22936APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Pmiset Identification-
Budding Address:
29
�2� G�
PERMITNO.
22936
m ares: one:APPLICAI
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION 1 PERMIT
BUILDINGILKTRICAI PLUMBING -MECHANICAL
'
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^,^. Lk.No,
DOHe�a 4 G]a LSTesaC% . a 0`P 4~C
CATEGORY
CONTROLS
Arc tvct/ . No:
L
IF
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
l FMMITISSUANCE
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Add.
LICENSED CONTRACTOR'S DECLARATION
]hereby afflrrethat l am Bcenwd under provbionso(Chapter9(commenc
Imensei in fun 2000) of Dlvfiset. flhe BuslnessandlkofntloneCode,and my
Ilwnae le In full f and A(ect. �8 /
APPLIANCE9-RESIDENITAL
JOB DFSCRII'f"N
PANELS
Lkenx lam4 Lk. Y .F] •-
Date / � / ContredarUP
TO 2DOAhTS
201-IODO AMPS
ARCHITECT EC
I and a rel'Ptah. shill be
OVER IM AMPS
SQ. FF. FLOOR ARE
8/SQ. FT.
ELECTRICAL
Lken ssiorulSIGNS
' SOD
0W- IALCIRCU1T/MI9C
ODECL1T,ON
WNER-B LDER
I hercbya(Nm that I am exempt fromthe Contractor's Llcenae Law fm the
TEMP. MEPER ORPOLE INST.
following reason. (Seelon 7011.5, Business and Professons Code: Any dtyor
oaantywhich mquim a permlt to comtmd, alteq Improve, demolish, or repalr
anystm=mpdormibiswame,alsomqulmtheappgcantforsuchpermltto
Al. a signed statement that he is licensed pursuant to the provbio® of the
]'OWER DEVICES
-
SWIMMING POOL ELECTRIC
EISSW[TCFIFSFIX'FIIREB
Commences License Law (Chapter 9(mmnpndng with Section 7000) of DIW-
sbn3 of the Buslnessand Pm essbv Code) orthal he is exempt therefromad
the basis for the alleged exemption. Any violation of Section 7071.5 by art
applicant for a permit subjects theapplkant los civil penalty of not reethan
VALUATION
1 -
I �O
five hundred della. ($.500.
n I, as owner of the property, or my employees with wages as their sole
NEW RESIDENTIAL ELFOTR SQ'FT'
STORIES
TYPE CONSTRUCTION
compensation, will do the work and the structure is not Intended or offered for
sale (Sr. 7044, Business and Professions Code: The Contractors License Law
don not apply to an owner of property who Wilds or Improves therms.and
who does such work himself orthrough hlsown employees, provided that such
OCC. GAOIIP
RFS. UNITS
Improvements are not Intended orofferd for sale. If, however, thebuilding or
Improvement bsold wlthirm ayearofcomplelWn, theowner-ImAderwill have
TO
'
the burden of proving that he did net build or improve for purpose of cab.).
LJ I, as owner of the pmperty, am exclusively contracting with licensed
contractors to conitmet the project (Sec. 7044, Business and Professions Code:
QTY. PLUMBING PERMIT FEE
MOOD ZONE
APN
PE4MITISSUANCE
The Contractor. License law don not apply to an owner d pmpeny who
Wilds or Improves thereon, and who contra for such p4ujects with a
my4ador(s) Rceneed pursuant to the Contractors License Law.
LJ I am exempt under Seo B & P C for this mown
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ALTER -DRAIN &VENTWATER (EA)
FEE SUMMARY
BACK FLOW PROTECT.
QUTSI IIF FEES
DRAINS. FLOOR ROOF, AREA, COND.
SANITARY Y N
RECEIPT 0
Owner Date
COMPENSATION DECLARATION
❑I hereby affirm that I have a certlReste of consent to set! -Inure, m a
ed-fiflot..fworkers'Compemati.l..r .mamrtifidmpythemof(Sec.
