24183 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POIN1 rtry vroL7 PLRMITNO.
Building Pro'ed Identification 24183
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APPLICA A
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�,/ ✓Nay 35H-9q7 CITY OF CUPERTIN0.61JILDINGDIVISION Q2
caof�dp(+Narre: . LIe.Na. APPLICATION /PERMIT
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ArthltM/En _ t I - ,. - ,v - - -� 5'�, :•' BUILDINGPERMIT INFO k li :
.QTy•, � ,' 1ELECTRIG.PERMITt t c. ,,'}:FTE' .. . .. ... . .
Address: A i ` PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION
IAPPLIANCFSRES3DENfIAL t.!O'B DSON
Ihereby firrothtIamdunder r naofChapter9(come /f
ngctto70 )ofDiv.i.3ofhBu.insandonsde,andmy L
--
PANELS
license is in full force and effect
I.Icensc Claes Lic.#
Date Contndor 201-1000AMP5
ARCHITECTS DECLARATION OVER 1000 AMPS 'SQ.FC.FLOOR AREA S/SQFf.
.
oZ I understand my plans shall be used as public records
0�O SIGNS ELECTRICAL
,. Licensed Professional
!n G FG'iOWNER-BUILDER DECLARATION. SPECIALCIRCUIT/MISC
I hereby affirm that I am exempt from the Contractor's License Law for the
ZO O following reason.(Section 7Wl S,Business a ad Professions Code:My dtyor TEMP.MEEK:OR POLE INST. "
0 Z'9p u9 countywhichrequlma permittommtmd,alteglmpmve,demolbh,orrepair
W` anyst.m,,pelt.its fastance, bo equlmtheapplIcantfor such permit to POWER DEVICES
[P4,y5a O file a signed statement that he Is Bansed pursuant to the provisions of the
PJOw�- Contractor's License Law(Chapter 9(mmmendog with Section 7030)of Diel- SWIMMING POOL ELECTRIC VALUATION
( SOS elon3 oftheBusinessand pmdeskma,Code)mthat bels exempt therefromand
the basis for the alleged exemption. Any violation of Section 7(315 by any ungis-swrrCI-IEgF1x711RES �—
applicant far.Permit subjects the applicant to a civil penalty of net more than
$ five hundred dollan(5N). NEW RESIDENTIAL ELECTR_FQ.FT. STOWES TYPECON5MUCTION
❑I,as owner of the property,or my employees with wages as their sole
6 compensation,willdothe work and the structure beat intendedor offered for
❑ sale(5ec 7064,Businessand Professions Code:The Contrad.e.License Law OCC.GROUP RIS.—UNITS
$$ doeanot apply loan owner of propertywho Wilda or lmproesthe ha sad
EE - whodoeswchworkhim iforthmughlusownemployees,p TTL:
improvements arc not intended proffered for sale.[Lhowevepthebulldingor _ - -
too provementissoldwitbinoneycare fcamp lgoo,the owner-bullderwlll have t., - u .i FEE,. FIAOD LANE APN
tenofprovingthathedidnot it arimprovefor purpoacofsale.). QTY. �. ,r''PLUMBING.PERMIT,'
U L as owner of the property,am exclusively matractlog with licensed PERMIT ISSUANCE �•
..i.e n to consmad the pro jM(Sec.7Ba4,Bta essand PrAesslonsCode: ,
The Contndor's License Law dcee not apply to an owner d property who ALTER-DRAIN&VENT-WATER(EA) '
builds or Improves thereon,and who anon# far such pPjeda with a i`a,. 1,M •,.FEE.SUMMARY
cgptr.&or(,)lice. . nuantro the Cantradoes License Law. BACK FLOW PROTECT.DEVICE
sal am exempt under&c B &P C for this reason SANITARY Y_ N_
- DRAINS FLOOR ROOF,AREA,COND. RECEFr#
Owner - 'Date -
WORKMANCOMPENSATIONDECLARATION FD(TURES PER TRAP SCHOOL TAX Y_ N_
❑3 hereby affirm that I have a certificate of consent to apy tnwre,ora RFAF.I'T N
redl(Icab of Workere'Comperwtian lruuranre ora certified copythereo((Sec. OAS EA SYSTEM-1 ING40[77LECS /e PARK FEE Y_ N—
MOO,
'•
polis Lab C.). OINGRECEDr N
� 1'oIIryM GAS EA.SYSTEM-OVER 6(EA) BUILDING DI VISION PEES
Cam any - PLANCHECK FGE
�CedWed copy In hereby famished. CREASE/INDUSML WASTE INTERCEPTOR ,
Certified copy Is filed with the city inspection division.
