24785 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY
OP CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL. 24785
� A r
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION L [f J
BUILDING ADDRESS: SANITARY NO. AAP�PLICATIONNSURMMITLALDATE
1 ,IT If LOT If
OWNERS NAME: P11 BE pgf CONTRACTOR'S NAME: LIC NO: N/C CONTROL k
RUTH F /ENGINE LIC NO: 0/& ESS: ❑
'ONTACT: pHONE:� ,
`�Oe5'/S BUILDING PERMIT INFO L 1 QTY. ELECTRIC PERMIT FEE
PERMIT ISSUANCE BLDG ELECT PLUMB MECH
l 262-�b1�
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
azz thereby affirm[hall am licensed underprovislons of Chapter9(commencing with TOB DESCRIPTION
POO Seatur7000)of Division 3ofthc Bimmessimd Professions Cade,and my license is in PANELS
� full force and effect.
Fila LDucense Class Contractor UP TO 200 AMPS
F y y 201-IOW AMPS
ARCHITECTS DECLARA'DON 5 T.FLOOR AREA $/SQ.FT.
Q�.,p [understand my plans shall be used os public records. OVER IOW AMPS Q'F
r N E W SIGNS ELECTRICAL
� �Q Licensed Professional
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
O L,O I hereby affirm that 1 am exempt from the Comment's License Law for the
3 0.ti following reason.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
O which requires a permit to construct,alma improve,demolish,or repair any structure
poor an its amore,also requires the applicam for such permit to file a signed statemem POWER DEVICES
doy Qp that heislhemsed porsuan
no the provisions of the Counselors License Low(Chapter
X� 9(countermen,wit mpt therefrmandthe Division 3o01n Bdexemptio Profession Code) SWIMMING POOL EIECfRIC � VAO�D
W-.m Sethi 7031. byan applicant
and for a basIsmail
beasegedexempti to.A civil Penalty of OUTLETS-SWITCHES-
_ ¢ rection 9031.5 by any applicant foraperntit subjemsthe epPlicannoacivil penalty of FIXTURES
d O ore then five hundreA dollars($SW). NEW RESIDENTIAL FLECTR SQ.FT.
KEm sownerof[he propery,ormyemployeeswith wegesastheirsolecompensa[ion, STORIES TYPE CONSTRUCTION
qgill rthe worknod the structure isnm intended orofferedforsale(Sec.9044,Business
ted Professions Code:The Comment's License Law does not apply n an owner of
toasty whobuildsorimproves thereamand whodoes such warkhimsclforthrough his
ownemployces.providedthatsuchimprovementserenotintendedorofferedforsale.If, OCCGROUP LRES.UNITS
however,the building orimprovement is sold within one yearofcompletion,the owner- TOTAL
builder will have the burden of proving that he did not build or improve for purpose of
els).
❑ hasowner ol'[he propeny,amexdusivelycomraaing with licensed contractors 1. QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
amstruct the project(Sec.9044,Business and Professions Cale:)The Comoster's -
LicenseLawdoesnot apply manownerofpropery whobuildsorimproves[hereon,and PERMIT ISSUANCE
who contracts forsuch projects with aaohbaamed licensed pursnantns the Contractor's
License Law. ALTER-GRAIN&VENT-WATER(EA) FEE SUMMARY
} ❑ I am exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE OUT'SID fEEs
SANITARY Y N
Owner Date pRAINS-FLOORNOOF,AREA,CONE. RECF.IPftl
. .
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ I hereby affirm that l have a ceniicateufconsero sclUinsom,ora cenificate of FIXTURES-PER TRAP RECEIPT
arkern'Campensmion lnsumnceoracerifiedwpy thereof(Sec.3g00,LabCJ which PARK FEE YN
rs al l employee's under this permit. GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT tl
Policy N BUILDING DIVISION FEES
Company
❑ Certified copy is hereby famished. GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Certified copy is filed with the city inspection division. ORFA$E/INDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS GREASETRAP SOILS FEE
COMPENSATION INSURANCE
Obal,emionnedlirm be completed ifthe permh is loran,hundred dollars IS I W) SEWER-SANITARY-STORM EA.E00FL ENERGY FEE
inles")
I eerily that in the perfamraree ofine workfor whi.lind,permit is issued,l shall WATER HEATER W/VENT/ELFCTR
not employ any person in any manner so as to become subject to the WorkersPAID
Compensation Lwsaf Czlimmia. Date WATER SYSTEMTRRATING Date Receipt
Q z Applicant
NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
Fr�r become subject to the Worker's Compensation provisions of the Lahor Code,you must
a forthwith comply with such provisions or this permit shall be deemed revoked: BUILDING FEE
pW, CONST'RUCTION LENDING AGENCY SEISMIC FEE
z
^a I hereby affirm that here is a concoction lending agency for the performance of
U C the work far which this permit Is issued(Sea.3099,Civ.C.) TOTAL: ELECTRIC FM
Lender's Name
O U Lender's Address QTY. MF3CHANICAL PERMIT FEE PLUMBING IEE
W I verify that I have read[his application and state that the above information is MECHANICAL FEE
0.. correct. [agree mcomply with all city and county ordinances antl Stam laws relmingm PFRMI'PISSUANCE
V) building construction,and hereby uuthorizerepresentaLives ofthis city memerupon the
above-mentioned t for inspection CONSTRUCTION TAX
(, 7 . eve, pec ton purposes. ALTER OR ADD TO MECH.
�7 a&ree m save,indemnify and keep harmless he City of Cupenino against
liab'dies, dgments,costs and x neswIt h 10,00Cmay in my way aceroeagalnslsaid City ATR HANDLING UNIT 10,OCFM)
n,, nee of the gmntia f is pe
AIR HANDLING UNIT(OVER IB0(10 CFM)
Signanr e U ono c r D e EXHAUST HOOD(W/DUCD
PAID
HAZARDOUS MATERIALS DISCLOSURE, HEATING UNIT(TO 00,000 BTU) Date Receipttl
the applicant or future building occupant store ter handle hazardous mama[
asde ad by the Cuperino Municipal Code,Chapter 9.12,and me lfeelm and Safe, HEATING UNIT(OVER 100,000 BTU) TOTAL:
Code Section 11 Yes 32(a)q ❑No VENTILATION FAN(SINGLE RESID)
WilOhen licanmrfmure buildin quipmen BOILP.R-COME(3HPOR IW,00(I BTU)
ISSUANCE DATE
pp gby the Bay touality Management
Dkeirtus nit contaminants ns defined by the Bay Area Air Quality Management BOILER-COME(OVER 100,000 BTU)
Disvict9
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.IT.
1 have read the hazardous materials requirements under Chapter 6.95 of the p
California Health&Safety Code,Sections 25505,25533 and 25534. 1 understand that P YC
if the building does hilt currently have a tenant,that it is my responsibility to notify the
occupant of the requirements which must be met prior to issuance of a Certificate of
Occupancy.
Owner or oumorrzed agent Date TOTAL: ISSUED BY:
OFFICE ify