
w as
becomhthis e
to the
I shall not employ any person in any manner w u to beronr`eubjett to the
Workers'Compensation Law.of Ca BfomWATER SYSTEM/TREATING
ia.Date PAID
0 Z Applicant NEW RESIDINTIALPLMB. SQ.FT. Date Recei t#
Z NOTICE
should comes L[CAect tothe elver making terCtion pro of Exemption,eLabyou
Code,you
mus surthwit the Worker'CompeurtlonproWions of s peril sallbe TOTAL:
LU N deemed u eked.rthwith romply with such provisions orlhb permilahellbe U IN
IL > deemed revoked. _ '
EE
CI, G CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby of lrmtbat there V a routrudion lending agency forth$perform ELECI-RIC FEE
M Z ante,ofthe work for which this permit is Luued(Sce.3097,Cl,C.) TOTAL: _
00 Lender.Name - - PLUMBING FEE
LL H Lender's Addmss - QTY. MECHANICAL PERMIT FEE MECHANICAI:'FEE
OW Icertlfy thatl have readthisapplication and&atethAtheabove Joinrrnait..
LU bromect.Iagreetommply with allcityand rountyardlnanouand state laws PERMIT ISSUANCE FEES PAID:
} relating to bulldtng wrotrudlon,end hereby authorize representatives ofthis
F dry above-mentioned
to enter upon the property for Inspection purposes, ALTERORADDTOMFLIi.
Z
Z (Vie)agree to save,Indemnifymv
an d keep hadcthe City of Cupertino Date RCCCIPt#
a g.hatlobililasud - nts,mksandexpenws iichmeylnanywayecarue AIR HANDLING UNIT(TO I0,000CFM) 'i SUBTOTAL:
agalnstaald Cityl qua soft vntin fthle permit AIRHANDLING llM'C(OVER 1D,000CFM) CONSTRUCTION TAX
2 CONSTRUCTION TAX PAID:
Slg tum o(ApptleA DOUS Data IXFUl15T HOOD(W/DIK:'O
HALV RDOUS MATERIALS DISCLOSURE
Will thelefireant the upbuilding nicipan ode, hapten le hazardous HEATING UNIT(TO 100,00)RTI))
mcAthaae defined by the Cupertino Municipal Code,Chapter 9.11,andthe _ Date RCceI I#
Flealihe. Safety Code Section75532'a)7 HIiATINGUMT(OVER 100,000BTU) - TOTAL: -IP
Will
lt No
which
haaarousair contaneartsaccupandbythet use Bay Atordevkn VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
which emit luzardoue air rontaminanisas defined bythe Bay Area Air - ,
Quality Management DOivuld7 BOILER-COMP(3HPOR 100,000 BTU) _ P A I D
4 Yn d No
m
have read the haza ease aterlals'requiremenls under Chapter 6.95 of BOILER COMP(OVER 100,00)BTU)
the Califomla l lealth&Safety Code,Sections 75505,75533 and 25539. L. (k[ep yq
understarad that if the building does not currently have a tenant,that It is my NBWRFSIDENIAL MUCH. - SQ.IT Or ' b
responsibility to notify the occupant of the requirement.which must be met
prior to issuance of a CerUBcate ofOcupancy.
Owner or authorized agent - Data TOTAL; ISSUED BY..,
OFFICE COPY