23230 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Pruiect Identification PEILwT NO.
Banding Address: , A 23230..
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' �- (r C� Yl,ane r APPIdl 11UN JUNM111AL UAlh
CITY OF CUPERTIN0.6UILDING DIVISION
Con�tnctoyra Na o APPLICATION /PERMIT _
_j,ZQp./ \ ��^�' S L ` �S BUILDING-LLECTRICA4PLUMBING-MCCHAMCAL CATEGORY CONTROL R
A ltect 8,near. Lie.No: L
R I ' " ,1" •„t,,BUILDING PERMIT,INFO-
'QTY ,, • '1,,,ELECTRIC PERMIT : i' . FEG •'
Add ess: PERMHIS5UANCE . 1:1 ❑ X ❑
LICFNR ED CONTRACTOR'S DECLARATION _
7 herebyion fifirro that
700),Iamlcensedh.Buimss provisions dloffe! ponr9de,and y APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Inert.i Section forA)of d effinon3 piths Buslnesaand ProfesslonsCodc,and my
Lana is In(u force and d(ed. PANELS /� •P�'
Date gClan( / LICK e�/ J �s 1LE.p ,
Dale. r+n[nRar �� LI21Q2QQAhfoq ,
'ARCHITECTS DECLARATION 2014"AMPS I
NO Zp I understand my plans shall be used as public records. OVER 1000 AMPS SQ.FF.FLOOR AREA $/SQ FT.
Wcenscd Professional SIGNS ELECTRICAL j
GG ktn+ OWNER-BUILDER DECLARATION
!`n ` SPECIAL CIRCUIT/M1SC
ZF'�� Ihercbyaffirmthat lam exempt from the Contractors Licence Lawlor the
p O 'tollowlog reason.(Secion 70315,Business and Professl.os Code:An ct or '
�z�pp'Iy county which rcqulmx a permit to cornWd,alter,Improve,demolish,or repair TEMP.MEfTR OR POLE INST. -
K anystsudurepriorto its union rice,also requires the applicant for such permit to
K file a signed statemen<that he h licensed pursuant to the provisions of the � R D
0�G Contractor's License Law(Chipmr9(cammmcingwith Section 7000).(Divl- SWB.1h0NG POOL ELECTRIC
SOS slon3offlu hislnessand Professions Cod0orthat helsexempt therefroman” VALUATION
6 S the basis for the alleged exemption. Any violation of Secon 7031.5 by any OUTTETSSWHCHESFIXTURES
p, appUcant for a permit subjects the apphcantto a civil penalty of not morethan
E" o five hundred dollars(5500).
Gl NEW RESIDENTIAL ELECTR SQ FT,
I,as owner of the property,or my employees with wages m their aoi• STORIES TYPE CONSTRUCTION ,
mpensatlon,wllldothe work and thestrvdureEnot intended or offered f.r
0 sale(Sec.7044,Business and Professions Code:The Contactors License Ls 1
B'j$$ does not apply to an owner of property who builds or Improves thereon,and
CC.• whodce suchworkhl if wthroughhlsownem w
ployee s,pridedthasu
tch OCC.GROUP RES.I11V1TS
Improvericnb am not Intended proffered forssle.I[however,thebuilding or TOTAL:
improvement hisold within oneyearofcomplelion,the owner-builderwill hat_
Ih�urdan of proving that he did not Wild or Improve for purpose of ask.). IQTY,I PLUM BINC PERMIT FEE'"; FLOOD ZONE APN
LJ 4 as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
cntncrom to construct the project(Sec.7044,Business and Pofessiom Code:
The Contactors License Law does not apply to an owner of property who
Wilds or Improves thereon,and who contracts, (w such p3ojeda with
ALTER-DRAIN k VENT-WATER(WA)
cc ador(s)amnwdpununtmthe Contad 's Llanse
Law. gpCg pfpW PROTECT. 'I t ,,'.FEE SUMMARY' t•
I_I I am exempt under See B 4 P C for this reason 1 f)I 1TCll)1'F1•F9
DRAINS.FLOOR ROOF,AREA,COND. I (SANITARY Y N ) I �j
Owner Date r RECEIPT p
[:]I b
WORKMAN COMPENSATION DECLARATION / FWTURES PER TRAP (/1'IZ �SCHOOLTAX Y N
hen affirm that I have•wdifiate of consent to ssRJnsure,or a RECEIPT M
mAifimteof Workers'CompamatlonlmuanmoramAifled copythercof(Sce.
