24326 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Oolldloj Pro bat Identification
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Budding Address: PERA9T NQZ
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2 �`�!� CITY OF CUPERTINOi6ILDING DIVISION
ContraaaraNan" Lis.No: APPLICATION I PERMIT
_ BUILDING-ELECTRICAI.PLUMBINGMECHANICAL CATEGORY CONTROL If
Architect/Engineer. Lie.N.
" QTy ELECTRIC PERMIT • FEE BUILDING PERMIT INFO
Address:
PERMITISSUANCE
LICENSED CONTR under rDECLARATION -
Ihereby
affirm on7000that l Division
fthe Bu provbioneofChapter9de,and APPf1ANCESRE5IDENTIAL JOB DESC ON
iPgwith Infull 7000)of Dlvfect. ofthe Buelne.andProfeuloneCade,and my _ —p.��'
Lkxr.s in full for.and effect. PANELS r7a�Vr•J1y
Licanx CWss Lk.N •
Date Contractor -
ARCHITECT'S DECLARATION 201-10DOAMPS
ne ZZ I understand my plane shall be used.public records. OVERIODOAMPS SQ.FT.FLOOR AREA $/SQ.FT.
E .. SIGNS ELECTRICAL A [ r, .I `
<<do(/ Limned Protemiowl
6 .OWNER-BUILDER DECLARATION SPEf_•IALCIRCUIT/M1SC i�;4
P�p, �7. owing yason.Chatlam313,B(romthe Contractor's Llmnx Law fort he fo0owln reason.(Section 70115,B mtmd and Professions Code:h tl r
n9 cauntywhich requb.apermltrommtnct,alter improve,demolNh,orrepalr TFMP.METIR ORPOLE INSC. ,
q anya signed
ned statements hatonce licensed
pursuant
to the pro room of t e POWER DEVICES DA E
�1 O file a signed statement that he is licensed pursuant it the tion 7")
) of the
FWj u,� Con3oftalLlcere Gw(Chapter 9(com)orthatwithSeoptthe00)afDivi.
'30 sion3o(the Business and Profemloru Code or[hat hels exempttherefromand SWIMIANG POOL ELECTRIC VALUATION
the basis for the alleged exemption, Any violation of Section 70715 by any y
0 OUTLETSSW[TC[-IFSFIX7T1RF5
applicant tars permit subjectsthe applicant to a civil penalty of net more than
five hundred dollars(,$500). NEW RISIDENIIAL ELFf_TASQ.FT. STORIES
�n I,as owner of the property,or my employees with wages as their sale TYPE CONSTRUCTION
compensation,wOl do the work and thestructure Isnot intended or offered for
0 to(Sec 7044,Business and Profeuiom Code:The Contractors Limme Law
does not apply to an owner of property who builds or improves thereon and .00C.GROOP .RFS UMTS
whodom
such work himself orthrough his own employees,provided that such
Improvements are not Intended mattered(urine.If,however,lhebuilding or T '
ImproveZrdosoldwithln oneyearofcompletlogtheowner-builderwlll have
Ad.
an of proving that he did am build or Improve for purpose of sale.).. QTY. PLUMBING PERMIT FEE FLOODZDNE - APN
as owner of the Property,am exclusively contracting with licensed PERM77 PLUMBING
ors to construct the project(Sec.7044,Business and Profeulou Code: ISSU ,
tractors License law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
r Improv.thereon,and who contracts for such ptojects with a FEE SUMMARY
�gpt(actor( on
s)hcenxd pursuant to the Contractors Lima.Law, BAIX FLOW PROTECT.DEVICE
L„J I am exempt under Sec. B&P C for this reas
DRAINS FLUOR,ROOF,AREA,COND. SANITARY Y N-
Owner Date .. RECEIPT N
WORICIAN COMPENSATION DECLARATION FB(TURRSS PER TRAP �,�,. SCHOOL TAX' Y_ N
% ❑I he
affirm that I have a certificate of moment to self-macre,or a RECER'I N
certifluteofWorken'Comper Umlne mn.ara.rtifWmpythereof(Sec.
3800,Lab C.) GAS EA:SYSTEM-1INCA OUTLETS PARK FEE Y N
_ ... PoliryN GAS EA.SYSTEM-OVER4(EA) BBC=#
Con' ny BUILDINGDIVISIONFEES-
�Certified copy is hereby th the city GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy V(fled with the city Inspection division:
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE
(IMeuctionnmd not becompleted lfthepernit LsforSEWERSAonehundred dolla. MTARY STORM EA.200FT. Date Recef t#
($t OD)orlessJ WATER HEATER W/VENT/ELECTR ENERGY FEE Y N '
Icertify thato the person
mnymnner so as to bca permit is issued,
I shall not employ any person In any manner m u to become subject to the WATER SYSTEM/TRETI
Workers'Compeneatlon laws of California AANG
.Date PAID `
O Z Applicant NEW RESIDENTIAL PLMB. $QDate R0t%1 t# -
Z 0 NOTICE TO APPLICANT.If, tu
,after sking Nis Certificate of Exemptionyou FT. -
should became subject to the Workers'Comperuatlon provleloru o(lhe Labor TOTAL:
N Cade,you moat forthwith comply with such pawislom orthis permit shall be I DING •E
W > deemed revoked.
dC CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z Iherebyal0rm thatthemi.aconstruction lending agency forthe perfomti ELECTRIC FEE $
anm of the work for whkh this permit i.b.0 d(Sec.M97,Civ.C.)
O O Lender's Name'- 7 PLUMBING FEE
LL - Lender's Address OTY, MECHANICAL PfiRMIT` FEE' MECHANICAL FEE
OW Imrtilythat I have read this eppllcationand statethattheabove Information
CL Ismrrect.I agree to complywith all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
relating to bullding corotructloM and hkaby au[hortae rep®xntatives ofthis
F 2 city to enter upon the above-mentioned property for inspection purposes. ALTTRORADDTOMECH. - Date ReCei t# 4 -
— (We)agree to save,Indemnity an d keep harmless the City of Cupertino P
against liabilities,judgments,men and expenses which may In anyway accrue AIR HANDLING UNIT(TO 10,000 CEM) SUBTOTAL:
against mid City in consequence of the an ting ofthls permit.
„�..i.� Os AIR HANDLING UNIT(OVER ID,ODOCFM) CONSTRUCTION TAX
re
of Applicant/Contractor Date ENHAUST HOOD(W/DUCT) - CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Mai'heapplkant or loom building occupant store or handle hmardoue HEATING UNIT(TO 100,WO BTU)
material as defined by the Cupertino Municipal Code,Chapter 9.1 2,and the Date Reaei t#
Ile❑alt Yen and Safety Code,Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
No
Will the applicant or❑future building occupant use equipment or devices VFNHLATION FAN(SINGLE RESID) ISSUANCE DATE -
which emit harerdous air mntanlmntsm defined by the Bay Area Air .
Quality Management Distrlcl7 BOILER-COMP C;HP OR IOg000 BTU) g7 p B D
❑ Yef n No G' P9 '
�1 Ihavereat Health&r�fet mode,Sections
25505, 5533underaChapter. 1 of BOILER-COMP(OVER 100,000 BTU) -
the GlAomla Health&Safety Cade,Sectlau 25505,75533 and 25534. I -
undentandthat lithe building does am currently haveatenmt,that it is my NEW RESIDENTIAL MECH. SQ.FT ®CT-At:t
responsibility to nctifythe occupant of the requirements which must be met prior to Issuance of a Certificate ofOmpanry. CrUG
Owner or authorised agent Date ISSUEDB
TOTAL:
OFFICE COPY