23748 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identlf"tlon • PEXLMIT NO.
Building Address:LQ Aj DA 02:02 S An A 23748
low
nee one
CITY OF CUPERTTNO-BUILDING DIVISION
ontractor'.Name: Lb.Na: APPLICATION if PERMIT
F-�II r"'• G BNLDINGELk�(WCALI'LIJMBINGMOCHANICAI. CATEGORY CONITOL0
AnchBect/Englmv Lk.Na .
QTY ELECFRICPERMIT FEE BUILDING PERMIT INFO
Add. PFRLgTISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR5 DECLARATION
IM1thSyof7009)tlamlice3.fthunder provt dPmfhep,9(mmd, APIrLIANC6RF9DI:MTAL pB DFSC:RE'HON
liamseh SectLou to00)d(Dlvidon0o(the BuMweand ProleWon.Cade,and e n f
Isxme la In full fa d d(R
PANELS
I
cont . JLicensecl.Date�29-F
ARCHITECT'S DECLARAnON 2M.10DOAMPS
W, Iurdemtard mAREA y plan,shall be used as public record& OVER LOW AMPS SQ.FT.FLOOR AR $/SQ.FT.
05 Licensed Professional SIGNS ELECTRICAL
OWNER-BUILDER DECLARATION 9'F7CUL ORCUIT/MLSC
Ihcrebydm
Ortlum
tl...semptfnothe Contradm'.Lkm
xelawforthe
9 lollntywrermr.f$tttlon7 to BueInesand Pimp` esCode:Mympir
°aunty which requlrmapemdt to mrutruct,Mter,Improve,dem.Beh,orrepalr
-sigrei stamm.ltsbmarce,aimosed m,oamt the porwdipeof t e
(Ile a Mgned Yatement than k 614enaed pursuant to the provblom d the
O Contractor'.I.fcense law(Chapler9(mmmenMg wish Sectbn7000)of Divi- 1I l
s Rlofthe Bu Mnerand Prfem mCade)orthathebeaempttherefromaM — C VALUATION
g the basis for the Mleged exemption. Any violation of Section 7(1115 by any / r 0
DA appliantforapeimiteub�[Uthea"p nttoawlperuitydndmomtHn
�i ! hundred Bolla"WW.
�n �I,as owner of the property,or my employees with wag"as their sole SWR® SOST. STORIES TYPECONSIRLCTION
C76 mmperumlon,wBldotk work,andthestmaurelarmt Wended or offered for
5 O sale(Sec 7011,Bmines aM Prderbro Cade:The Com does W"roe Law
$ dace rwt apply to an owner d property who W IWn or Irnprovro lheneoR and CCC.GROUP RES.UNITS
soh roveme is am n Mmee Bed orwgh hbowne.If,ho i,provided that arch
Improvementartnm Intended orrofc foreale.If,however,theerl Unaor TOTAL:
Improvement beold within°neyuro/camplMbgtkowmr-buOderwlB have
t4LIZInIer,of pmmg that he did not Budd or improve for purpareo(aale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE MuN
Lj 4 as owner of the property,am excluMvely mntncUng with Ifoensed
oant .n to mrotruct the project(Set,7011,Busluae andl'm(tmom lCode-
The
nct
The Contractor's Liocrue Law does not apply to an owner of property who w ppR-DRAIN&VENT-WATER(EA)
bullas or improve themor, and who mntncv foe suis pIo)ects wW a
c9nlfadors)licensed pursuant to the Contractor.Llcerae Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec B h P C for this reason
DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y N
Owner Date gECp�p 0
�. WOR KMAN COMPENSATION DECLARATION
Of hereby affirm that I havece
a certificate of consent to sell-Insure,orapIX'IlTRES PER TRM 54100E TAX Y_ N_
te Y
certNam
m o(Worken'Compensation luranos or a cenBled copy thertofiSee. RECGAS EA.SYSTFl t-i INc10U11.E15 PARK FEE Y N
,n, .bGW-/?&?/ 2 6 RECFRII'.—
C�� GAS EA.SYSTEA1-OV113Z 1)
Y—l.._ BUILDING DIVISION FEES
CerWed Copy b hertbytumWed. GREASE/WDUSTRL WASTE INTERCEPTOR PLANCHECIC FEE
Certlfli ropy b filed with the dty Ivpection division.
