24149 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMITNgf/,T
Building Addres:O Y 10 (.N 4 1 4 9
sonar Mme: one
CITY OF CUPERTINO-BUILDING DIVISION
cantrattor.Name: L Llc.Na: APPLICATION I PERMIT rasaIr� C.�
A Altect/En neer. �t&'1 BUILDING-ELECTRICAL PLUMBINC-MECHANICAL CATEGORY L �"
Lic No: L o
6 - QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: 4 u v IJ - _
'K'R115 - PERMIT ISSUANCE l ❑ ❑
Ram
that LICENSEDCONTR under r vi LARATION
Iherebyam,7000l ivRcenxd underprovtslonsoffeuma.9(commme- APPLIANCESRF.SIDENTUL ]OB DLSCRIPDON
Incense is In fullM 0)ofd died.3o(the Buslneesand Profesdona Code,and my
Ilcenx la In full rqLce and erfect. PANELS
Limns Class Luc
Date
O -
Date Contractor —IT IQ 2MAMPS
ARCHITECTSDECLARATI 701-1000 AMPS
FQ+anx Iunderstand my plans shall be used as public records, OVER1000AMPS I. .(LOQR AREA S/SQ.Fr.
E od� Licensed Professional SIGNS ELECTRICALJaW lu( Ili. •17
G;6N OWNER-BUILDER DECLARATION SIrECULCR T/
Ihereby affirm that!am exempt from the Contmeor's License law for the
pp following reason.(Section 7MIS,Business and Professions Code:Any city or
Z f. TEMP.M• INST _
cmnlywhichrequbesapemdt(omrutr d Oter,Imprave,dem)'I sh,orrepalr
q anystmd mpr rtoltslesuamgalsorequirestheapplimntfmsuchpertN[to D
PJ file a signed statement that he Is Revoked pursuant to the pro is!, of the
Ow
Contractor's License Law(Cha plan 9(mmmentlngwith Settlors 700l DIN-
SOS don3ofthe Bualnessand Profewbm Code)orthathebexmptthemfromand SW1MhRNG LELE VALUATION
the barb for the alleged exemption. Any violation of Section 70115 by any
< appllantlora perMbubjeda the applicant too dull pnnaity ofnd morethan OUTLETSSWITCHESH
flt�undred dollan($500). NEW RESIDENTIAL ELECTR Sl STORIES TYPE CONSTRUCTION1,as owner of the property,or my employees with wages as their sale
7s, corepensalion,wW dothe work,and thestructure b not Intended or offered for
O sale(Sec.7064,Business and Professions Cade:The Contractors License law
does not apply to m owner of property who Wilds or improves thereon,and OCC.CROUP RFS.UNITS
whadmsuch work homseeorthrough hlsawn employees,provided that such
improvements arc not intended oroffered for sale.If,however thebullding or TO
Improvementissold withlnaneyearofcomplell.Ntheowner-bu0derwN have IL NZ7.,r
th�+rden of provingthat he did not build or improve for purpose of sale.). QTy. PLUMBING PERMIT FEE FLOOD ZONE APN
L_j L as owner of the property,am exclusively contracting with licensed
mntramm to construct the project(Sec.7064,Business and Profeaslons Code: PERMIT ISSUANCE
The Contractor's License law does not apply to an owner of property who ALTER-DRAIN&VENT (IvU
bullae or Improves thereon,and who contrafor surd pd -
laje
a with a
c LJ -
,n[[ador(a)licensed Pursuant to the Contractors License Law. PEE SUMMARY
ee I am exempt under SB &P C for this reason BACK FLOW PROTECT.DEVICE
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N.
FITS
Owner Date RECEIPT a
WORKMAN NSATION DECLARATION N—
� rm I hereby affithat I havehave.a certificate of consent to self-Insure,or FTXTITRES PER TRAP SCHOOLTAX Y a RECEIPT,N
3800 ate of Worken'Compewtian Wunnce macertl(led copy thereof(Sm. GAS EA.SYSTEM-1 INCA 3800,Lab PARK F� Y— N
Pollry N -O'9 RECEIPT p
Cram an GASEA.SYSTM-OVER4(EA)
; Y BUILDING DIVISION FEES
I I Genuflect copy is here tumecityhed. CREASE/1NDUSIRL WASTE INTERCEPTOR PLANCHECK FEE e2 6fyo
Ia�E—lCediOed copy is filed with the city inspection division. L► �C
CERTIFICATE OF EXE7NPFION FROM WORKERS' CREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.20OFf. Da[e Recel ted
(TNssedian need no[ed completed if the perMt is(or one hundred dollars
Wall that
WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
]certify thatothe person In
the work fo as to became
cleated, —
I shall not employ any person In any manner n es res become abject to the WATER SYSTEM TREATING
Worken'Compensation Lawe of 011fomW. Date. / PAID
Applicant
Z 2 NOTICETO APPLICANT:If,after making this Certificate of Exemption,you NEW RESIDENTIAL PLMB. SQFr. Date Recei ted
Hshould become subject to the Workers'Compeivatlon provisions of the Labor TOTAL:
CC
N Code,you mustforthwith comply with such proWiam arthis permit shell be
deed voked. - I I 'E
demreCONSTRUCTION LENDING AGENCY SEISMIC FEE
I herebyaffirm that there is a constmdlon lending agency for the perform- ELECTRIC FEE
M Z ante of the work far which this permit is issued(Sen.3097,Civ.C.) TOTAL: L
(� O lenders Name PLUMBING FEE
LL E— ]enders Address QTY. MECHANICAL PERMIT FEE ME L
OW I certilythat I have realthis appllatianand statethatthe above information
1 is correct.I agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEE
relatingtobuilding comtmtllon,and herobyauthoreen reprexntatives of this —1{ )
1— Z city to enter upon the above-mentioned property for inspection purposes. ALTER OR ADD TO MECH. Date $eCLj 1N
— (We)agree to save,Indemnify an d keep harmless the City of Cu ped ono P
against liaabilit/iters,,judg rts,mks and
'exp/eI the BranJni/rase$s_}�'hlchnuyle.eywayaya'cccrru/tee AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL'
agaim hlw/IY u ( a/ f A permit
�iA /i4S/`9
AIR HANDLING UNIT(OVER lO,OW CFM) CONSTRUCT ION TAX
I A pct t/ Dorn rFlats EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or Emote building occupant store or handle havardoas HEATING UNIT(TO 100,000 BTU) Date ' ted
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health and Safdy Code Section 25532(a)2 HEATING UNIT(OVER 100,000 BTU)
M Yes �No
Will the applicant orfuturn Wilding occupant use equipment or devices VENTILATION FAN(SINGLE MEID) ISSUANCE DATE
which craft haeardous air mntaMnants ate de0ned by the Bay Area Air -
Quality Management District? BOILER-COMP GHP OR 100,000 BTU)
[ply es 9 No
ave madtheb. out materials requirements under Chapter 6.95 of BOILER-COMP(OVER100,W0 gni)
the California Health&Safety Code,Sections 25505,25533 and 25534. I
understand that if the building don not comently have a tenant,that it is my NEW RESIDENTIAL MECH. SQFr �
rapomibility to notify the occupant of the requirements which must be rnet
prior to issuance of a Certificate of Occupancy. '
w
Owner or authorlaed agent Date ISSUED BY:
TOTAL:
OFFICE COPY CITY Ur wrtHIINU