24114 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
But.,nems Pro ect,ldemificabion - PERMIT NQc; PhLTR 4114 '
Building Address: - - - l '} Z
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73o-b9b CITY OFCUPERTINOBUILDINGDIVISION G
trArcMtect gine¢r. Lle.Na:
actors Name: 1 . APPLICATION /PERMIT O �'7 2
s ' `' BUILDING-ELECTRICAI.PLUMBINC-MECHANICAL_ GATTI BY CONTROLN
.
( (� rI 474 . ELECTRICPERMIT FEE BUILDING PERMIT'INFOAdd.. 1091 ,
f So— rl:TOR'N:IZ''i a"1 PERMITISBUANCE B= �ffrri El ❑ z ❑
LICENSED CONTR sed under rDECLARATION
thereby eHtrmthat Dlmlf 3ofthe Burpm .ldIs,(ChapteC.dco"ena - APPLIANCESRESIDENTIAL JOBDESCRE'HON
]i.e.h .full 70009and effeon3.(the Buslnenand ProfeulonsCade,and my JOB
b in full tarts end c.a PANELS "00AARFA License Cbn _ Lorti eDate Contractor ARCHITECTS DECLARATIONNOWzzIunderstand my plans shall be used n public records, - OVER 1000 AMPS f/SQ.Ff.
FLZ(Cj Licensed Profeniarul SIGNSELECTRICAL
< OWNER-BUILDER DECLARATION g[+ECIALCIl2CUIT/MISC
zIp— Iherebyaffirm that I am exempt from the Contractor's License Law for the
�2" following reason.(Section 7031.5,Business and Professions Code:Any cttyor
� wantywhielirequiresapermit to roeutmct,alter,lmprove,demoWh,arrepalr TEMP.METER CREOLE INST.
a nystmctmPriortoltsbuante,aborequimatheappllcantforsuchpermitto ]OWER DEVICES .i
file a signed statement that he is licensed pursuant to the provisions of the
w Conteagor's License Law(Chapter9(commencing with Section 7000)of Divi--
�V,q sion3oflhe BuAnenand ProfesslomCode)orthathelaexempttherefmmand SWIMMING POOL ELECTRIC VALUATION
the basis for the alleged exemption. Any violation of Section 70315 by any OUTLETS-SWITCHES-FIXTURES
�{I applicantfora permit subjeobiheappRcanttoa rdvil penalty.(not more than
five hundred dollere(g5D0). ,
�n ❑I,aq owner of the property,or r%employesaw
ith wages u the sok NEW RESIDENTIAL ELECTR EQ.FT. STORIES compensatl.n,wllld.hework,andthesfroctureIs not Intended or offered for TYPHOONS TION
qsale(Sec.76 Business and Profenl.eu Code:The Contractors Liceme law
• $ done not apply to an owner of property who WIT1tt lmpmvn tbereory and
Who doessuch work himself or through hlsown employees,provided that suchMVENT-WATER
OCC.GROUP RES,UNITS
Improvement ere not Intended or offeredfor,ale.IL hoivevey thebulldingorTOTAL-
imp
rovement bsold wlthlncen arofcompletiaM the ow utllderwlll have - '
tl urden of Ming that he did sea build or lmpmvefor purpose o(eale.). NG PERMIT FEE '
u I,as owner of the proEvery,am exclutivsly contractlog with IlcenndFLOOD TONE APN
contractors to CoristNct the Project(Sec.701{,Buatess and PrMenbru Code: - ��TheLicenselawdoes seatpplytoan owner a(property whobuilds or Improves thereoM and who contracts toe each pojecte with aNT'-WATER(EA)ctor(s)It...d Pursuant to the Cantredus.Llmme law. FEE SUMMARY
am exempt under.Seo B&P C for this reason, CT.DEVICE
Owner
Data ` DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_
WORKMAN COMPENSATION DECLARATIONRECEIPT N -
❑1 hereby affirm that I have a aer0ficate of consent to self-Insure,or
RXTURFSs PER TRAP SCHOOL TAX Y N
certificate of Workers'Crmpecention Insurance or certified copy thereof(Sec. RECEIPT N
3800,lab C.) GAS EA.EYSTTM4l INC.4 OUTLETS PARK FEE Y_ N_
Policy If RECEIPT N .