3800,Lab C.) (GAS EA.SYSTEM-1 INC.40UTLEFS I PARK FEE Y N
Policy P RECEIPT M
- "Cr %n GAS EA.SYSCEMiOV ) A.
� Y � H_ DIVISION FEES
CertBind copy l4 hereby furnished. GREASE/INDUSTRL sTt mroR P I EC FEE
�certined copy is niece with the my inspection aivlsmn. II 1�
CERTIFICATE OF O(EM"ION FROM WORKERS' I GREASE TRAP • ( I•I) D AT! -
CO cN5AT10NINpURANCE SEWER-SANITARY-STORM EA.200M IfYi Dal t#
(TMssedlAmyllc/reed Ided if the permit Is(prone hundred dollars �'1� 7 P
($10f)or Ica WATER HEATER v/VEN'l�' LkTR YFE Y N
IaMty th rice ewwktorwhkh[his permit le bsued,I _ —
I shall not e n4,manner an as to become subject to the I WATER SYSIHM/.I.RFATING PA'ID'D
orkers'Cin Callfosula..DMr
O Z pliant Z U NOTICETO he aoroam- camper Cert ificate of&e fThs",you
NEW RESIDENTIAL FILMS. SQn. I Date - Receipt#
sode,yo must eurthwit the Work en'Compematlon provbions of the Labs I - - 1 TOTAL:
WH N deeeyou muat forthwith comply with such provisions or[his permit shallbc 13UILDING F6F.
j deenad revoked.
U CONSTRUCTION rucito LENDING
[en ACCNCY �.. SEISMICr EE (
1 Ihcrebyatfhm'rwhtc Ilea ermwdssu lending agency for.) perform- Itr. ELECTRICFEE
� O aria of the work(car which this permit V4sued(Sec.3097,Civ.CJ TOTAL:F"� -
V Landers Name PLUMBING FEE �•'•
IL I— lenders Address IQTY. MECHANICAL PERMIT t FEE MECHANICAL FEE,
U I anitythat l have read this application and gatethatthe above information)
O W• loco ed.I agree to complywith all city and county ordinances and state laws PERMIT ISSUANCE I FEES PAID:
}.a realing to building rog=,a d hereby act representativesofthis
[_ fA city to enterupon the a rope or Wpmlon purposes. ALTERORADDTOMECH.
(We)ages to savety ke rmless the City of Cupedirw Date Receipt#
against Bablhtse%Jud a e as w%h.yinany.y.ccmj IAIRTHANDLINGUMTU'010,000CFM) SUBTOTAL:
against aid City In h e Suit
� AIR HANDLING UNIT(OVER 1np00CPhD . I �CONSTRUCTION TAX
S,y.turcof pl nt�ntracme_ Date EXHAUST HOOD(W/DUCI7 I CONSTRUCTION TAX PAID:
II HAZARDOUS MATERIALS DISCLOSURE
Will the ppllantorfuture building occupant store or handle haeardouc I HEATING UNIT(TO 100,000 BTU) I I Date
material as dented by the Cuperd no Mu nicipal Code,Chapter 9.1 Z and the Receipt# _
Health and Safety Code Sedion25532(a)T HEATING UNIT(OVER 1(10,000 BTU) I I TOTAL: •y �� I
M Yes N No
Will the ippliantorfuture building occupant use equipment or devices VFMILATION FAN(SINGLE MID) I ISSUANCE DATE
which emit haaardous air c.ntamimntsas defined hythe Bay Area Air -
Qu hty Management Disirid7 BOILER-COMP OHP OR 100,000 BTU)
qYea I—I N. p
`T have read the haaar�i uses materials requlrcmenh under Chapter 6.95 of I B01LCR-CO\1P(OVER 700,000 B7U) p
the CallferNa Health k Safety Code,Sections 25505,5533 and 2!534.1
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECFi. SQ IT.
respomlbllltytonotif yt heompantoftherequi;rourawMchmusibemet JAM 27 1992
Price to(nuance of a Certificate,of 0m panty.
Owner.rawn.riaeaagent Date I /�a�1YL " Y
TOTAL I 'ISSUEUIIY:
OFFICE COPY