24323 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Peeler Identification PEIMITN24323 O
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,j� S zS S 7 CITYAPPLICATION If PERDING VISION
c Ira(y�y ,��y\m: APPLICATION / PERMIT
AID _ .1 r!L SaJ_ •S BUILDINGELECTRICALI'LUMBING-MLCHAMCAL CATEGORY CONTROL N
Architect/Engineer. LIc.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE ��L ❑ ❑ ❑
LICENSED CONTRACTOR'SdanderrDECLARATION I�
I hereoction nthatlam Bcm dunderproviilons of Chapter9(commme- APPWANCf5RE5IDENTIAl JOB DGSCQQQpRE'''IDDI
Inense I.in cell force anDleffect o(Ihe Ousinessand Profogons Code,and my tr}.��1 r
limnsebin full form and effect. PANGS S f I e�Al
Llmnu Clan LION
Date Contractor UP TO 1O12DUAM
ARCHITECT'S DECLARATION OVER 1000 AMT'S c�FF ARTA $/�.FF.
pWpW Got Z I understand my puns shall be used n public records. /L f' E D I n B
E Z Licensed Professional FINLr,\ L B6/I \tl1
<Q 9GNS ELECTRICAL
Q OWNER-BUILDER DECLARATION { 6° LIT E R
1n E3 SPECIAL GRRGIBT/MLSC
Ip.., Z (hereby af0rmlWtlam exempt from the Contractor's License Law(w the ZOZi.� following..a.(Section70115,Business arad Professions Code:Any city or TEMP.METER OR POLE INST.
E countywhich requiresa permit tocorutrucq alter,Improve,demolish,oreepalr •O
anystm=mpriortoltsdsuance,alsorequimstheappllantforsuchpermitto POWER DEVICES
Nle a signed statement that he Is licensed pursuant to the provisions of the _
,
Contractor's License Law(Chapter9(comnnncing with Section 7000)of Divi- SWIMMING POOL ELECTRIC VALUATION
O<<< sion3 ofthe Buslnessand ProfenlonsCode)orthat he is exempt therefromand
the basis for the alleged exemption. Any violation of Section 7011.5 by any jects OUTLETS-SWIMHESEXTURES 100 5fffziii3
applicant fora permit subthe applicant to a civil penalty of nor more than
five hundred dollars(S.SDO). NEW RESIDENTIAL ELECTR SQFF. STORIES TYPECONSIRUCTION
I,as owner of tho property,or my employees with wages as their sok
C%¢ compensalton,will dothe work and thestrocture is not intended or offered for
,J sole(Sec.70K Business and Professions Cade:The Contractor's Limree Taw
p�Q does mol apply to an owner,of property who builds ar improves thereon,and
OCC.GROUT' RFS.IINI'1'S
who does such work himself or through hisownempleyees,provided that such
Improvements arc not intended oroffered for sale.If,however,thebuilding or TOTAL:
Improvement u sold within oneyearofcompletlon,the owner-builderwill have
the Iden of proving that he did not build or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
Lj L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec.7044,Business and Professions Code:
The Contractor's License Law does not apply to an owner of property who
Wilda or Improves thereon, end who comraots for such pRojed, with a ALTER-DRAIN&VENT-WATER(EA)
aQO.tlado,(.)licens•-d pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
1_I I am exempt under Sec B&P C for this reason
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
• Owner Date RFCEixFN
WORKMAN COMPENSATION DECLARATION FIXTLIKES PER TRAP SCHOOLTAX Y_ N_
❑I hereby affirm that I have o Ins certificate of consent to copy thereof
ora RECEIIrI'M
certificateof Worken'ComperwtlonlnsuraQnm oracertlfkd copythemof(Sec. GAS EA SYSFEYI-1 INCA OUTLETS PARK FEE Y_ N_
3801).LabCJ �/1 431r� I I
Policy h f/�rE F RECEIPT0
Co�mpanv r+ I N GAS EA.SYSFFAi-0VERd(FA) BUILDING DIVIBION FE ES
1 ICCrtined copy 1,hereby furnished. GREASE/INDUSIRL WASTE NTFRCFPTOR PLANCIIECKFEE
ff[Certilied copy b filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM FA 200I"F Date RCtt`I TN
(This union need next be completed If the permit b for one hundred dollars
(S1W)or len.) WATER!{EA71R W/Vf:NT/ELECTR ENERGY FEE Y_ N_
I certify that In the performance of the work for which this permit Is Issued,
I shall not employ any person In any manner so as to become subject to the WATER SYSTEM/TREATING
Workna Compensation Lawsof GBfomia.Date PAID
O Applimnt Date RDcci t#
2cate NEW RESIDENTIAL PCMB. SQ.FT.
ZO NOTICETO MPLICAM:ILaNrker makingpe Compensation
Ens ofthe ,you
HN should become subject to the Worken'Compensation provlalons ofthe Labor TOTAL:
Q _ Code,you must forthwith comply with such provisions orthh permit shall be BUILDING "E eo
W ' m
deeed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
a IherebyaQlrm that there b a construction lending agency for the perform TOTAL: ELECTRIC FEE
D Z ance of the work for which this permit to leaned(Sec.3097,Civ.C)
OO Lenders Name PLUMBING FEE
LL r Lender's Addren QTY. MECHANICAL PERMIT FEE MECHANICAL PEE
U icedlfy lhatl have read thisappBmtlonand slate thattheabove Information
O W iscorrM.Iagreelo complywilh all cityand county ordinances and gate laws PERMIT ISSUANCE FEES PAID:
} d relating to building construction,and hereby amhari a representativn ofthb
H Z city to enter upon the above-mentioned property for inspection purposes. ALTERORADDTOMECH. Date Receipt#
(We)agree to save,indemnify an d keep harmless the City of Cu pert loo
V
against liabilities,0dgmenx,costa a rad expenses which may In any way amue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
.ga. nJd City 1 mnxquentt of the granting of this permit.
Vl fNVi AIR HANDLINGUNIT(OVER 10,WOCFM) CONSTRUCTIONTAX
/ Sig tare of Applicant/Contractor Data EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS UI SCLOSURE
Will the appllm nt or future building occupant store or handle harardous HEATING UNIT(TO ID0,000 BTU) Date Recel t#
material as defined by the Cupertino Municipal Code,Chapter 9AZ and the
IIealth and Safety Cade Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: S XV
❑Yes MN.
Will the applimrat or future bu ilding occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emll hamrlous air contaminants as defined by the Bay Area Air pp D
m
Qua lity Ma nageent District? BOILER-COMP pIfl'DR 100,0(96TU) (r((�� p�
4 Yes R ° OCTave read the haze smateriala requirements under Chapter 6.95 of BOILER-COMP 100,000BNI
thr�alifcrnlaliralth&Safety Code,Senlons75505,25533 and 25534.I V I 12 IFIL
understand that if the building does not currently have a tenant,that It is my NEW RESIDENTIAL MECJ I SQ.FT
I responsibility to notify the occupant of the requirements which must be mss T
prior to Issuance of a Certlfimte of Occupancy. "IIY Uf CUI'Cri 1114U
Owner or authorlaed agent Date TOTAL: ISSUEDBY: N. Yx )S
OFFICE COPY