20249 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMITNO.
Building Address: /l
2449
n O n A n
l/ _ G
hers one:jo
-
CITY OF CUPERTINO-BUILDING DIVISION
Contracts{a Na Lk.No: APPLICATION /PERMIT
G BUILDINGELECTRICAI.PLUMBING-MECHAMCAL CATEGORY CONTROL M
Arch„ect gineer. Lk.Na
ELL Qtr ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Address: - 0409A PERMITISSUANCE ❑. ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
Iherebyaffimnthat lamllcensed under provislonssr Chapter9(commene APPLIANCFSRESIDEMTAL JOB DESCRIPTION
ingwith Sedton7W0)of Divieon3ofthe Buslm"UdProfeaslonsCode,and my
It bin fail( anddfect. PANELS C /nin G�
Lkenae�Ja Ck.N_ C�Z-Z�9 A/F.'rJ
Date T Contractor UP TO 200 AMPS
201 IODDAMPS
ARCHITECTS DECLARATION
mO pO I understand my pleia.hail be used u public records. OVER 10(10 AMPS SQ.FT.FLOOR AREA $/�.FT.
k c(� Licensed Professlorul SIGNS ELECTRICAL
<�6 OWNER-BUILDER DECLARATION S)+p-CIpL CIl2CUIT/M1SC
2 p�4 I herebyaffirmt)at l am esempt from the C.ntactoh Ll¢nx Lw f¢the
(.Bowing reason.(Seel(..70315,Business and Prefenians Code:My city or
O TEMP.METEt OR POLE .INS
FE sountywhirh raquBesa pemdttowrotros;alcer,lmprove,demolbh,orrepair
a enyeuveture prl¢celas lesuawe,also rcyubealheappBaant(¢auch perMtm POWER DEVICES
(E4
it ..Ifined statement that he Is licensed pursuant to the proWbn of the
X3µ3. Contmeto{e License Low(Chapter 9(commencing with Section 7000)of DWI- swmh� FOOL C
WW�OJ god 3 ofthe Buslnessand Pro(reeloes CodOmthat he Bexempt the¢fromVALUATIONand .
< the basis for the alleged exemption. Any violation.f Section 7031.5 by any /
applicant fora permit subjects the applicant to a civil perky.(not nnre than VILE IC14FIXTURES �IQ� CRa
five hundred dollars(5500). kX
W AL EL
Z I,as owner of the property,or rey employees with wages as lheB sole SQ'FT' STORIES( TYPECONSTRUCTION
K16 compensation,will dothework andthe structure Is not intended or feredfor
F O sale(Sec.7066,Business and ProfeasWna Code:The Contrast.{s Ll Law
�$ does not apply to an owner of property who builds or improves ther@oqry and
^ whod.eeauchworkhlmael(orthr ghhisownemploye ,provldedtlufsuch OCC.GROUT' RFS.UNITS
improvements are not Intended proffered for sale.IL however,thebulldlpg¢ TOTAL:
ImpmvementBwldwithinoneyearofcompidloMtheowner-bulderwill)i v
th,q.tfardlen of proving that he did not build or bnproveforpurposeofsak.) PWM91NG PERMIT FEE FLOODZONE APN
LJ L as owner of the property,am exclusively contacting with ll¢'need P CE
contractors to ronrtruct the project(Sec.7016,Busmen and I'mfeaioro Code:
The Contact.{a Lkenas Law does not apply to an owner of property, AL D N A VENT-WA (EA)
Wilds or Improves thmern,and who contrasts for such Iun)ests wit FEE SUMMARY
CE"tilensaW licensed pursuant to the Contractor's License Law. BACK PLOW PROTEC CE
LJ I am exempt under Sec. B k P C for this reason OUTSIDE FEES
Owner Data DRAINS FLOOR,R P, COND. SANITARY Y_ N_
WORKMAN COMPENSATION DECLARATION a
❑I hereby affirm that I hive a certificate of c...or to self-Insure,or a FIXNRP.6 SCHOOL TAX Y N
¢.Nene of Workera'Comperuatlon Insurance sracertlfied copy theme,f e'..
