23404 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project Identification - PERMIT NO.
BI iOdm �darem 0� Coo \ 23404
ser• ams: ane:
CITY OPPLIC TTION I DINGPER DIVISION
Con ctor'e ossa: Lie,Na APPLICATION 1 PERMIT
^ BUILDINGELECTRICALPLUMBINGMECHAMCAL CATEGORY C /a
h A hitect/ neer, Lk.No: 6
I QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address I
PERMITISBUANCE
LICENSED coNTEunder SDECLARATION
Ihereby 4K, that lamB.3ofhe BuerwLslonsof-h-I' erode, aene APPLIANCFSRESIDENML JOB DESCRIPTION
inersel llf Ica
afelon3oflheguelnemand Pro(eulonaCode,and my
license n(uB(o anaaffect'
-�,- �� PANELS
LI C^m Llc tl
ate CITFEECr 201IOODAMPS
ARCHITECTS DECL blit or
M;11 ]understand my plane shag be used upubLLc records. OVER 1000 AMT'S SQ.FT:FLOOR AREA f/SQ.FT.
E Licensed Professional SIGNS ELECTRICAL
<6 OWNER-BUILDER DECLARATION
{Jn SPECIAL CIRCUIT/MISC
po, I hereby affirm that l am exempt from the Contractor's License Law for the
02 following reason.(Section 7031 S,Businessand Professions Code:Any cityor 'CEMP.MET[ROR POLE RV57.
F� county which requires a permit to cor ,fal
utructer,improve,demolish,or repair
qY < any stroctum prior to its Issuance,also requires the applicant for such permit to POWER DEVICES
ti a0 U file a signed statement that he is licensed pursuant to the provisions of the
Q6 Contractor's License Law(Chapter 9(mmmencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC VALUATION _\
Mon3o(theBusnees dProfemWmCode)orthathebexemp"herefmmand OC7
6 5 the basis for the alleged jectsthe p Any violation of Secnatty o net m re any OUTLET-SWLTCHESFIXTURES Ig �vO
fiveapplicantdred aperndtaubjcctsthc applicant taadvll penalty of net more than L s
flue I,as o nerdolof the pr. NEW RESIDENTIAL RL CM SQ.Fr. STORIES TYPE CONSTRUCTION
❑I,as owner will
the property,or my employees with wages as there sok
C G
compensation,Business and rendthes Code:The
Contractorot Intended or License
/
q� d for
❑ sale(Sec.7064,Business and Professions Code:The Contractor's License Law
Pj $ does not apply to an owner of property who builds or improves thereon,and I i.
who does suchwork himself orthugh his own employees,provided that such n C.Q RES UNITS
m
improvementeamno tendMorofferedfmule.If,howevegthebulldingor T ? 1 I1� �j
Improvement isseld wlthinoneyearofcompletion,theowner-bullderwE)have yy,, '�✓ tl
t rden of proving that he did not build or Improve for purpose of sale.). QTY, PLUMBING PERMIT I1 IJ ZD
�L -qP
as owner of the property,am exclusively contracting with licensed - PERMIT ISSUANCE
contractor,to coretrod the project(Sm 70H,Business and Prdessiom Code: ATE
The Contractor's License Law does not apply to an owner of property who
builds or Improves thereon,and who contracts for such projects with a ALTER-DRAIN&VENT-WATER
olia.dor(s)I carted pursuant to the Contractor's License Law. FEE SUMMARY
L j I am exempt under Sec B&P C for this reason BACK FLAW PROTECT.DEVICE
Owner Date DRAINS FLOOR ROOF,AREA,COND. SANITARY - Y_ N_
RECEIPT tl
WORKMAN COMPENSATION.DECLARATION FIXTURES PER TRAP SCITOOL TAX Y_ N_
❑L hereby affirm that I have•motlflests of consent to selMosurs,or a RECE PT tl
certNcate ofWorkeri ComperuaHanlmuranceoracertBbd copythemeof Gae. GAS EA SYSTEM-1 INCA OUTLETS PARK FEE Y N
Policy
olk lois C.I RECEFf A
C -
BC- _ GAS EA.SYSTEM-OVER4(EA)
om ray BUILDING DIVISION FEES
-
Certlfiearopylshereby furnished. GREASE/INDUSCRL WASTE INTERCEPTOR PLANCHECK FEE
❑Certified copy is filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAII��_-t � �O
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.7AOFI'. Date ecei t#
(Thlsseedon need rad be completed If the permit Y fororu hundred dollen
(f10o)orless.) WATER HEATER W/VENT/Fr erTR ENERGY FEE Y
I certifythat In the perf...m of the work forwhich this permit Is issued,
1 shag rad employ any person In any manner n as to become subject to the WATER SYSTEM/TREATING
Workera'Compenaatlon Lawsof Callfamla.Date PAID
O Z Applicant NEW RESIDENTIAL PLMB. SQFr. Date Rece1 t#
Z 0 NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you
Fshould become.ubjed to the Workers'Compewtbn provisions of the Labor TOTAL:
cc (� Code,yournustforthwithcomplywlthuchpmvlelomorthlepermltehallbe BUILDING FEE
�•
LU > deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE ei LL
- Ihereby ale hat there b a construction lending agency forthe perform T L ELECTRIC FEE
3 Z an of the workfor which this permit is Issued(Sec.3097,Civ.CJ ELECTRIC FEE
V 2 Landers Name
F Lendcr.Addresa - QTY. MECHANICAL PERMIT FEE
LLt-
Imrtifythat l haveread thbappllcation and Yatcthatthe above information MECHANICAL FEE A�
O W bcorrect.l agree to comply with all city and county ordinances and Yate laws PERMITISSUANCE FEES PAID:
>. IL relating to building construction,and hereby authorize representatives of this
F N city to enter upon the above-mentioned property for inspection purposTR
es. ALTORADDTOMECH.
? agm to save,Inde-atly an d keep hamdem the City of Cu pert lw Date Reeel t#
U o set llab111Hes,Ndgmente,cosmand expenses which may In anywayaccrue AIR HANDLING UNIT 10,000(FM) SUBTOTAL:
gal"�1 id City In consequence of the granting of this permit.
1lastat � ' IA", '5':--j2-q2_ AIR HANDLINCUNIT(OVER IO,000CFM) CONSTRUCTION TAX
Slgmture of Applic t/Contractor Data EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will theapplicant or futum building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date Reaef 0
material as defined by the Cupertino Municipal Code,Chapter 9.1 7,and the
Health and Safety Codera�Section 25537037 HEATING UMT(OVER 100,003 BTIJ) TO A .
11��I Yn l�I No
�Villthezpplicantor(uture building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air costa mtunts as defined by the Bay Area Air
Quality Management District? BOILER-COMP OHP OR 10B000 BP9 TL1) P p 1
Yas ❑No
410
hazammsa tedabmquimwntsunderCbapter6.95o( BOILER-COMP(OVER IW,000BTU)
the California Health&SafetyCode,Sections 75505,25533 and 75534.1 MAY 12 1992
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT.
responsibility to notify the occupant of the requirements which at be met
prior to Issuance of a Certificate of Occupancy.
CI ser CUPtnIIIw�
/Tuner or authorised agent Data ISSUED BY:
T
OFFICE COPY