24137 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building project Identlfimdan PERMITNO.
Building Addms: 24137
me. hone: AiT0nKTT6VTCRWTrrArA
f CITY OF CUPERTIN6BUILDINGDIVISION
C tt APPLICATION / PERMIT
Arthl ett/Engineer. Lic.Nu UI
BLDINGELEEC
CMUCAL-PLUMBING-MHANICAL CATEGORY CONTROL#
Q ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
_ � �
a Address: - PFRMITISSUANCE xe
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under prervlslona of Chapter 9(mmmenc. APPLIANCFSRESIDENTIAL JOB DFSCRBTIO
Inensei in fon 7(100)of d elect afthe OuslveandProfnBionsCode,and my
licensebInfull!o and c.#' �U7 PANELSLicc
D.ta Clau_�_LICM J
Date Contractor 171.A,177- UP TO 200AMPR
ARCHITECTS DECLARATION 217-1000 AMPS
pkp�vv O
MX I understand my plans shallbe used u public records. OVFA 1000 AMPS I •F $/:4.FT.
k (� Licensed I'ddexlovl SIGNSELECTRICAL r"
<< m OWNER-BUILDER DECLARATION �e_r
Iherebyaffirmthat Iamexempt fromtheContractorsLicense Law for the SYI'f_7ALCIACIRT/MISC P
ppfollowingreason.(Section 7031.5,BuslnewandProfessionsCode:An ci or 4—
OZI:. y 7' 'I'EMP.ME7Q2OR POLE INST. DA E /G�
countywhlN requlrvapermlttorovtruR,alter,imprwe,dennWh,orrepalr,
nystmmmpdortoltedwamc abomquimtheapplicantfovuchpermitto NK ]OWER DEVICES
file a signed statement the,he Is licensed pursuant to the provisions of the _
3w Contractor'sLicense Law(Chapter 9(commencingwith Section 7000)ofDwl-
�0� .n.3 oftheBuslnesand ProtemlonsCode)orthat he b exempt therefromand SWIMMING POOL ELECTRIC VALUAT(�ybk
the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWHCHES.HXTURES 7—t
LAW
pA applIant fora permit subjectsthe applicant to a civil penalty of not nom than
five hundred dollars($500).
'4..' ❑Lasownerofthe property,or my employee with wages asthelrsole NEWRESIDENTIALELECTR SQ.Fr. STORILS 7YPECONSTRUCTION
zh? rompevatloMwildotMw kandthe Bunt mre nml tendedaroftemd for
FO sale(Bet. pply BuslvwerfPropety Co Wild@ or leepctols License Law
�$ doe notepplytoanowvrofpvughhlsoaemporlmprwvided thereon,that
OCC.GROUP RE&UNITS
who doesguchworkhimself carthrwgh hlsor s employees,providedthat such
Improvementsne,siarenotintended earofodtorsele.If,however, Ilderhe ill have
Improvementbwld within aneyearo(complMlon,the vwner-bu0derwBl have
the Wdienof proving that he did net build or improve for purpose of sale.). QTy, . PLUMBINGPERMIT FEEPLOODZANE APN
m
M L as owner of the property,am exclusively contracting with licensed pp R ISSUANCE i
ntraRon to cow
nsct the Project(Sec.7614,Busineseand Professions Code:
The Contractor's License Law does eat apply to an owner of property who ALTER-DRAIN&VFNI'-WATER QA)
builds or Improves thereon,and who contracts fee such p lajects with a
c�DI(+ctor(QLicnsed pursuant to the Contrattots License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
Lj I em exempt under Sec. B k P C for this reason
C� OUTSIDE ITE—S
Owner Date DRANSSANITARY Y N_FLOORROOF,AREACOND. RECEPTR
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
I hireby affirm self-loam, pp(•(UggS PER 7RN'that I have a certificate of consent to or a �s
r., flcateofWamkeni Campevatlolvumnmoram"(fWmpythemfSe.
RECEIPT M
3800,Lab C.) S F.A.PA.SYSTEM-I INCA OUTLETS
PARKFEE Y N
Policy# CAS EA.SYSTEM.OVER4(EA) _ RECEB'TM
Co any_ BUILDING DIVISIONFES
edified coy b herebyth the
GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
edified copy b filed with the city Inspection division.
CERTIHCATE OF EXEMPTION FROM WORKERS' GREASETRAP - PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 2(gFI. Date RC i t#
(This session need not he completed i(the permit b for one hundred dollars
($100)oify th WATER HEATER W/VENT/ELFCTR ENERGY FEE Y N
I cent that o anyhe prism in any
insihe der
so a to b co permitjest to hewed, —
1 shall not employ any pemon In any manner w u to become subject to the
Workeri Compeosatlon Iowa of Ca BfomWATER SYSTEM/TREATING
la.Date PAID
O Z Applicant NEW RESIDENTIAL PCMB. DRM RCcei t#
Z Q NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you —SQ.FT•
should become subject to the Workers Compensation provisions of the Labor T I AL:
N Code,you most forthwith comply with such provisions orthb permit shall be D
j deemed revoked. DUIL
aCONSTRUCTION LENDING AGENCY SEISMIC FEE f —
Z Iherebyatfirmthat there is a construction lending agency for the perford, s_ ELECTRIC FEE
once of the work for which this permit b Issued(Sec.3097,Civ.C.) PTAI
02 I<ndeta Name PLUMBINGF ea'as
LL F Lender's Address QTY. MECHANICAL PERMIT FLE MECHANI E
O W Icedlfy thatl have read thlsappiintionand statethatthe above lnformmlon
iscorted.I agree to comply with all city and county ordinancesanddatetawe \ PERMTTISSUANCE FEES PAI
IL relating to building cavtructlon,and hereby authodze repmsentatwes of this
I'- U)
city to enter upon the above-mentioned property for Inspection purposes. ALTER OR ADD 7O MECH. y Retel t#
— MO agree to cave,Indemnify an d keep harmless the City of Cupertino
agalnst liabilities,jtdgments,costsand expenses which may In anywayaMMe AIR HANDLING UNIT(TO 10,000CPM) S BTOTAL:
against said City In consequence of the granting of this permit.
AIR HANDLING UNIT(OVER to Mo CFM) CONSTRUCTIO TAX
Signature of Applicant/Contractor Data l EXHAUST HOOD(W/DUCT) CONSTRUCTIO TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE -
Wllltheappllantorfuture building occupant store or ha rad le hazardous HEATING UNIT 00 100,000 BTU)
material as defined by the Cuperti no Municipal Code,Chapter 9.1 2,and the Date RCCCI t#
tlealthand Safety Code Be Ion25532(a)9 HIATINCUNIT(OVFRIDg0WBTU) TOT
❑ Ye o
Willthe applianl r tum bulltling ocmp.rtuseequip.rtmdxvixa VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit haeardous air contaminants as defined by the Day Ama Air
Quality Management DbM 7 BOILER.00MP(3HPOR100,0E0BTIN pP
o Y� hh
ad theh us ruler,Scdio 25505,SS33 anhapler8.95 of BOILER-COMP(OVER 100,000 BTU) a V
Iardt Health bSafety Corte,Sections 25505,25537and25SM.I AUG ���
f understand that if 11e Ihldingdoeeno cumentlmment lenangt titbmy NEW RESIDENTIAL MIiCH. SQ.FT
ropovib ton Ity theompant the requirements whic sibe met 19
pri t uancc fa Cedifiat o ccupan C//.r
neror authorised age t pat ur '
ISSUED BY-.---
OFFICE
Y:OFFICE COPY