20956APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Pro as Identification �. O^ l C
Bvllcilag Address:
231; GQ iS�3 D L) L_
PERFffN
TO,
20956
ON me
CITY OF CUPERTINOBUILDING DIVISION
APPLICATION / PERMIT
BLTLDINGELECTRICAL PLUMBIMFLF{ANICAL
3 1 0
c i v eName: �./Jy� cnIIJc o:
" — "
CATEGORY
CONTROL Y
Ardlle t/Englr�eer. Lle. No:
QTY,. ELECTRI PE ;Fg;
BUILDING PERMITANFO
Add. .
PEFMTISSLikN L-�6
❑ ® ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
Ihereby affirm that l am lkmeed under prwlalone al Chapter 9 (oorennem,
#t �SccKn7d0()af plvly3ofthe Bu Cade, and
bore. �Lk
Date Cortractor
ARCHITECTSDECI.ARAT N-AVIn
I understand my plant,h.11 be used u public rtcrrd.
Llecnsed Profembnal
OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt froura the Contractor', Lim. Law for the
following reason. Se.Y1m 70715, Busln®aM Pmlesbv Code: My city o
countywhich requlraapemd[[omrelruct, alien improve, demall.h. orrt-EIN��
any strudute prier to its issuance,. bo requires the appBantfce ouch pe
file a signed statement that k is licensed pursuant to tha prod.lov of
Contractor'. Lkense Law (Chapter 9(mmmencing w,don 3 ofthe Bu.sinms and Prefewbrm Code) orthat hebesempHherdram
the bawls far the alleged exemption. My violation of Sedbn 70715 by any
.pph.tforapermitub*e theapplk.ntto.dullpeskycfnatoursthan
By undrrel dollars 5500). -
6—of
1, a. owner of the property, or my employees with wages u their sole
comPeruatlon, will dothe work and the structure L rot irdeMeei or offered for
sale( See 70K Bushes and Pr f.ion. Code: The Cormad.e. Ilttrae Law
does not apply to an owner of property who bull" or improves thereon, and
who doea.uch work hlmxlf or through hie own employees, provided that arch
Improvemesarerwtlntendedorofferedfmsale. If,however,thebuildingor
Impmwa me a Ml thinomyearofe« pletbn,thewvner-bullde lhave
tlKkurdenofprovingth hed[d tie Udorimpmvefwpurpaseof.sale.).
LI 4 a. owner of the property, .m e.lualvely mntractlng wph Iken.ed
o�ntndontomrelrud the profed (See 7074, Bwinea.aM Prdeabv Code:
The Contrador'. Lkeruie Law does no apply to an owner of property who
Wilda or Improves thereon, and who mrdnda far such PV uota with •
aador(.)Barued wrna.nt to theemtrador'. Gasue Law.
LJ I am exempt under Sec B 6 P C for this reason
APPLIAN L
]OB DESCRR'I7pN
PANELS
-
O /
A
SQ" FT. FLOOR REA
(gyp\
\ h
$/9Q. FL.
s GA
CFS
TOOT. C
VALUATION
,
-
.�SWIICI�S ES
�
TR SQFE
STORIES
TYPE ODNSIROC[ION
_
- TOTAL
QTY, LUMBING PERMIT FEE `
--
PFRMFFISSUANCE
ALTER -DRAIN 6 VENT -WATER (EA)
OCC. CROUP
AES.UNI'IS
FTppDZONE
ApNr
-
FEESUMMARY -
BACK FLAW PROTECT. DEVICE
DRAINS FLOOR, ROOF, AREA, CON).
PERTRAP.TRAP
N_
SANITARY Y_ RICETTe
Owner .- Date
WORK)ANCOMPENSATION DECLARATION
I hereby affirm that that I have a rertff et e of cmr, m
❑nt to self.Ire, or a
mrdffcate of Workes CompevaHm Erearance or. oenllled ropy thereof 6=.
3800, Lab C.)
Polley .
SCIi00l TAX Y_ N_
RECEIPT Y
GAS EA. SYSIPM-I INC40
RK FEE Y_ N_
B L DI BION FT.ES
Ca
Co ny
GASFA.SY51T2.I-0VER4(FA)
IZVL
CenNed mpybhereby /urnL+hed.
