19951APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification
Building Address:
PERMIT NO.
19951,
V951.
wovr..: Phone:
Ala 03 of
-CITY OF CUPER77N0.BUILDING DIVISION
APPLICATION / PERMIT
BUILDINGELECTMCA4PLUMBINC-MECHANICAL
.21
lb ' lk�
c°"o-ado s sore: Lic.No:
el,a-G Q
CATEGORY
CONTROLp
Architect/Engineer. Lk. N.
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Addreem
❑ ❑ ❑
PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am Beamed under prmWons Of Chapter 9(commene-
IngwlthSedion70ID)of DiWsion3ofthe Businemand Pmfesalons o c, and my
licemelsin�defced
LicensuCla yf.6j`�
Date d: -/L•90 CmAmcor_ad q G C'p,
APPLIANCES -RESIDENTIAL
JOB DESCRE'770N
q"M
PANELS
UP TO 2DO AMPS
201-1000 AMPS
ARCHITECT'S DECLARATION
I understand my plane shall he used as public records.
OVER 1000 AMIS
SQ. FT. FLOOR AREA
s/SQ. FT.
SIGNS ELIC AL
Licensed Professional
MI
' OWNER -BUILDER DECLARATIONSPECIALCBtC
I h...by.fluorthat I am exempt fromthe Contractor'sLicense Law for the
T04P O
following reason. (Section 7031.5, Buslness end Professions Code: Any dty or
countywhkh requU apermlttocmutrud,alwrimprove,demollsh,orrepalr
anystmu mprlortaltalseuame,alsorequimatheappBantforsuchper tto
file a signed statement that he h licensed pursuant to the Indenture of the
COntracmrb License Law (Chapter 9 (commencing with Section 7000) of Divi-
wm 3 of the Business and Profeslons Code) Or that he is exempt therefrom and
pOWERD 5
SWEr1h1ING L E C
VALUATION
the basis for the alleged exemption. Any violation of Section 7031.5 by any
applicant fora permit subjects the applicant to a civil penalty of net morethan
UTLETS-S FI
'
five 1, as O nerdolof the pr .
❑ I, as Owew of the property, Or my employees with wages thele door
W k EL FQFT.
STORIES
TYPE CONSTRUCTION
on, do work and the sr' Isnot Intended or offered for
r
sale (Sec. Businessill odure
(Sec. Business and Code: The ves Licensehereon Law
to f property or Improves
apply mpr
does who does rk ownerofpropertywho nempl yees,pveetMreory and
such work
whodoesmchworkhimselfe
OCC. GROUP
RFS. UNITS
orwghhieawnemp,Oyeea,ertIdesthatsu or
improveneenls am issold ithindneyearferedfor eaor. If, owner-build
improvementbsoldwithin oneyearolcanpletlon,the °wner-buBderwlllhave
erwill have
TOTAL:
ttF-irurden of proving that he did not build or improve for purpose ofsak.).
jJ L as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec 7044, Business and Profewhons Code,
QTY, PLUMBING PERMIT FEE
'FLOOD ZONE
APN
PERMIT ISSUANCE
The Contractor's License Law does not apply to an owner of property who
befids or improves themon, and who contracts for such pwjects with a
c t etor(s) Bcensed pursuant to the Contractor's License Law.
f_I f am exempt under Sec. B & P C for this reason
ALTER -DRAIN & VENT- WATER (EA)
FEE SUMMARY
BAIX FLOW PROTECT. DEVICE
DRNNS FLOOR ROOF,AREA,COND.
SANITARY Y_ N_ -
RDCEErT p
Owner Date
WORKMAN COMPENSATION DECLARATION
❑l hereby affirm that I have a certificate of consent to mINnsure, or a
certileste of Workers' Compensation lneuance ora certified copy thereof (Sec.
3800, Lab C.) p
PoliryX (�C 6O�al �T ��.Z .�
FDCIURE4S PFR TRAP
SCHOOL TAX Y N
RECEPT M
GAS F.A. SYSTEM -1 INCAOUTLEI'S
PARK FEE - Y_ N_
•' RECEE'[ p.-
S -O
GAEA. SYSTEM -OVER 4 (EA)
Com env _aQ
BUILDING DIVISION FEES
Certified copIs Is filed withh tthhherebyte city
Certified copy dty e Inspection division.
�ty
CREASE/INDUSIRL WASTE INTERCEPTOR
PLANCHECKFEE
GREASE TRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
PAID
SEWER -SANITARY -STORM EA. 20017'.
COMPENSATION INSURANCE
Rhisection need not be completed lithe permit b (Drone hundred dollars
Date Recei tN
WATER HEATER W/VENT/ELECTR
ENERGYFEE Y N
PAID
Date Recei til
($100)rtifyt.)
the person in ny mannhe er sou wto cern permitisblued,
Ill not employ
I shall not employ any person to any manner co ate to become subfed to the
s'Compensatian laws o(GB(ornh. Date
Applicant
NOTICE co APPLICANT: after making this ationkate of Fiem that 1, you
should becomeforth to the Workers' Doh a Lab or
WATER SYSTEM/TREATII4G -
NEW RESIDENTIAL PLMB.SQFF.
TOTAL:
dCode,eem you must forthwith comply with such provhloru orthb permit shall be
such provisions p
deemed revoked.
BUILDING FEE
SEISMIC FEE
coxsrgucnoN LENDING AcetvcY
I hereby affirm that there is. construction lending agency for the perform-
ance of the work forwhich this permit Is Issued (Sec. 3097, Cie. Cd -
TOTAL:
ELECTRIC FEE
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
Lender's Name -�-
Lander'a Address
I coAdythatI have readthhappBationand statethatthe abovelnformatlon
Incorrect. l agreeto comply with all city and county ordinances and elate laws
MECHANICAL FEE
-
PERMIT ISSUANCE
FEES PAID:
relatingtobuliding construdlon, and hereley authorize representatives of this
city to enter upon the above-mentioned property for Inspection purposes.
(We) agree to save, Indemnify an d keep harmless the City of Cu perino
against bablBtim,judgments, coetsand expenses which may In anyway accrue
against said City In consequence of the granting of this parsnip
-L 7 l
ALTERORADOTOMECH.
Date Recei tN
P
AIR HANDLING UNIT fro Tome cpm)
SUBTOTAL;
AIR HANDLING UMT(OVER 10,000CFM)
CONSTRUCTION TAX
ignature of Applicant/Contractor Date
EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT CTO 100,000 BTU)
Will the apphant or future building occupant store or handle hazardou4
material as defined by the Cupertino Municipal Code, Chapter 9.12, and the
Health and Safety Code Section 25532(x)?
❑ Ves cup+-[,� No
Wiiltheapplicat oFTuture building Occupant use equipment or devices
-Date Recel r'!1
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
VENTILATION FAN (SINGLE RESID)
ISSUANCE DATE .
which eMt hazardous air contaminants as defined by the Bay Area Air
Quality Management District?
❑ yea ®®No
I have read the hazaWouymaterials requirements under Chapter 6,95 of
. the California Health &Saf Code, Sections 25505,25533 and 25534. 1
understand that if the building does not currently have a tenant, that it Is my
�GEfR�
. ti
•� u. p:i99Q
BORER -COMP pFN OR 100,000 BTU)
.BORER-COMP(OV)R 100,000 BTU)
NEW RESIDENTIAL MECH. 'SQ.FT.
res notify the or of the requirerrents which moat he met
orlossuan ofa Grtif Occupancy
Ck of COIROW _
P"SUED BY:Z3IrYY LW
Owner mored agent - Dam
TOTAL: ^f
OFFICE COPY