20985APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification
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CITY OF CUPERTIN66UILDING DIVISION
APPLICATION / PERMIT
BUILDINGELECMCAGML BING-MF.CHAMCAL
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CATEGORY
CONTROL N�
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Archllect/En neer.• Lk. No:
(OAS
QTY ELECTRICPERMIT FEE
BUILDING PERMIT INFO
L����C
Addreae • • CAiat+\ ;o moi\ k'SO "*C 6.V
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PFRMIn$UaN(.$
LICENSED CONTRAcTOR'S DECLARATIO
Ihercbyaffbmthatlam Bcensed underprovbloneo(Chapwr9(ommmc-
Ingwlth Section 7DOO)of Dlvidon3ofthe Budnnsand Pmfe maCode, and my.
llanse,s In full force andeffect, l
LlcenseC ss' Lm.M F�sl
Date Contractor .��-r-rt+1'
APPLIANCES�RESIDEMfAL
JOB DESCRBTION
lT a
`—�����. ��
PANELS
201-ODO AMPS
ARCHITECT'S DECLARATION
Iundentandmypiay.hallbeue mpubhcmwrda
OVERIODDAMPS _\
SQ. FT. FLOOR AREA f/SQ. FT.
SIGNS ELECTRICAL
Licensed Professional
SPECIAL CUIT/M
OWNER -BUILDER DECLARATION
I hereby a(0rm that I am eiempl (romthe Contractors License law far the
TEMP. M RPQLE NST.
following reason. (Sedlon 70015, Business and Professions Cade: My city or
cvuntywhlch requ4esa pemdtwoomtmct, alter, Improve, demolbh,orrepair
anytructure prior to ltslssuana, also requiceslheappliant for such perrrdt to
his a signed statement that he is licensed pursuant to the provbfom of the
Contractor'sLicense Law(Chapter 9(comostrumg with Section 7000)of D1v1-
don 3 of the Business and Professlom Code) orthat he b exempt therefrom antl
the basis for the alleged exemption. My violation of Section 70315 by any
applicant fora permit subjects the applicant to civil penalty of not nare than
POWERD
SWIMMI ELVALUATION
UILETS
'(S
V (-J
WREST TR SQ
five hundred dolhrs ($5M.
I, as owner of the property, or my employees with wages as their sole
STOW
TYPO CONSTRUCTION
compe... tlon,willdothework, and thestructure is not Intended or offered for
sale (Sec. 7094, Business and Professkma Code: The Contractors License law
doe. nota pply to an owner of property who builds or Improves thereon, and
who does such work himself or through his own employees, provided that such
OCC.GROUP
RFS. UNITS
Improvements are not Intended oroffered forsals. If, however thebuilding or
TOTAL:
impmvemnntbsoldwithinoneycarofcomplOt ,thea. __ ullderwillhave
tll6 jardenofpmving that he did not build or improve for purpose o(saleJ.
U L as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7614, Business and Professlom Code:
QTY. PLUMBING PERMIT FEE
FLOODZONE
APN
PERMITISSUANCE
The Contractors License Law don not apply to an owner of property who
ur Improves thereon, and who mntracis for such pSojecb with •
mr04.0or(s) licensed pursuant to the Contnatola License Law.
LJ am exempt under Sec, 0 k P C for this reason
ALTER -DRAIN & VENT -WATER (EA)builds
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
DRAINS FLOOR ROOF, AREA, COND.
SANITARY Y_ N_
RECEI T N
Owner IDate
WORKMAN COMPENSATION DECLARATION
❑I hereby a(llrm that I have • certificate of consent to self -insure, ora
cartificateo(Workers'Compematlonlmukruvora certified mpythereof(Sec.
3900, Lab CJ
- S�S��I, EaS.