GREASE TRAP PAID
• CERTIFICATE OF EX"PCION PROM WORKERS' . Date Recci t#
COMPENSATION INSURANCE SEWER-SANHARY-STORM EA.20017.
(rhlsecdlon need res be completed lithe permit b(orone hundred dollars ENERGYFEE Y N_
(SIM)mIces) - WATER FIERIER W/VENT/ELECTR
I certify tliat to the performance of the work for which this permit is Issued, -
- I shall not employ any person in any nunner so as to become srbjed to the WATER SYSTEM/TREATING PAID
WorkersCompensation Laws of California.Date Date Recei t#
O z Applicant NEW RESIDENTIAL PLMB.__SQ.FT,
Z O NOTICE TO APPLICANT:If,after ma king t his Certificate of Exempllon,you TOTAL:
should become subject to the Workers'Compematbn provisions piths Labor BUILDING •'E
N Cod,,you must forthwith comply with such provairms orthls permit shall be
j deemed revoked. - SEISMIC FEE
WI CONSTRUCTION LENDING AGENCY 'ELECTRIC FEE
"C. I hereby effirmthat there is.rowtrudlon lendingagency,for the perform-
2 once of the work for which this permit is blued bee 3097,Civ.C.) PLUMBING FEE _ alms
O O Lender's Name QTY, MECHANICAL PERMIT ''•.' " .'FEE" MECHANICAL FEE
LL P: Lender's Addnzs /
redifythatlhavereadlhiaappllatlonaM statathauheaboveln(omutlon PERMIT ISSUANCE FEE'S PAID:
U l
O W [scarned.Iagreem comply with all cityand countyordinances and slate laws
r fY relatingtobulidlegcorsomation,and berebyauthoroampresentativaofthb ALTER OR ADD TO MFCH,
F W city to enter upon the above-mentioned property for inspection purposes. Date Receipt#
? (We)agree to ave,Indemnify an d keep harmless the City of Cu ped loo AIR HANDLING UNIT(7O 10,W0 CFM) SUBTOTAL:
O against liabilities,iudgments,cons and expenses which may in any wayacame
against said City In consequence of the granting of this permiL' AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
• - FxHAusr H000(w/Duce CONSTRUCTION TAX PAID:
g fAppllant/Contndor Date
HAZARDOUS MATERIALS DISCLOSURE HEATINGUMT(TO10IMOBTU) .' Date Recel t#
Will the applicant or future building acwpant storeor handle hazardous _
material as defined by the Cupertino Municipal Code,Chapter 9AZ and the HEATING UMT(OVGR 100,000 BTU) TO AL:
I ealth and Safety Code Section 25532(a)i
Wl -
❑Y,4 Ll No VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
llthezpphcnrt or future building ottvpart use equipment or devious 4,y D
A
which emit havrdousalr contaminantsaa defined by the Bay Area Air BOILER{OMP OFI'OR 100,000 BTU) it F4 V
Quality Management D 3
❑Ya s CNo
^I have and the nav ouoa]N°a materials requirements under Chapter 6.95 of BOILER.COMP(OVER 1(3,000BTU) SEP - '4 .1992
the California 11alth&SafetyCode,Sedions 75505,75533 and 25536.I NEW RESIDENTIAL MECH, 5Q.Ir1'
understand That inn building docs not currently have a tenant,that It b my
responsibility not[ the occupant o(the rcquarromottw ichmustbemet CI��T''Y``��Ur L��aura 6mw
prior to tssuan o(a fiats of Occvpanry. .,� v✓•� y /
Owac,mivathorl agent - Date / ISSUED BY:
OFFICE COPY