24219 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Hui ldln to ect Identification PERMIT NO24219
/�
Building Address:
2)r � t V �. (sl 4 Z 1 9
as�o n,�
hero a / one: AlIPLICA 11 JN SUBMITTAL
FCD T� N4 CITY OF CUPERTIN&BUILDING DIVISION 0
centra eraN ro: Lie. APPLICATION /PERMIT '
,2 qeBUILDINGELECTRICAL1PLUMBINGMECI fAMCAL CATEGORY CONTROL 11
A Its Engineers • y
y: QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Add PEthITISSUANCE ❑ ❑
LICENSEDC A OR'SDECLkRA ON
Thereby affirm lMtiam Bcensed underprovldonsoI apter9(mmmmc AI'PLIANCESRFSIDENTUL ]OB DESCRIPTION
ingwith Sedion70M)of Division3o(the Businsssand Pm&sslonsCode,and m
license is m(u rce and effect. PANES 6t`k V'R'LJ
Llcen��Lk.N a -
Dale ContraUP TO 200 ANTS
ARCHITE DEC ATI N 701-IOOOAMPS
q�q�uu otZp lundemtanderypta..hal uxd aa- Be de. OVERIODOAMPS SQ.FT.FLOOR AREA $/SQ.Fr.
O
E d Licensed Professional SIGNS ELECTRICAL
<�6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC
Ihereby a(Brmthat I am exemptfromthe Contractor's License law for the
following resmn.(Section 70'31.5,Business and Professions Code:Any city or
O TEMP.METER OR POLE INST.
KE countywhkh icqulrsapermittoromtroct,alley Impress,demolish,or repair
aAy structure prior to its Issuance,also requires the applicant for such permit to POWER DEVICES
O ilk a signed statement that he ts licensed pursuant to the provblons of the
Contactor.License Law(Chapter 9(commencing with Section 7000)of Dwi-
3 mm3 of the Busineasand ProfessionsCode)orthat he 6 exempt there(romand SWIMMING POOL ELECFRIC VALUATION
< the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLEISSWITCHESFIXTURES
applicant fora permit subjects the applicant I..civil penalty of not mare than
five hundred dollam($SM. NEW RESIDENTIAL ELECTR
�n
F1 1,as owner of the property,or my employees with wages an their sols SQ'FT. STORIES TYPE CONSTRUCTION
compensation,wRldothe work and thestructure is nut Intended or offered for
OstIn Ike.70K BuaNesaand Professions Code:The Contractors License Law
$ does notapply to an owner of property who Wilda or improves thereon,and OCC.CROUP RFS.UNITS
whodoes suchworkhlmaeBorthrough hieownemployess,provided that such
improvements are net intended or offered for ale.If,however,thebuilding or TOTAL:
impmvement b sold within omrarofcompl&ion,the ewner-bullderwill Mve
tburden of proving that he did nm Wild or improve for purpose of Is.). QTY, PLUMBING PERMIT FEE
FLOOD ZONE APN
L as owner of the property,am exclusively Business
and
with licensedcenPERMIT ISSUANCE
The Co ora to es Liven the project(Sec,appy Business and of property
Code:
The Coor Impre License law does net apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
builds or Improves Hereon,and who contracts for such pSe)ects with a FEE SUMMARY
�gnt�actmor exena,mpt pursuant tot eC tractor's B A,,Law. BACK FLOW PROTECT.DEVICE
LJ 1 am exempt under � B &P C for this mason
Owner �/ Date DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y N
RECEIPT N
WORKMANIhCOMPENSATION DECLARATION FDCTURES-PER TRAP SCI{OOLTAX Y- N
❑1 hereby aBlrm that I have o cemOme of consent to op thereof
era RECEIPT M
certificate of WorkersCompensatlonlwurancemaanlFled copy thennf tgec. GAS F.A.SYSTEM-1 INC.10UTLETS PARK FEE Y N
7NW,lab C.},,/1 1l RECEIPT M
I'ollay.Y_V4l GAS EA.SYSTEM-OVER 6(EA)
Com anv/_ppE `y/ � r fBUILDING DIVISION FEES
Fffc.McdmpyN reby/u Ied. GREASE/WDUSIRL WASTE INTFRCE'TOR PLANCHECK FEE
❑CertUed copy Is filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GRFASETRAP PAID
o4 beomCOMPENSATION
INSURANCE
(Thtsaectlon need nes completed the permit V(Drone hundred dollam SEWER-SAMTARY-SIORM EA.IDOFf. Date Receipt#
($100)or tem.) WATER HEATER W/vPN7ym crT.R ENERGYFEE Y N
I certify that in the pedorm omof the work lorwhich this Penner 1.loved,
I ehail not employ any person In any manner n as to become object to the WATER SYSTEM/TREATING
Workers'Compensation Law o forma. Date PAID
O Z Applicant NEWRESIDFNI7ALPLMB. SQ.Fr. Date ReCel t#
Z Q NOTICE TOAPPLICA R dngthls Ceniflateof Exemption,you
should became aubjed m the t lar mis'Compensation provBions of the Labor TOTAL:
M N Code,you must forthwith comply with such provbiom orthb permit shall be
�j deemre
ed voked.
BUILDING FEE
W CONSTRUCTION LENDING AGENCY R SEISMIC FEE
a 'I herebya(0rm thattherebaconstmctlon kndlngagenryfortheperform TOTAL-. ELECTRIC FEE
M Z soon.(the work!or which this permit is Issued(Sec.3097,CN.C3
U O Lender.Name_ i a9 PLUMBING FEE s�
F Lender'.Addreaa QTY. MECHANICAL PERMIT FEE
LL MECHANICAL FEE
OW Ianlfythatlheve d a atlonand matethat<heabove Infornutlon
1 Iscorren,lagreetocomply, Ith alldtyand muntyordInanmeand tlate laws PERMUISSUANCE FEES PAID:
relating to building construction,and hereby authorize representatives of thin
N city to enter upon the above-mentionsd property for impection purposes. ALTERORADDTOMECH.
? (We)agree to save,Indemnify an d keep harmless the City of CL ped loo Date ReCel t#
V against ltabWtks,Judgments,miss and expenses which may In anyway accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL'
against mid City In consequence of the granting of this pemdL AIR HANDLING UNIT(OVER IQODOCFM) CONSTRUCTION TAX
Signature of Applicant/Contractor Date EXHAUST IIOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will theappliant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date ReCel t#
material as defined by the pertino Municipal Code,Chapter 9.12,and the
licalth and Safctycl a Ion 2S532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL: yo
❑Yrs o
W(Iltheappllant or E' building occupant use equipment or devices VENTILATION PAN(SINGLE RESID) ISSUANCE DATE
which cost MardoXN,
taminsmsm defined by los Bay Area Air 3� p
Qiality Managenis7 BOILER-COMPOHPOR100,000BTU) Ir 4Y. r
4 Yes have read thebmaterialsrcquircmentsunderChapter6.95of BOILER-COMP(OVIR 100,000 BTU)the California tiealt Code,Sections 25505,25533 and 25S34.1 "OCTIN900.p
understand that if the building does not currently have a tenant,that It a my NEW RESIDENTIAL MECH. SQ.Fr
msponsf Wty to notify the occupant of the requirements which must he met
Judo uanceofa CertlO to Occupancy. !� ) CITY v
ner or au a en Date ISSUED BY:
TOTAL:
OFFICE COPY