23571APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project identification
Building Address:
PERMIT NO.
038 old . Ave -
23571.
hers ;me: ^ one:
(n Q s in, 4 A. 2St 0)Q Y-
S
CITY OF CUPERTINOBUILDING DIVISION
APPLICATION / PERMIT
BUILDINGELECTRICALPLUMBING.MECHANICAL
_ A
n
Contractors Name: LiciT
`T'o $ L'. a b a g l g 8
CATEGORY CONTROL N
Architect/Engineer. Lk. No:
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Address
r�d ❑
❑ ❑
PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION
Thereby
hereectio 70 that ofDlvi licensedunderBudrestaonaof Chapter9xe,and
(ngwe 7001ga(Divis(on3aftheBudneeeand ProlnslonsCode, andm
APPLIANCES -RESIDENTIAL
JOB DFSCRII'CTON
�R(�PT
1Section
License Class S( LIc N Y K 19 ti (^—
Li en s le In s for�e and c. 0
PANELS
u'
I
P � `wry — ,f..r.7(" T L:
DateUP
O_rl_7_QlARCHI actor�C m..'j r
ARCHI TECTS DECLARATION
I understand my ptahall?gaed logo pp Rc Ebcprde.
Ilrr
TO 2DO AMPS
OVE IOAMI'S
OVER 1000 AMPS
.ET�.�iEA - .
5/SQ. Ff.
SIGNSELFGTRICAI,
1l C.Va'vs^t
Licen ealo I
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
following reawn.(Section 7015, Business and Professions Code: Any city or
countywhich requires a permittomMrvid, alter, improve, de=lbh, orrepalr
�� ,�v
SPECIAL CIRCUIT/M15C
P.METER OR POLE INS?.
anystmmmpr rtolbl ame,alsomqul theapphmnt(orsuchper tto
file a signed statement that he isroisi
licensed pursuant to the pvons of the
POWER DEVICES
SWIMMING IDOL ELECTRIC
OUTLETSSWITCHESFTXTURES
Contractor'sLicense Law (Chapter 9(mmmencing with Section 700) of Divi-
sloes 3 of the Business and Profeadma Code) orthat he is exempt therefrom and
the basil for the alleged exemption. Any violation of Section 701.5 by any
applicant fora permit subjects the applicanito a civil penalty of net =mtMn
VALUATION
NEWRESIDENTIALELECIR SQFT.
Ove hundred dollars(SM.
❑ I, ae owner of the property, or my employees with wages as their role
STORIES
TYPE CONS[RIKTfON
compensation, will do the work and the structure is not intended or offered for
sale (Sec. 7044, Roams . and Profession Code: The Contractors License Law
does'not apply to an owner of property who Wilds or Improves therms, and
who does such work himself or through his own employees, provided that such
OCC.GRCUP
RES. AMTS
Improvements are not Intended oro(fered forsale. If, lu wever,the W ildiogor
TOTAL:
impmvementbsdd withlnomyeare(mmpletfon,theowner-W Ilderwill have
t"rden of proving that he did net Wild or Improve for purpose ofsakJ.
u L as owner of the property, am exclusively contracting with licensed
contractors m construct the project (Sce. 704, Busmessami Pro(esedo s Code:
QTY, PLUMBING PERMIT FEE
FLOOD TONE
APN
PERMIT ISSUANCE
The Contractors License Law don not apply to an owner of property who
builds or Improves thereon, and who contracts for such pco)ects with a
yB((attor(s)Bceneed pursuant to the Contractors License Law.
I am exempt under Sec maven
B 4 P C for this
ALTER -DRAIN &VENT- WATER
FEE SUMMARY
BACK FLOW PROTECT. DEVICELI
OUTSIDE FEES
DRAIN& FLOOR, ROOF, AREA, COND.
SANITARY Y N_
RFLFR'f N
Owner Date
WORK MAN COMPENSATION DECLARATION
❑I hertby affirm that 1 have a certificate of consent m self -insure, n a
artifiate o(Worken Compensation insurance ora certified copy thereof(Sec.