CERTIFICATE OF E)[ MPFION FROM WORKERS GREASE TRAP PAID
toe bee
COMPENSATION bfE SEWERSANITARYSTORM FA 20FT Date Recti tft
(Fhb section need ria k canplMed Bthe perMt b lorone hundred dollen
(5100)or ler.) WATER HEATER W/VENT/ELI)M ENERGY FEE Y_ N
Icenot thatothe enure nceof thewok(nrwhlchoopemw1,lutea,
I°hall not employ any Laws In any runner at as to beCome subject to the WATER SYSITM/TREATING
Worsani Compensation I�w.dGalBmnla. Date _ PAID
0 Z Apphont NEW RESIDENTIAL PLMB SQFT Date Revel tk
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
rhould become subject to the Worsen'ComperaMion provbbro of the Labor TOTAL'
~ N Code,you mut foethwnh complywlth such provbbru ortM1b permit ah°Ilk
LU > deemed revoked. 6
W G CONSTRUCHON LENDING AGENCY SEISMIC FEE
ll I hereby afTrmthat there b.construction lerding ageacy furtive perfom,
Z ance ofthe work(orwhkh this pvmdbbwed(Sec 307/,CIv.G) TOTAL ELECTRIC FEE
U O Lole.Nans, PLUMBING FEE
LL r Lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
I centlythat l lave read thlaappBratioo.nci Matettat theshove informant.
O W
boor .I agreetocomplywith all cityand county ordlnenmane state laws PERMIT ISSUANCE FEF;PAID:
} M relatingto bulkingmmtroalrn,and hereby authartm mpm,smatN"ofthb
?N dty to enterupon the abo,mentbrad property for impectbn purpman. ALTER OR ADDTO MECH.
(WO agree to save,bdemu fy an d seep harmless the City of Cupen W Date Rmci tk
V agaWt BabWtl",)adgments,mseaMe.p manwhbh may inanywayaceue AIR HANDLING UNH'CTO 10,000 CFM) SUBTOTAL:
against said City in consequen"of the granting d this permit.
AIK HANDLING UNIT(OVEIR IO,OD)CFI) CONSTRUCTION TAX
Signature of Appllant/Contractor Dare EKRAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCIASURE
Will theappBcam or bture Imading oavpmt More.,handle ha>,rdws HEATING UNIT(TO 100,ODO BTII) pate Revel tb
material as deftned by the penins MuNCpal Codc,Chapter 9.1 Z and the
Eleallh and Safety Code Ioo=(a)7 HEATING UNIT(OVER IW,p BTU) TOTAL. v
quiI Ym
Wme.ppBam ase turtanduangamrpantuby the Bay
adevlas VENTILATION FAN SINGLE RESID) ISSUANCE DATE
whkh eMts anedom air cuntamW nU as deBmd by the Bay Arta Air
Quality Mamgemem 7 BOIIFA-COMP OtB'OR 1t70,Oro BTU1 A '
4Y" o
M110.re t It futyC.d,,S equlrcmenbunderCM1255M. A of BO CA-COMP(OVQ t00,XUB V) MAY 29
the Gldomla Health bSafety Code,Se mmntly veate ant, 5 t. I 1(i� )
uMentard that l(tM1e bulldingdm not mrrently love atemnt,that it la my NEW RESIDENTIAL MECH. SQFT J��J/�I
impomlbBLLy to ndify the aavpaq d tM1e rcqulrcmente which mast k met CI I r
�r da CenlllateofOavpanry. use (a(1rGE11 it,,TOTAL
err o/auth.rTud agent Date ISSUED BY: WTf
:
OFFICE COPY