24096 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT.PEN ONLY.
Building Yroen Identification _ ,l'FRh9TNQ, 4-0;9 6 -•
Building Address: �GJ
ners "en) —N/ Phone: A,
CITY OF CUPERTINO-BUILDING DIVISION '
con t 'e Nam: Llc. APPLICATION /PERMIT
BMDING-ELFICIMCALPLUMBINGMECIIANICAL CATEGORY CONTROL
Arch a /Engineer. •LIc. o.
t,,.. If., ... r:. c r . .I"+.1� i + ., it,.t':�I'BUILDING"PERMIT INFOi - :•-!(��
QTY a1. ',..ELECTRIC PERMIT "FEE
Addrne:. a ('\ PEtMITISSUANCE 1:1 [1 ❑
LICENSED CONTRACTOR'S DECLARATION -
Iunchyaffirmthat lamlicensed under p Monro(Chapter9(commrn APPLIANCFSRESIDENTIAL ]OB DESCR11710N
ingwith Seti°n7000)of Db,Je.3 heBusineasand rofeseensCodeedleny
fiocraxi.i.fyt!In d MtttY. /il PANEIS. . Ips �y
Date Contnct r UP TO 2DO ANMS '
ARCHITECTS DECLARATION 201-1000 AMPS'
reO Zpq. I..dent d my place sh.B be used as public records. OVER 1030 AMPS !j +'I „FG c_ R t; -S/SQ.FT'
�(0 Licensed Professional SIGNS ELECTRICALr" �
�6 OWNER-BUILDER DECLARATION SPECIALCItCU1T/MLSC ..y li� LI .,., 1_
7 �a Iherebyeflrm that lam exempt from the Contractor's License Law for the
pO lo0owing reason.(Setlon 9031.5,Business and Profevlona Code:An oft r flf
OZi.pp y y° TFMP.MEITR OR POLE INST. SIL
pi t4, counlywhlch requlrcaa permit cornutmct,esthemprovgdemolbh,orto
9 ❑a any assigned tate eats that
he is Esmsed pursuant to
pu blon,moch ofpermit e POWER DEVICES . "
ry1 a V file a actor.statement thar he b r9(co pursuant it the pro MIT) of the -
4� Contntor.eStsirue Law refcater9(rommenctathela xemonherefof Divi.
mand SWMMINGPOOLELECTRIC VALUATION
F�Oe Won3o(the Buaineseand Pro(evioauCodc)orthat hebexemp[therefromand
J the basis for the alleged exemption. Any violation of Section 70315 by an
�G applicant fora permit subjects the applicant to a toll peraltyofnot nennrcthI1TLEISSWITCHESFI%TURFS
QQ five hundred1,asod°Ibrshepro SQE7, STOIOES TYPECONSTRUCUON'
Yi - NEW RESIDENTIAL ELECTR
WWW
1,as owner of the property;or my employees with wages r their sole
coin&c. 0Kion,wilichoBusinethework,andthes Code:rche In ot Commaintended Lierea s d for
Law
O vie(Sec appy to ernoaandf property
Code:The or Improves
License Taw
does does
apply toanawner orthmug his own
n emporlmpmvvdedthtand OCC.GROUP RES.UNITS -
pp:: imodoosuch are not maelfedorough Msowne.If,ho however,
he
building
lt or
improvement are ithindncycarftomprofferedl rnle.If,howeerthe it will have -
Improvementbsoldwithinoneyearofcomplctiogthe ownerbu0derwill have
th¢+rdenolproving that hetlld not build orimprove for purpose oTule.). QTY. . ',;`;:',PLUMBINQPERMITI ' aI'�a •+"FEEtIt FLOOD7ANE APN
L i L as owner of the property,am exclusively contracting with Brensed PERMIT ISSUANCE
contractors to constrot the project(Sec.7W4,Business and Profesau.Code: '
The Contractors License law does not apply to an owner of property who ALTER-DRAIN VENT-WATER(EA)
Wilds or Improves,thereon,and who contracts for such pro)eab with a - ..at „ ,t
cgp(ractw(s)Bcereed fummtt to the Contractor's License Law. ) ,'L'l,"h'e+':FEE SUMMARY
LI
I am exempt under Sec. B k P C for this mason
BACK FLOW PROT[CT.DEVICE
Owner Date ''
DRAINS FLOOR ROOF,ARCA,GONE, SANITARY Y_ N"
FEES
RFGE1PTp
WORKMAN COMPENSATION DECLARATION
•
01 hereby af(Irm that I have a certificate of consent to eel!-inwrc,are FIXTURFS-I'FR TRAP SCHOOL TAX Y .N
RECEIPT N
re0DIL.eo(Workers'Compereatl°nlruunnreararertlfkd ropythere°((Src. GAS EA.SYSTEM-]INCAOUD.ETS PARKFEE Y N
3N0D,lab C.) .