380, Lab C.)
�.�S PER TRAP �—
SCHOOL TAX Y_ N_
RECEIPT N
GAS RA. SYSTEM -I INC4 OUTLETS
PARK FEE Y N
RECEIPTNN
Ceimppolicy N
GAS EA. SYSCEM-OA) VER d (E
BUILDING DIVISION FEES
19any
Certlfied copy b hereby furnished.
❑ Certified mpy b filed with the city Inspection division.
CREASE/INDUSIRL WASTE INTERCEPTOR
PI.ANCHECK FEE
GREASE TRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
PAID
COMPENSATION INSURANCE
frhis stolon need not becamplend lithe permit ts forone hundred dollars
Date Recej t#
SEWER -SANITARY -STORM EA. MFT.
WATER HEATER W/VENT/m er.1.R
ENERGY FEE Y N
(5100orlese.)
I cem
rtBythat in the perfownce of the work forwhich this peen is Issued,
WATER SYSTEM/TREATING
I shall not employ any person in any manner m as to become subject to the
WorkersCompensation Lawsof Call(omla. Date
PAID
NH
NOTICE
OIICE TO APPLICANT: , after making this Certificate of Exemption, you
should become subject to the Workers' Compesuatlon provisions of the Labor
NEW RESIDENTIAL PLMB. SQ.FT.
Date Recel t#
-
TOTAL:
BU ILDING FEE
Code, you =at forthwith comply with such provisions or this permit shall be
deemed revolud.
SEISMIC FEE '
CONSTRUCTION LENDING AGENCY
I hereby affirmthat there is a mistruction lending agency for the perform-
ance of the work for which this permit Is Issued (Sec. 3097, Civ. C.)
lenders Name
Landers Address
I certify that I have mad this application and state that the above information
Is correct.I agree to comply with all city and county ordinances and state laws
- TO
ELECTRIC FEE
PLUMBING FEE
QTY. MECHANICAL PERMIT FEE
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID:
relating fobulldlng construction, and hereby authorize representative. 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 Oupertma
against liabilities, judgments, mesa and expenses which may In any Myacaue
ALTERORADDTOMEICH.
Date Receipt#
AIR HANDLING UNIT (TO 1(,000 CFM)
SUBTOTAL:
against said City In consequence of the granting of #I. Permit.
p - ',�/27/�
AIR HANDLING UNIT (OVERlB,000crh()
CONSTRUCTION TAX
M. CXR
Sig of pliant/Contractor A `—Dam—
IXtW(1ST HOOD(W/DLK:T)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSUR E
HEATING UNIT (TO 10,000 BTU)
Date Re0e1 t#
Will the applicant or future building omtrpant atom or ha rad to hazardous
mstcrial as dented by the Cupertino Municipal Code, Chapter 9.1; and the
Health and Safety Code Section 25532(.)?
I—I Yn. M No
HEATING UNIT (OVER 10,00 BTU)
IOTA
I
VENTILATION PAN (SINGLE RF5ID)
ISSUANCE DATE
111 the applicant or future building occupant use equipment ordevires
which cont hazardous air contaminants as defined by the Bay Area Air
Q�jalfty Management District?
BOILER -COMP (3HP OR 10,0(10 BTU)
Yea j❑ No
have read the haz.9.us materials requirements under Cha pter 6.95 of
PAID
BOILER -COMP (OVER 100,000 BTT)
the California Health h Safety Code, Sectlors 25505, 25533 and 25534. I
understand that if the building don not currently have a tenant, that It is my
NEWRESIDENTIALMECH. SQ.FT
rnporsibll(ty to notify the occupant of the requlmmets which moat be react
prior to Issuance of a Certificate of Occ upahcy.
APR 27 19 9*
ol
TSS(IEIYBY Jt' x - XV
Owneroraulhmurd agent Date
TOTAL:
OFFICE COPY