24412 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building ern ea Identification PIRMIT NQ
B.0ding Addm.: 24412
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wnem hon p
NV6P//V(eCA4e)4, Z6;7�-5P37 CITY OFCUPERTINO-BUILDING DIVISION �b Qq
Contraeorsluame: Wc.No: APPLICATION /PERMIT
Z57bYnVG7-0 BUILDINGS.ECTRICAI.PLUMBINC.MECHANTCAL CATEGORY CONTROL N
ArcFBect/Engineer Lic.No:
�r'Jr�fC �� QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address �`j/ {'(� S
PERMIT ISSUANCE 1] 1:1 11LICENSED CONTRACTOR'S DECLARATION
amlicansed usiroslonsotessimsr9(commmc APPLIANCES-RESIDENTIAL JOB DESCRIPDON
ingwah5Mlon force
effton3o(the Buelneaand('tofesslons(:ode,and my a '� "♦\ IS _ _ �a
license Is In fiats force and effect. PANELS
License Class LIc.It
Dale Contractor —UP TO 200 AMM
ARCHITECT'S DECLARATION 201.1000 AMPS
x4, (understand myplamahailbe used apublicrecords. OVERIOJOAMPS le Eli R !I 5/SQ.Ff.
�00C d
U Licensed Professional SIGNSELFGTRICAL
OWNER-BUILDER DECLARATION
t.., 1herebyaflrm that l am e.empl from the Contractor's License law for the SPECIAL CIRCUIT/MISC 1
F :I following reason.(Section 7071.5,Business and Professions Code:Any city or
muntywhich requlresa perrok to construe,alter,Improve,derrolish,or repair TEMP'MEM OR POLE INST. DA 'E
anysnrueure pectin Its lsaance,alaorequirestheappllcant for such permit to
file a signed statement that he la licensed pursuant to the proidlom of the POWER DEVICES
3w�
Contractor'.LicenseLaw(Chapler9(comnaencingwith Section 7000)of Divi- SWIMMING POOL ELECTRIC
sion3ofthe Busies dProfemiomCode)orlhat hebexempttherefromand VALUATION
the basis for the alleged exemption. Any violation of Section 7031S by any OUTLETSSWITCFTESFT%TURFS
app6mnt for a permit subjects the applicant to a civil penalty of nee more than
livkundred dollars($5110). NEW RESIDENTIAL ELECTR_$Q.FT. SRJW6 TYPE CONSIRIICTION
�n I,as owner of the property,or my employees with wages a their sole
compensation,will do the work and the structure Isnot Intended or offered for
Ole(Sec.7614,Business and Profeaiom Code:The Contractors Llcena Uw
$$ does not apply to an owner Of property who Wilds or Improves thereon,and OCC.GROUP RES.UNITS
who doessuch work hbmelforthawgh his own employees,provided that such
improvements arc not Intended oroffered for sale.If,however,the W Ilding or
improvement b sold within one yearofcomptAmn,the owner-bullderwill have
thIi*rden of proving that he did nes build or Improve for purpose olak). QTY. PLUMBING PERMIT FEE pLOOD7DNE APN
LJ I,as owner of the property,am exclusmly contracting wkh licensed PERMITISSUANCE
contractor to construct the project(Sec.7044,BusNea and Pro(ealom Code:
The Contractors License Law does not apply to an owner of property who _
Wild. or Improves thereon,and who common; for ch pwjees with a ALTER-DRAIN Is VENT-WATER(EA)
mea"-
rased pursuant to th Contractor's seLaw' BACK FLOW PROTECT.DEVICE FEE SUMMARY
am exem under Sec k P for Is n
•
own
` DRAINS FLOOR ROOF,ARCA,GOND. SANITARY Y N
ORI OMP O RATON ftECEIPI'N
I by off I hav cert consent to set(-Inmr or• �TUR6S PER TRAP SCIiOOL FAX Y N
ce
of
WOr C morass 0racertlfkd ropythereoff5ec. RECEITN
3800,Lab C.) GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y— N
Policy N RECEIT N
GAS F.A.SYSTEM-OVER d(EA)
Com any BUI LDI NO DIVISION FEES
�CertlOed copy I.hereby furruQed. CREASE/1NDUSTRL WASTEINTERCEPTOR PLANCHECK FEE
Certified copy 6 flied with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER.SAM.I.ARY.S ORM EA 200FI. Date Recei til
(fhlsserfion need not b completed 1(nhe permit la(arom hundred dollars
(8100)aryth) laMWATER HEATER W/VENC/ELECTR ENERGYFEE Y N—
I
the performance for this pemNb Issued, —
1 shall out employ any person In any manner an as to become subject to the WATCIR SYSTEM/TREATING
Wmkan'Compensation Laws of California.Date PAID
OZ Applicant NEW RESIDENTIAL PLMR. SQ.Fir. Dale RC0.'1 tR
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
should become subject to the Workers'Compensation provisions of the Labor TOTAL
LA Code,you=at forthMth comply with such provisions orthis Nrrmt shall be NG
LU > deemed revoked. BUILMFEE
a CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 hereby affirm that there Is a construction lending agency for the perform- ELECTRIC FEE
Z anmo(thework lorwNchthio permit latuued Cree 3097,CIv.C3 TOTAL:
(� O Loader's Name PLUMBING FEE
1L F LendteaAddrea QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
I condythatl have read thhapplimtionand state that theabove informaron
O W
a bcomect lagreetocomply wlthallcityand rountyordlnanoes and state laws PERMITI.SSUANCE FEES PAID:
W relating to building construction,and hereby authorize representatives ofthla
(— Z city to enter upon the above-mentlomd property forW on purposes. ALTER OR AODTC)MFGH. Date Recei tp
to save,Ind.rourd(y an d keep Farm a City of Ou Iro
L) ag.matllab Ities,jrdgments,mtonde.penntr ldemaym.nyw. coveof AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL'
against sal City Inconsequence of the fi l4, of thls perm/C
AIR HANDLING UNIT(OVER I00000CIM) CONSTRUCTION TAX
SI Nreo(Ap' c /Canty or Date EI(IiAUST HODD(Yr/ouc') 'CONSTRUCTION TAX PAID:
/ HAZARDOUS MA SCLOSURE -
Willth pp cess or uNre Wildlogoccvpant store ar handle hazardous HEATING UMT(T'0700,000 BTU) Date RCCef 1p
material as defined by the Cupertino Municipal Code,Chapter 9.I2,and the
I ealth and Safety Code Section 25532(a)? HEATING UNIT(OVER 100,000 BTU) TOT
❑ Yes M No
Will the applicant or Lure building Occupant use equipment ordevices VENTILATIONFAN(SINGLE RESID) ISSUANCE DATE
which emBt hazardous air contaminants as defined by the Bay Area Air
Qu lily Management District? BOILER{OMP(3HPOR 100,000 BTU)
Ym n❑No
F1
ercad Healthe h
Safety
Code,
rcquimrrenhunder ndChapter h.95 of BOILER-COMP(OVER 1p0,OW N7l)
the GIIandt Health &Shing Code,Sections25505,ve.tand25534.I IE
understand thatn of theonupant of the mquiyment. hick that met NEW RESIDENTIAL MECIi. SQFf.
responsibilitya cenfatytheaate of of the cy.Wments which swatWmm Q
prior no issuance ole Certi(Icate m(Ompancy. ^(1'IV
Owner or authorized agent Date ISSUEDNBY
TOTAL
OFFICE COPY