Po cy N. GAS G.SYSTEM-OVER 4(PA) RECEIPT N
an - BUI L DWG Of VI SION FE ES
_M1 filed copy b herebyfurnished.thehed. GREASE/INDUSML WASTE INTERCEPTOR PLANCHECK FEE
❑Certi(I,ed ropyVfiled with the sty imps tion arocacon:
CERTIFICATE OF EXEMPTION FROM WORKERS' CREASETRAP - PAID
COMPENSATION INSURANCE SEWER-SANITARY-S1OItMG 200FIt Date' RCcel tf✓
(Thlascrum,need act be completed lithe permit is for one hundred doll..
($7I nordless.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
I rent that o any phe aormance of any
m nner so as to b co eemnit b issued,the
I shall not employ any person In any manner so u to become mbjet m the WATM SYSTEM/TREATING
Worken'Compensatlon Laws o(Gllfomia.Date •" PAID -
O Z NO Applicant
TICENEW RESIDENTIAL PLMB, SQ}7, Date RetC'1 IR -
Z O, NODCTO MPLICANT:II,after making this Certificate of Exemption,you
Fshould become subject to the Workersl Compensat ion provblous of the Labor TOTAL:
N
Code,you most forthwith comply with such provisloro or this permit hall bit BUILDING ••
W >
deemed revoked.
aCONSTRUCTION LENDING AGENCY - - SEISMIC FEE
I hereby efirmbthat there a construction lending agency for the perform. ELECTRIC FEE
Z once of the work for which this permit b Issued(Sec.3097,Civ.C.) • + TOTAL:
(� O Lender's Name - r - PLUMBING FEE
U. I- lender's Addreas QTY. 'MECHANICAL PERMIT FEE;+ MECHANICAL FEE
OWIcertlfythat l have read this app11ationand a tate Natthe above Information
IL brorret.I agree to cumplywith all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
} relating to building rovWtlon,and hereby authorlu representatives of this
Z city to enter upon the above-mentioned'property for lropectlon purposes, ALTERORADDTOMECH. `
Date Recei of
V _ )agree to nave,Inde co rset a keep esw Ith rsa City of Cupertino - - P
atom tllabl City,pd nig[po ceof th expenses which mayin any wayaccrue AIR HANDLING UNIT CFO 10,0N)CFM). SUBTOTAL:
a City In con lquence of the gramE` Anis. - - -
sr AIR HANDLING UNIT(OVER 16,000 CFM) CONSTRUCTION TAX
STg $�R
Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
DOLS MATER IALS DISCLOSUREWllltheapplcfuture building occupant store or handle hazardous I'[EATING UNIT(TO 100,000 BTU) Date - RcceiptN
material as definyhe Cupertino Municipal Code,Chapter 9.1 2,and the -
Health and Safety Code Seat..M2(e)7 IWATING UNIT(OVER 100,0D)BTU) TOTAL
❑Yea, No
Will the applicant o�ture building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE�,fYTE
which emit havardous air contaminants as deflnedby the Bay Area Air - _ ,J
Quality Management Distda7 - ROILER-COMP(3)B'OR IDD,"BTU) - IP ��
4Yee ❑No
havemad the Health&Safetmode,SectJuircmenb5533anChapter 6.95of KI.ER-COMP(OVER 1W,0006TU).
+theGlifomla Health Sectiorently have
a tenant,
534.that
.
omensand/h at notify the ocgpoes notcurrentlyreq.to en atenanl,that ltbmy NEW RESIDENTIAL MECH. SQ.I7.
responsibility to notify the occupant of the requirementawhieh at be met
priorlo Issuance ofaCertlficateof Occupancy. - ^( � U-, 4,U
Owner or authorized agent - + Date - ISSUED BY: . l
IOIAL: —
c
OFFICE COPY