RECEIPT N
3800,Lab C.) GAS EA. 4
1 INCA OUTLETS PARK FEE Y_ N_
RECEIPT 11
a GAS G. -0VER6(EA)
CoCom any BUILDING DIVISION FEES
Certified copy I,hod with the cityed. CREASE/MDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
�Certifled copyb(0ed with the city inspection divlaion. -
CERTIFICATE OF EXEMPTION FROM WORKERS GRFASETRAP PAID
COMPENSATION INSURANCE SEWER-SANUARY-STORM EA.20GIT. Date Recei t#
(Thies t.nneednaebecompleted ifthepermitb!worsehundreddo)lars
(5100)¢Iy WATER HEATER W/VENT/E.ECTR ENERGY FEE Y_ N_
I eerily that le the performance of ahew¢k(orwhich this penult b Issued,
I shall not employ any person In any manner as as ' me subject to the WATER SYSTEM/TREATING
Work.rs'Com sown..Laws lfomia.Dat - PAID
O Applicant Date Rece'1 t#
Z 0 NOTICE T: after dug a Certificate of Exemption,you W RESIDENTIAL PLMB. SQ.Ff.
ehouldbrom subj"<cl to[he Wa ra'Comperoatlon prolsi.ra of the Labor TOTAL:
N
Code,you=at forthwith comply with such provisions orthls permit shall be
W j deemed revoked.
CL CONSTRUCTION LENDING AGENCY SEISMIC FEE aST
I hercbyafflrmthat there iso conatruedon lending agency for the perform TOTAL ELECTRIC FEE
D Z once of the work(or which this permit b issiud(Sec.3097,C1v.C.)
U O, Lendsea Name PLUMBING FEE
LL
H Lenders Addren QTY. MECHANICAL PERMIT FEE
MECHANICAL FEE
O W omet.Itagreet complemad „bappBatynandatatyordinanus ndgat saws
1 lewrmst lagrceto comptywo ,alnd hereby uthortxrepr¢eaed gate laws PERMIT ISSUANCE FEES PAID:
r W cityrelat ng to oenteru pang construction, reby property
orlIn represenpurpoa of this
cit Wentero n theabodemnify and (dean Ion ALTER OR ADD TO MECH.
~ ? y(We)agree 1 ave,Indemnity an d keep h mien the iryo Cupertino - Date Receipt#
U agaimt liabWt4ro,Ocigments,coed and expenseawhlch may In anywayamue AIR HANDLING(IMT CTO 10,000 CFM) SUBTOTAL: all _
agx lout said City in wnaequen¢of the granting of this permit.
e AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
CONSTRUCTION TAX PAID:
g r�( pp HAZARDOUS
Date IXE3AUST HOOD(W/DUCT)
HATARDOUS MATERIALS DISCLOSURE
Will the applicant orthe future building occupant Code,
hapten le 91Zanrdthe HEATING UNIT CM 100,000 BI1J) Date Recei f#
material as Safety by the Cupertino Municipal Code,Chapter9.1�,and the
Health soul Safety Cad.Section 25537(m)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: 172,EV
qyes M No
lllthe applicant tum conte building part use eq.the Bay Area Ai vlccs VENTILATION PAN(SINGLE MID) ara
whkheManagement aurid? vents as defined by the Bay Area Air ((+ Lj
Quality Management D'aMctt BOILER-COMP OHP OR 100,000 BTU)
❑Yea ❑N. q MAY Q a 1990
I have mad the haaarcloua materialarc ulrerrcnb under Chapter of BOILER-COMP 100,000 BTU)
the California Health A Safety Code,Sectlon 75505,25533 and 25534.1
understand that lithe building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.PT
resto notify the occupant of the requirements which resat be met City of of I�II�3QIU..y4'�
no
prior to Issuance of a Certificate of Occupancy.
Owner or authsdred agent Date
TOTAL: ISSUED BY:_y'_���.Q
OFFICE COPY