24008 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO..
Building Address: 24008
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`LfIMe_ CITY OFCUPERTINO-BUILDINGDIVISION
ntraraN.me: Le.No: APPLICATION / PERMIT
n�C.0 36�t 7YS BU[LDING-ELECnUCATePLUMBINGMECFf LAICAL CATEGORY CONTROL p
rchitM/Englnrer. Lk.No:
'QTY ELECTRICPERMITFEE BUILDING PERMITINFO
Address: PERMIT ISSUANCE ❑ ❑ Y E]LICENSED CONTRACTOR'S DECLARATION
Ihereby Smfioaffirm(fio[am sim3ofheBusirovslansof Csslms9de,and c APPLIANCFSRESIDENTfAL trio DF ON
Ing withSefullfo00)of Dlvffect. rtheBusineseand Pm(esalonsCodc,and my ' \PWT
license lslnfull force and c-41 PANELS
License Clan LICK 1�
ate Contractor ` r`�
ARCHITECFSDECLARATION 201-IODO AMPS JJJ��, V//
WZ LundemtandmypbreshaBbeuwdupubhcremrds. OVERIODOAMPS SQ.Fr.FLOOR AREA $/SQ.Fr.
qO
�() Licensed Professional SIGNS ELECTRICAL
6 LG'JI OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/M15C
Pt-'�� IFerebyafflrmthatiamexemptfromtheContractor'sLirenseLawforthe
(ollowin meson.(Sen1on 70313,Business and Professions Code:An city or I1 1
O t' coon which re uire,a permit toronetmct,alter,ins y P TIMP.MCTIR OR IDLE INSC. I r n
u� h' 9 P Prose's,demolsh,arre air J
anystmumprimtoib Wuame,ahorequirestheapphmntforsuchpermitto _ _
file a signed statement that he s provisions pursuant to the proions of the ROWER DEVICES / r
2
3cc Contractor's License Law(Chapter 9(commencin with Section 7000 of Dist. t 6✓ " ll a
OI"n B ) SWIMMING BOOL ELECTRIC - J ^
the basis fo the �analleged exemption. Any)violation
of sum therefrom and / VUU�L TION
G the boas for the alleged exemption. Any violation o(nalty a 70713 by any OlJ]LE1SSWITCFIESFIXT--
applicant for a permitsubjectsthe applicant toactvll penalty of nor more than
E five hundred dollars($500). NEW RESIDENTIALELECTR ,FI;
�n ❑1,as owner of the property,or my employees with wages as their sale SMRIES TYPE CONSTRUCTION
compensation,will do the work,and the structure is not Intended or offered for
O sale(Sec.7044,Business and Professions Code:The Contractors Limme Law
$ don not apply to an owner of property,who Wilds or imprevn thereon and OCC.GROl/P RM UNITS
who doessuch work himself orthrough his own employees,provided that such
improvements.re not Intended oroffered forsale.If,however,thebuilding or TOTAL:
imp sense:sold within oneyearofcomplellon,theowner-WRderwlli have
t burden of proving that M did not build or improve for purpose of sale.). QTY, PLUMBING PERMIT FEE
I,as owner or the roe FLOOD ZONE APN
property,sty,am exclusively Business
contracting Pro with licensed PERMIT ISSUANCE
contractors m construct the project(Soc.7044,Buslnen and Profeuloru Code:
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN k VENT-WATER(EA)
Wilds or Improves thereon,and who modems for such projects with a
oq�j(actor(a)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec. B k P C for this reason
DRAINS FLOG ROOF, SANITARY Y_ N
Owner Date R AREA GOND' P
WORKMAN COMP cSATION DECLARATION ' RECEIPT tl
SCHOOL TAX Y— N—
❑1 hereby Wind that I have a a certificate a!consent to sell-Inre,ora FIXTURES PER TRAPRECEIPT It
3800,I.bCJ o(Worken'Comperuatlanlruuranceora certlkd copythereof(Sec. GAS EM
EA.SYST -1 INCA OUTLETS PARK FEM Y N
Pelt sle
Poll tl DING X
S FA
any CA .SYSrFIN-0VER l(FA) BUILDING DI VISION FEES
Certified copy Is hereby furnished.
GREASE/INDUST'RL WASTE.INTERCEPTOR PLANCHECK FEE
the
❑Certified copy is flied withhthecity Inspection division.
city
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP - PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200IT. Date RCLY'I IN
(Tbsseneed notWcompleted if the permit sfororm hundred dollars
(p 00)orless.)sa.) WATER HEATER W/VENT/E.ECTR ENERGYFEE Y N
I certify hatcop o the person nce of in any m work so as to b co eeroutsubj is sued, —
I shall not employ any person In any manner m u to become subject to the WATER SYSTEM/TREAHN)G
Workers'Compensation Tawe of Glfornia.Date PAID
ZZ Applicant NEW RESIDENTIAL PLMB. SQ.Ff. Date - Recei t#
Q NOTICE TO APPLICANT;If,after making this Certifcateof Exemption,you
F should berome subject to the Workers Comperuation provisions of the Labor TOTAL:
J= W Code,you must forthwith comply with such provisions or this permit shall be
j deemBUTNG ed revoked. - FEE
W C CONSTRUCTION LENDING AGENCY SEISMIC FEE
0. I bereley afOrm that there is a construction lending agency for the perform+ ELECTRIC FEE
Z ance of the workfor which this permit is Issued(Sec.3097,CIv.C.) T ' �
O O Lenders Name PLUMBING FEE a-�
IL F Lander.Addems QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW I mAifythat l have mad this appRcationand nate thaltheabove lnforrtutlon
C Incurred.I agreeto comply with all city and county ordinances and slate lam PERMIT ISSUANCE FEES PAID:
N relating to building construction,and hereby authodze representatives ofthls
F Z city to enter upon the above-mentioned property for impection purposes. ALTERORADDTOMECH. Date Reeei tN
_ (We)agree to save,Indemnify an d keep harmless the City of Cu pertino
a airwtllabihtl dgments rtsandexpen which mayin anywayaccme AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
a alnt ul ort of(his Permit. AIR HANDLING UNIT(OVER I0,ODOCFM7 CONSTRUCTIONTAX
Signareef App t/Contractor Date EXHAUST HOOD by/DUCT) CONSTRUCTION TAX PAID:'
HAZARDOUS MATERIALS DISCLOSURE
Wlllthe applicant or futurebuilding occupant stemorhandle huardous HEATING UMT(TO 100,000 BTU) Date ReceioHl
material as defined by the Cupertino Municipal Code,Chapter 9.I Z and the -
Heallh sed Safety Coir Section 25532(e)? HEATING UNIT(OVER 100,000 BTU) TOTAL —
❑ Yes NN.
Will the applicant orfumm building occupant use equipment ordevices VENTILATION FAN(SINGLE MID) ISSUANCE DATE
which emit haaardma it romarmoset...defined bythe Bay Area Air
Quality Marogermot District? BOILER-COMP DFP OR IO,000 RTU)
Ye ❑❑No
havereadthehaaarclous materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,OOD BTU)
the California health k Safety Code,Sections 25.505,25533 and 25534.1 JUL 22 1992
understand that if the building does not currently have.tenant,that its my NEW RESIDENTIAL MECH. SQ,Fr.
rnponsibWty to notify the occupant of the requirements which must be met
Prior to Lauann of a Certificate of Occupancy.
CIIY Ur WrcnIfile )
Owner or authorized agent Date
TOTALISSUED BY-. �/
:
OFFICE COPY