22640 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERKING.
Bulldin&Addresa: 1 I'� n 0
O G Lt
wn rs aameone:
CITY OF CUPERT[NOLBUILDING DIVISION 4
c.^tra�taNw. „r•f'f Lie.N. APPLICATION /PERMIT '— 1
br+�0�- BUILDING-MECTRICAL-PLUMBING-MECHANICAL CATEGORY CONTR(
Architect/Engineer. Llc.Nce lo(p
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add. PERMITISSUANCE "�� f-52�
LICENSED CONTRACTOR'S DECLARATION
Ihereby affirm that l am licensed under provlelonsof Chapter 9(mmmem - APPLIANCES-RESIDENTIAL JOBDESCRI'HON
Ingwith Senion7000)o( )ivlelon3ofthe Buslnessand Professions Code,and m
license Is In full fora and effect. fj PANELS /�•�� .
Limnse Cls® Lic.M
Date Contractor UP TO 2DO AMES
ARCHITECPS DECLARATION 201-100DAMPS
p0.±all e: I understand my plant shall W used s public records. OVER 1ODO AMPS SQ.FT.FLOOR AREA $/SQ.Fr.
Eo� Licensed Profestmal SIGNS ELECTRICAL (yl '30.
-ku OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MLSC J O lW ' v
7 i„E�h l�8 I hereby affirm that I am exempt(romthe Cool License Law fee the
OR .following reason.(9ecd.7031 S,Bushes and Prof.t..s Code:Any dty or .� Q 6�'
O Z .METER ORPOLE INST.
P4muntywhichrequimapemdwmmtmct,alter,lmpmv demolbh,ormpalr
q 6 anystructure pdorto Ila issuance,also requlreatheappheant forsuch permit to POWER DEVICES
Nd V Ole a signed statement that he Is licensed pursuant to the provisions of the
gn Contrador's License Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC
SOS don 3 of the Business and Professions Code)or that he is exempt therefromand VALUA11ON
< the basis for the alleged eedsthea Anyviolation.($cobran0. by any UTLETSSWITCHFSFI;I;ES — V O(• 4C
OA appBcantf.ra pemdt aubjectstheappllcent toadvll pevltyanal mom than v 1p J
�u veh red dollars($500). NEW RESIDENTIAL ELECTR SQ. I. SIOWFS TYPECONSHRUCTION
ea owner of the property,or my employees with wages as their sole
c p atlon,w111dolhework,and thestmdure lana Intended or offered for -
Ie cors 7My to anowand Pro(mi.s who builds
or Improws Ucese law
$ docsnotapply torn owner apropertywhobuildsorImprovesthereon,and OCC.GROUP RES.UNITS
who messuch mentsa not Intended
Nsown e.If,
provklhowever,
dthat such
bnprovemenb are not Intended orof(ered fwsale.IL haweveq thebu0dingw TOT
Improvement bsold within one yearo(completlon the cwner-builderwll)have
burden of proving that he did not build or Improve for purpose of sale.), QTY. PLUMBING PERMIT FEE
I,as owner of the property,am exclusively contracting with licensed FLOOD ZONE "NpQRMR ISSUANCE !