Com any - GAS EA.SYSTEM-0VER4(EA) BUIL DING DI VISION FEES i
❑ ..YiRed copy b hereby furnished. - -
ertlfledcopyb(Ikd with the ctty lrupeelion division. GREASEANDUSTRL WASTE INTERCEPTOR PLANCHECIC FEE
CERTIFICATE OF EXEMPTION FROM WORKER!F GREASETRAP PAID
COMPENSATION INSURANCE '
(Th os section need not be c
00)or less.) ompleted if the permit's for one hundred dollars SEWER-SANITARY-STORM EA.7(N)FT, Date' Receipt#
(fl
I cartrfythat t the performance ofthe work forwhich this permit is Issued WATER HEATER W/VENT/ELEC7'R ENERGY FEE," Y' N
I shall not employ any person In any manner so a,to become subject to the —
O Worken'Compereatlon Lam of Callfomla.DateWATER SYSTEM/TREATING PAID
-
Applicant
Z Q NOTICE TO APPLICANT:1[eRer making this Cekfflote of Exemption,you NEW RESIDENTIAL PLMB. eOFf. Date .Re i t#
Hshould become subject to the Workers'Compensation provislmu of the Labor - -
WW Code,you must forthwith comply with such pembdoes or this permit shall be TOTAL
> deemed revoked. BUIL12ING FEE .
IL G j, CONSTRUCFIQN LENDING AGENCY _ SEISMIC FEE "
Ihereby affirm that there b a construction lending agency for the perform-
ELECTRICFEE
:3Z ante of the work for which this permit b Issued(See.3097,Civ:CJ TOTAL:
V 0 finders NamePLUMBING FEE 7 *
LLI— Lenders Address - QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W 1certl"atl have readthbapplicationand statethattheaboveinformation
IL lectured.I agree to comply with all city and countyordinances and state laws PERMITISSUANCE FEES PAID:
} W relating to building conslmction,and hereby authorize representatives ofthis -
H Z city to eat athe abovo-menHoned property for Inspection purposes. ALTER OR ADD TO MECH.
(W agree save,Indemnify n d keep he ese the City of Copertmo , Date Receipt#
.Be it, ill ,jodgmenb1. rad Pen Ich mayinanywayaceme AIR HANDLING UNIT(To 10,0D0 GEM)
ag nets IIn SUBTOTAL,
ty ronseque of a of thio permit.
8 f� AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
Si reof AppRont/ ontractor Date D(HAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE '
Will the applicant or future building occupant store or handle hazard.., - HEATING UNIT(TO HXIODO BTU) -
material as defined by the Cupertino Municipal Code,Chapter 9.IZ and the Date Recel t#: ,,
Health and Safety Code Section 25537(a)771 Yt. NrHEATING UNIT(OVER t00,0008TU). TOTAL:
'
Willtheapplicauntre building..Part
uas
equipment or devices VENTILATION FAN(SINGLE RESIDj - Cq" r-r_a�A•1•E
which emithazardous air hazardoair contaminants as defined by NISSU
e Bay Area Air t`�'
ualitYManagement District?ea No BOILER-COMP gFiI'OR 100,000 BTU) '
have read the baza ousmaterials requirements under Chapter6.95 of RORER-COMP(OVER 100,000 B7'fJ) AUG •j ty 1992the California Health&Safety Code,Section,25505,75533 and 25534.I 1 1
understand that lithe building does not currently have abreast,that it is my, NEWRESIDENTIALMECH, SQ.Fr
responsibility to notify the occupant of the requlremonts which must be met - -
priortolssuanceof a Certificate of Occupancy. CITY Uf vU('tFI'I V(VU
Owner or autr o ma,agent - -Date
• .TOTAL: - ISSUED BY: .Jk VA
OFFICE COPY
i