FIXTVREs PER TRAP
SCI IOOL TAX Y N_RECEIPT
GAS -EA. SYSTEM -1 INCA OUTLETS
PARK FEE Y N
RECEIPT M
Po11ryN
Cam tins �jaCS
❑ acti ed sopy�b hedwith to city
ertlfled copy Is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
CAS EA, SYST�M-OVERd(EA) r
BUILDING DIVISION FEES
GREASE/INDUSIRL WASTE INTERCEPTOR
PLANCHECK FEE
CC������ (tea
PAIDtea=r7bQ
��• D
GREASETRAP
COMPENSATION INSURANCE
RhbxRlon need not becompldedBthe permit Isfor one hundred dollars
SEWER-SANRARY-STORM EA.200FT.
Date Recei tq
WATER HEATER W/VENT/ELECTR
ENERGY FEE Y N
(f1M)celess.)
I certify that In the performance of the work for which IN. permit le Issued,
WATT R SYSTEM/TREATING
I shall not employ any person In any manner so an to become subject to the
Workeri Compensationlaws of California. Date
PAID
NEW RESIDENTIAL PLMB. SQ.FT.
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you
should become subject to the Workers' Compensation provisions of the Labor
Code, you moat forthwith comply with such provisions or thin permit shall be
Date Recei t#
TOTAL:
BUILDING��
OC
deemed revoked.
CONSTRUCTION LENDING AGENCY
I
SEISMIC FEE
—Z
TOTAL:
ELECTRIC FEE
Iherebylflrm that there bacomtrudion lendingagenry forthe perfomv
a.m of the work for which this permit la Issued &c.3097, CIv.C.)
Iandre.Name
LenaeraAthatI
ImrtifythatIhavereadfhisapplldty nandpatethattheabove In formation
Ismmciobuilding comply wllh aRcityandcountyiae repncesand daMaws
relyingnteru onteabovelon,andherebyatyorin reption pulvn of lFIs
d ( to Wenterupon the, indemnify keeperty(orlmpe Cit purposes.
(We)abuse to•ave,Iads, mks and keepharmiem the Clay ayaccrno
against lbbllltles.�dgments, mks and expenses which may In anywayacerue
PLUMBING FEE
Q7Y• MECHANICAL PERMIT FEE
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAI
�-
tits eO Iii
ALTER ORADD TO MFCH.
- AIR HANDLING 11MT UO1, CFM)
SUBTOTAL:
tinh 0.
agarutsad Gty n. ria ofthegrantmg ofmb permCnp . he)-�
AIR HANDLING uNlr (OVER P D,uoocFnT
CONSTRUCTION TAX
SignafAppllcanl/Contr-Data—
EXHAUST HOOD(W/DUC77
CONSTRUCTION TAX PAID:
HAZARDO ATERIALS DISCLOS RE
WIIl /he appBcant or future ilding occupant store or lwndle hazardou.
HEATING UNIT 100,000 BTU)
Date _ Recel tM
material as defined by the Cupertino Municipal Code, Chapter 9.12, and the
Health and Safety Cade Sedion2S532(a)7
❑ Yea :0 No
Will the applicant or future, bulldmg occupant use equipment or devices
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
aOO. Ia
VENTILATION PAN (SINGLE RESID)
TW"CE
TW"CE DATE
hkh emit harardoue air mntamimnb a. de(Imd by the Bay Area Air
alhy Management Dut 7
uL�� Yn 'Ie N10
(have read the barzrdou. materla3s requirements under Chapter 6.95 of
the California Health h Safety Code, Sections 25505, 25533 and 25539. !
understand that if the building does not currently have a tens fir that it is my
C❑
s GC' ,1990
"
Dp.ks�
BOILER -COMP 100,000 BTU)
BOILER-COMP(OVFR 100,000 BTI!)
NEW RESIDENTIAL ME CH. SQFr
responsibility to notify the occupant of the requirements which must be met
aa�Fa
jv 4,p, OPIUM
pr 'to nuance of aCediflcateofo'.k, nry.
v
ISSUED BW
er or authod ag t Data
TOTAL:
OFFICE COPY