contractors to construct the project(Sec.7044,Business and Professlmu Code:
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN VENT-WATER(EA) -
Wilds or Improves themom and who contracts face such pRojem with s r�
acto(s)Ocensedpunu tto the ontradm'e License Law. FEE SUMMARY
exam sand B k P C for this reason BACK FLOW PROTECT.DEVICE
er - `�� Date DRAINS FLOOR ROOF,AREA,COND. SANITARRECY N
W IIONAN COMPENSATION DECLARATION
QI hereby affirm that I have a cedlOcam of consent to self-Imre,ora ��FIX.NRES I'ER,ISNP $CIiC10L FAX Y RECEIPT
N NR
mdlflwteufWorkeri Comper donlsumnmoramdNed copythemcf Eam. 1
M,Rab C.7 CAS EA.SYSTEM-1 INCA OUTLETS aaa'• PARK FFP Y N
Polley N RECMPT M
GAS EA.SYSTEM-OVER 4(EA)
Com
�Cany - BUILDING DIVISION FEES
edifled copy Is herebytM. CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
�CedlOed copy la filed withh thethe city Impaction division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GRFASETRAP PAID (..1}
COMPENSATION INSURANCE SEINEWSANITARY-STORM EA 200i•T Date ReCel tit � "
(TNsuRlon need cad be completed tithe permit V fwone hundrtd dollars
($100)orless') WATER HEATER w/VENT/EL[CTR ENERGY FEB Y N
I certify that in the pedomanm of the wmk forwtdch thlu permit W b®ed, —
I shall not employ any person In any manner so s to become subject to the WATER SYSIEN/TREATIN'G
Workera Compensation Laws of California. Date PAID
SQFr. Date Remi tp '�
Applicant
Z 0 NOTICE TO MPLICANT:I,after making this Cedlfkate of Exemption,you NLW AE4OENTIAL PLMB.
I-
Pshould become subject to the Workers'Compensation provisions of the Labor TOT R
N Code,you must forthwith comply with such provisions or this permit shall be
K 9 deemed revoked. 6UIL G •E
W 3 - CONSTRUCTION LENDING AGENCY SEISMIC FEE
ll I heroby afOrmthat there b a construction lending agency for the perforce, FEE
M Z ance of the work for which this permit Is issued(Sec.3097,Civ.C.) 70
02 Lenders No PLUMBING FEE
LL I- I<ndera ndd,ea, QTY. MECHANICAL PERMIT ME MECHANICAL FG
OW Ices ltythat l have readthisapplicatlonand watelhatehe above lnformatlon
4 lacorrect."grmlo comply with all city and county.rdinancesandwatelaws PERMIT'ISSUANCE FEES PAID:
r relating to building comtrudlon,and hereby authmlme representatives of this
(.. Z city to enter upon the above-mentioned property for Impaction purposes. ALTERORADDTOMECH. ��
(We)agree to save,Indemnify an d keep harmles the City of Cupeutince Date 'ptH
V against llabWtles,Pdgments,cows and expenses which may In any way accrue AIR HANDLING UNIT CFO IO,OW CFM) $UBT AL•
agalst sal Incoseque oftbe antinga this perm .
_ AIRHANDWNG UNIT(OVER ID,000CFM7 CONSTRUCTION T4
-1 ;gdenatu of Applu C tractor ' Date EXHAUST HOOD(W/DUCT) CONSTRUCTION PAID:
DOUS MATERIALS DISCLOSURE _
WBltheappli cat or future building occupant acre orhandleh.,dozes. HEATING UNIT(TO 100,000 BTU) �" Date R i tH
trvterialasdefin by the Cupertino Municipal Code,Chapter 9.12,and the -
HeNo
alth and Safety Code Section 25532(a)7 HEATING UNIT(OVER 100,000 BM T�•OYen ,
ilitheappllcant or(urum a•.Ilding occupant use equipment or devices LATION FAN(SINGLE RESID) �— 19S4$0 DATE
which emit hazard...an com mduu is as cieOnsd by the Bay Area Air
Quality Ma nagemcnt District? BOILER-COMP OHP OR 100,000 BTU)
4Yes �I No , NOY 22 1991
havereadthehaur�ouamatedalamrylremenunnderChaper6.95ot BO LERCOMP(OVERi00,000BTU
the California Health A Safety Code,Sections 25505,25573 and 25534.1
understa cad that if the building does not mrmstly have a temriL that it 6 my NEWRFSIDENTIALMECH. SOFT. /�
responsibility to notify the occupant of the requirements which most be et Ci'I Y'wt,ouitwfl-INQ
prior to Issuance a a Certificate of Occupancy. res '
Owner or authorized agent Date- ISSUED B .
lOT
OFFICE COPY