23307 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Preis I Identification 7 - PERMIT NO.
Building Address: �E AAvzf1 !3L VD cuOG'R7 n/p CoA 4S�/4 2�^� O
♦ 1
M one: I^ A -.
Mr. came. CITY OF CUPERTINOBUILDING DIVISION , C
'� C9ntnctofs Name: _ L a: APPLICATION I PERMIT
BUILDINGFIECTRICALPLUMBINGM IMMCAL CATEGORY CONTROLN
Archlte t/En neer. Lk,No..'T, BUILDING PERMIT INFO
QTY ELECTRIC PERMIT FEE
Address: (jGlr D /)LMAy ' E PefA PFRMInssuANCE X rj; El
LIC ENS EDCONTRACTO WR
LiceI nhse lam atl licensed ro Chapter 9(mmmm
APPLIANCES-RESIDENTIAL JOB DESCRIPTION
IngwthSedion700pDIv3aftheBusinmdPmfeesonsCode,end my
licenseis InfoL(o effect. PANES
Lle.Ir y SSI a s ConI& its Q
Date tndor
ARCHITEC`9 DECLARATION 211-IODOAMPS
a0 Z I understand my plans shall be used n public records. OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
rO.
LlSIGNS ELECTRICAL r �`
Licensed Profea+lanal
< OWNER-BUILDER DECLARATION
1n FA SPECIAL CIRCUIT/MISC
pQ., Ihengcatuan that lam exempt from the Contractor.License Law for the
ZO2H (ogowing reason.(Section 7031.5,Business a nd Professions Code:Any city or TEMP.METIR OR POLE INST.
F,E cauntywhlchrequl aper Jttorommm.1ter,Impmve,demolbh,orrepalr
anystmu mpr tolGbwanceaborcqulreatheappBantforsuch permit to }OWER DEVICES
fit...igned stsmomm,that he b licensed pursuant to the pro barer of the
�Ona, Cont.me.Llcenaellw(Chapler9(commendngwith Sed"o 7000)of DIA- SWIMMING POOL ELECTRIC
Og uon3 of the Businneand ProfemlonsCode)orthat hebexempt therefromand VALUATION
< the basis for the alleged exemption. Any violation of Section 711IS by any OUTLETS—SWITCHES-FIXTURES
apphant fora permit subjectathe applicant to a civil penalty of not more than
five hundred dollars(SM, NEW RESIDENTIAL ELECTR SQXT. STORIES TYPE CONSTRUCTION
�n ❑I,as owner of the property,or my employees with wages as their sole
Compenutim,will do the work and themiucture is not Intended or offered for
psale(Sec.7094.Business and Profembn Code:The Cmdractoe.Lt..law
don not apply to an owner of property who builds or improve thereon,and OCC.CROUI' RES UNITS
whodoeamchworkidev elf orthmugh hisownemployees,prervidedthat such
improvements arc not Intended mattered for sale,If,howevegthebuildmg or O
Improvement Issold withinomramfcampldimytheawner-bullderwlll have
t"nfro of proving that he did not baud or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD MINE APN
II L as owner of the property,am exclusively contracting with licensed
contractors to comtwct the project(Sec.7094,Business and Procialana Code: PERMIT ISSUANCE
Thu Contmemri Llcenae Law don no apply to an owner d property who ALTER-DRAIN A VENT-WATER(EA)
wn
Wilds or Imprthereon,and who commentfor such ptoJects with a FEE SUMMARY
�gp3(achrts)licensed pursuant to the Cmtactor's License Law.
1bI am exempt under Sec. B h P C for this reason BACK PLOW PROTECT.DEVICE
DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y_ N_
Owner Data
RECm'TN _
WOR]OMAN COMPENSATION DECLA RATION FIXTURES PER TRAP SCHOOL 7A% Y_ N_
C31 hereby a((Irm that 1 have a ced(lanail-Insure,ile of consent to il-Inre
su ,ora RECER'F N
ornlflateo(Worken'Co vatlonlruurarce a(c.e/9tlfled aythereof(Sec. GAS EA.SYSTEM-1 INC40UTLM PARR FEE Y N
3800,Lb C.) ( C . I I I_G ( RECEB'I'X
policy N GAB-EA.SYSTEM-OVER 4(EA) BUILDING DIVISION FEES
' Com any /1
❑eedlfied copy is hereby famished. GREASE/INDUSTRL WASTE INTFdICEPTOR PLANCHECKFEE
❑CedBled espy is filed with the dty inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEyyp,R.gpNgTARy.gTORM EA 200Ff Date —Recei t#
(Thlssedlon need no W eamplded Bthe permit b for one hundred dollars
($10(fimless.) WATER HEATER W/VENT/M TR ENERGYFEE Y N
I edify that In the performance of thework forwhlch this permit Is Issued,
I shall not employ any pension In any nenner so as to become subject to the WATER SYSTEM/TREATING
Workers'Compensation Laws of Californb. Date PAID
O Z Applicant NEW RESIDENTIAL PLMS SAFE Date Remipt
Z 0 NOEECETO APPLICANT:If,after making this Certificate of Exemption,you
d+ould become eubjod totha Workers'Componaatlon provblonaof the Labor TOTAL:
N Code,you most forthwith comply with such provision or this permit shall be
BUILDING FEE A�b
LU > deemed revokea.CONSTRUCr10NLEvowGAGENCY SEISMIC FEE I N
t1 Ihercbyafftmnthat there Is a commudion lendlogagency for the perfomf r ELECTRIC FEE
7 Z ane of the work for which this permit b bwed(See.3097,Civ.C.) TOTAL:
00 Lender'.Name PLUMBING FEE
LL F Letdce.Addreas QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OO lomilythatl have read thbappliationand statethattheabovelnfomution
a bcorrect,I agrestocomplywithalletyand couniyordinancesand state laws PERMIT ISSUANCE FEES PAID:
} relmingtobullding conurudion,and herebyauthodu repressumativnof this
HZdtytoenterupon the abve-mentlmed property fee Inspection purposes. ALTERORADDTOMECH.
_ Date ReceiptN
(11t)agree to cave,Indemnify and keep harmless the CityIna of ayaccueupertino AIR HANDLING UNIT 10,011 CFM)
V against said ityindgocEugnfes the
exacting which may ln anyweyaccrue SUBTOTAL:
agalr,stud Cirymcons,quGna the gnnling aftMspermit. CONSTRUCTION TAX
2 IR n2 AIR IiANDLING I1Nl"l'(OVFR 10,(IOOCFM)
Sigruturenf AppBaMn
nt/Caetrn Data'! EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or forme building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date Recei tN
material as defined by the Cupertino Municipal Cod,Chapter 9.17,and the
Ileslthand SafetyCodeS�,.^�,,dion25532(a)2 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑Yes [2 No
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit haurdoug air contaminants as defined by the Bay Area Air
Quality Management District? BOILER-COMP DM'OR l00,IXD BTU) Qp p '
Yvs No 000 BTU) Ir Ile
ha tread the h oug malodais requirements under Chaplet 6.95 of W1LFR-COMP(OVER 700,
the California Health k Safety Code,Sections 75505,75533 and 25534. 1 1992
understand that lfthebu0dlng doe,rot currently have a tenant.that It is my NEW RESIDENTIAL MECH. SQdT RIND e � 4I
fnespanal6ilBy to ndttytheompart of the requirements which must W mot MAR Odor uses daCedlfk eo panCy.
0.,cr�rW,,autl�'`rmd��� t� 1 at` S a till V Ct' rr
Owner maul- b" hodud agent Date _ TOTAL: ISSUED BY:_W
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