TMJ Certuled copy b filed with the city ivpee ion divi lane
CERTIFICATE OF EXEMPTION FROM WORK FAS'
COMPENSATION INSURANCE(EeasacUon nee. nd be cmnpldea Btk pemdt �f«o�hanared donara
(slm)rele.�.)
I cerHly that In the performance of the work for which this Fronds V iaued,
I shah nor employ any persm in any manner ro as to brooms wb)ed to the
WOrkm
eef Copensatbn laws of Callfornh. Date
ApplirabUTICnt
should TO ,subjetto H, after makingtea Coon poria EaempteLyou
Code, become urth tothe Workers' Comperoviala provbbrrofthelabor
Cade, You selorthwkh comply with such prvvdmro or this permit elull be
deemed revoked.
CONSTRUCTION LENDING AGENCY
Iberebyalirm Nattkrtls. mvtructlon knding.gemy fartk perform
an. of the work for whkh this perrNt N lined IS, 3097, CW. C)
Lender's Name
Lender.Add.
I certify thatl have read this appBcatbnaM rtatethat them
above Inforation
Is correct. I agreeto comply, with all dty and munty, ordlnanm and late lows
relating to building mvirudioo, aM hereby authemn, repersentatives of this
city, to enter upon the above-mentbvd property for Inspection purpeae..
(We) agree to save, IMentrfy an a keep harrNess the City of Cu pertain
aga WtOab ,j rdgrrrnta,mrt.a! a wh"eraytranyw.y.mus
:8. try in ren of tingdthh pemdt.
/f C
GREASE/PIWSIRL WASTE A
UP
Recei t#
1—
FFNERG�YFEE N —
PAID
Date Recei t#
GREASE TRAP,
sEwFR'sANrrARY-sroTiM
WATQtI-�wTeRw/vEarr/EI.Ectn
WATER SYSIII.1/TREATING
NEW RESIDENTIAL PLMB. SQFL
TOTAL:
-
BU
SEISMIC EEE
' TOTAL:
ELECTRIC FEE
QTY. MECFLANICAL PERMIT FEE
PLUMBING FEE
MECHANICAL FEE
PERMIT ISSUANCE
ALTFRORADDTOM H.
FEES PAID:
Date ReceJ t#
AIRHAN)LINGUMf(COt0,000CFM) -
-
SUBTOTAL
'AIR HANDLING UMf(OVFR 10," CFM)
CONSTRUCI70N TAX '
dor Date
SfrummofAppuFfEwm
S MATER] sDISCLOSURe
WWtheapplloorbulldNg omrp.nt store or handle haurelous"
mrterlal as deErud by the Cupertlno Munidpal Cade, Chapter 9.17, and the
Heahh.MSafetyC a mon 75537(.)?.
❑ Yes
WBltheapp"n't or tore hulldingoccupantuseequlprrcntordevims
which eMt hanonert tandrunts ee deRned by the Bay Area Ab
Fu I yhLrugamant Distdd?
4 Yen
have mad the us node, rea.255entsunder Chapter 534.15 of
the Glifomla Health SafetyCMe, Sectlov 5505, 25533 and 75534.]
und=rAthatlfth bulldingdoo ntlyhaveat...ot that it i.
re.povibllu' nd By the.p. th requlramentawhlch mu
prior nmofa Ce to "nY.
IXHAUSTHOOD(W/DUCT)
CONSTRUCTION TAX PAID:
Date Revel t#
HEATING UMT CM 100,(00 BTTl)
-
HEATING UMT(OVER 100,000 BTU)
'TOTAL: S
VENTILATION FAN( SINGLE RESID)
ISSUysey�-IyDATE
— /1(�
a+
x1990 '
��sal
ISSUED BY. �lA—a
�F—
BOILER{OMP DEN DR IW,II(9 BTU)
BOILFRCTJMP(OVER 100,D006'N)
NEWRESIDENTIALMECH, SQFT.
er or uth 11
TOTAL:
V . OFFICE COPY