3800, Loh CJ
FDIfMWORKMAN
n p
m '1
10OLTAX Y N
RECEE'f a
G EA. S!'PM_]INC.40fI1L
d t�
pA FEE Y_ N_
RECEIPT
Policy#
Com any
G FA. Sa'F�.t,,;OVER4ffN�
BUILDING DIVISION FEES
CerllRed copy hereby fumishd.
CedlBd copy bflled with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
G E/INDU ASTE I
G 7RAP
P NCHECK F Ra /1 O 1'
` � Cte
PAID
COMPENSATION INSURANCE
(fhb section need not be completed If the permlt lafmom hundred dollars
IS 00)or Inas.)
I cemlythat N the performanceof the work forwhlch this permit Is Issued,
GEWER SAN(fARY STORM F.A.200FT
Recel t#
WATER IIFAIII2 W/VENT/F].ECTR
ENERGY FEE Y_ N_
WATER SYSIFAI/TREA7TNO
I shall net employ any person In any manner so n to become abject to the
Wmkda! Compensation Laws of California. Date
PAID
NEWRESIDENTIALPLMB. SQ.FT.
Applicant
Date Recei t#
NOTICE TO APPLICANT: E, after making this Certificate of Exemption, you
should become subject to the Workers' Compemat ion provblom of the Labor
—TOTAL:
Code, you must foe hwith comply with such provblon or this permit shall be
MILDIN
deenad revoked.
CONSTRUCTION LENDING AGENCY
I hercbyaorkfthatthere baromitis Bond Gee. agency 397, Civor the perform
once of the work for which this permit b Issued (Sec. 3097, Civ. CJ
Lender. Name
Lenders Address
I cenity thA I have read ehla application and parethat the above (n(ormaden
brorrcd.]egmlo<DmplywltF andtyand county odinP=.atnd stamlawa
TOTAL:
QTY. MECHANICAL PERMIT FEE
FEE
PERMIT ISSUANCE
relating to building commotion, and hereby authorlu repressntatvesof this city to enter upon the above-mentioned property for Wpection purposes.ALTER
agree to save, IndemNly ao d keep harmless the City of Cu portico
agahut Rabilltkro,Pcigmenta,m&sad axpan. which nay In any wayacnus
OR ADDTO MECH.R(We)
KEI
AIR HANDLING UNIT(TO 10,000 CF M)
TOTAL:
agalrut said Clty In mnagFenm the grantin tNe perm
A)R IiANDWNG IINfC (OVER IO,000CFM)
AX
Sigmlu Applicant/Comma r Dhte
EXHAU57ILOOD(W/DUCT)TAX
PAID:
HA]AROO S ATERIA DISCLOSUREWRI eppBcacatortutu Ilding pant store or handlehazadous
CYeI t#
4IFATING UMT(TO f00,000BN)
materbl as de0rud by the C rtlno Municipal Code, Chapter 9.12, and the
Healthand Safety Cd on 25532(a)7
❑ Yes o
Wlllthe applicant ortuturebullding occupant use equipment ordevlas
HEATING UNIT (OVER 100,000 BTIA
TO
VENTILATION FAN (SINGLE RESID)
pyo
IPUAI_gDATE
which dett haeadoua ab contaminants as defined by the Bay Area Nr
QuailtyMawgement d2
4Y. No
have mad the ous materials mquiremeres under Chapter 6.95 of
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j
IA OV 3 1991
BOILFR-COMP QHP OR 100,000 BTU)
BOILER -COMP (OVER 100,000 BTU)
the Califomb Health & Safety Code, Sedlom 25505, 25533 and 25534. I
understand that if the building don not currently have a tenant, that it is my
responsibility m ectify the occupant of the requirements which must be met
1,
E H�INtJ
Cary OF CUP -
NEW RESIDENTIAL MECH. SQd7
pemt.lssuanceM rtlRr o(Occvp t
/ ate
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ISSUEDBYY
Ower aulhmlard agent
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TOTA
V ✓ OFFICE COPY