24305 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PEPMITNO.
Building Address:
21540 Lboga (l)a eil I'1-b Z
4305
caner a "p�Wons
hone:
1 ASUBMITTAL
L�,.a"V' I� CITY OF CUPERTINQ BUILDING DIVISION
Comtr :k N ' APPLICATION I PERMIT to 1-
ArchLLect/En n rBUILDINGELECTRICAL-PLUMBING-MDCHANICAL CATEGORY CONTROL#
"\. 8i mLie.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE ❑ ❑ ❑
LICECONTRACTOR'SCLARATION
I hereby affirm thlona o(Chapter9(commenc APPEANCFSREEDENTGL ]OB DESCRI?LON
tngwith Sedkm7000)of DiAdon3ofthe Bustnessand PrefessionsCode,and my
Liconelsinfu8 force and c.a PANELS / � L`
License Chm Lkec (`%� I��
Date Contractor.
ARCHITECT'S DECLARATION 701-1000 AMPS
�7 I understand my plans shallbe used as publicrccorda. IOVERIODOAMPS SQ.Ff.FLOOR AREA S/SQ.Fr.
O_
c4 �j Licensed Profeaslorul SIGNS ELECTRICAL
OWNER-BUILDER DECLARATION BPFGWLCIRC[RT/M15C
7y, Ihercbyafflrmthatlam eaempt(romthe Contractor's License law forthe
following reason.(Section 70312,Business and Professions Code:And or
O e- county whichrc Iresa permit tocoestru alter,less rove,demolis y p TEMP.METERORPOLE INST.
F of Y ty 9'r P c4 P h.arrc air ❑ �� -
an a signere tatermiU that
he I,Licensed
pursuant to the reelalons,of the POWER
DEVICE
El�C_S
�� file a signed statement that he b Rcssnsed pursuant to the provision,of the �
MContractor.License Law(Chapter 9(d mmenetng with Section 7000)of Divi- SWIMMING POOL ELECTRIC
OS ston3ofthe Business Rd Professlon,Code)orthathebexemptthemfromand VALUATION
the basis for the alleged exemption. Any violation of Section 7MISan
pp�p applicant fora permit subjects the applicant to a civil penalty d nore than mOVDRTSSWITCHFSHXTURES Ir B 1
EBF five edreddollars($500). NEW RESIDENTIAL ELFCTR I�/ll r_ Ef.
�5.. as owner of the property,or my employee with wage as their sole MPS I '1YPE CONSfRUCT10N
pensation,will clothe work and thestructurc is not intended or offered for
$ p (See.7044,Business and Profession,Code:The Germane.License Law
Id es not apply to an owner of property who builds or improves thereon,and
r'-$^ whodocs.chwarkhimselforthraaghhisownemployees,providedthat.ch OCCGROIIP RES.UNITS
improver ntsarenotintendedorofferedforsale.ILhoweverthebuildinger TOTAL:
improvement Issold withinoneyearofcompleti theowner-bullderw0l have
t"rdenof proving that he did not bund or improve for purpose of sale.). QT-y. PLUMBING PERMIT FEE FLOOD zORE --X—PN
LI 4 as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
dentract rs to construct the project(Sec.^044,Business and Prefessbra Code:
The Cmdrec or.Lt...Lew does not apply to an..or of property who ALTER-DRAIN kVENT-WATER(EA)
Wilds or Improve thereon, and who contracts for such ptojec a with a
TLt ct (.)licensed pursuant to Me Contractor's LI...Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
-- J I am exempt under Sec. B k P C for thinreason
OUTSIDE FFL5
O
DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y— N wner Date
WORKMAN COMPENSATION DECLARATION RECEIPT#
FIX.NFFSPFR.TRAP SCHOOLTAX Y— N
I hereby affirm that I have a certlRnte of consent to selFln.re,ora RFCE'T#
certificate of Workers Compen,atlon Insurance or a certified copy themoeine. , GAS EARMMI INC 4OUTLETS PARK FEE Y N
3800,Tab C)
CamPolie R GAS F.A.SYSrCM-OVER4 LEA) RECEwa
Y BUILDING DIVISION FEES
Certilled copy.hereby furnished. GRF.15E/INDUS[RL WASTE INTERCEPTOR
Certified copy Is filed with the city leopectlon division.
CERTIFIGTE OF EXEMPFION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWERSANITARYSFDRM EA 200Fr Date Recd t#
(this sedlon need rad be complcted if the permibt forooe hundred dollars
(S1 W).rless.) WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
Iceres Matinthe pcese performance thework so as permit to t.M, —
1 shall not employ any pens in any manner ro e to become subject to the WATER SYSTEM/TREATING
Worken'Compensatbn Iowa of GE(omla. Date PAID
O Z Applicant
ZO NOTICETOAPPLLCANT:R,aftermaklngthiaCdiff.teof Exemption,you NEN'RESLDENTIAL PCMB. SQ.FT. Date ,Recei t#
ahwld become subjectmthe Workers'Compensation provtslon,ofthe Labor TOTAL:
C N Code,you stfofthwtthmmplywithsuchprovbion,orthbpermttshallbe
LU > deemod revoked. BUILDING FEE
CL O CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there b a construction lending agency for the perform,Z ance ofthe work for which this permit b Issued(Sec.3097,Cle.C.) ELECTRIC FEE
L) O T`nder'e Name PLUMBING FEE
LL F Lender's Address QTY. MECHANICAL PERMIT FEE
O O MECHANICAL FEE
I certilythat l have read thisapplicationand date thatthe above information
1 .rowed.I agree to comply with all dtyand county ordinances and state laws PERMIT ISSUANCE FEES PAID:
>. W relating to building construction,and hereby authoress representatives of this
F Z city to enter upon the above-mentioned property for bapection pu racers. ALTER ORADDTO MECH. Date Recei t#
— (We)a m save,Indemnify an d keep harmless the City of Cu portion P
age W ell its,jtrdgmenb,artsand expenses which nay In anyyyy�-��ay roue AIR HANDLING IIMT(TO 10,000 CFM) SUBTOTAL-
.fFi !raid t"HA�RDDU
it a ntftgrIthbpermit CjrB
�(j/ AIR HANDLING UNIT(OVER lo,000CFM) CONSTRUCTION TAX
signature fApr a ExHAUS'r HOOD(w/DIX:T) CONSTRUCTION TAX PAID:
MATERIALSDISC O URE
Willt eappilding occupant stor rhendlcharardous HEATING UNIT(TO 100,000 BTU) Date RCCeI f#_
material as defined by the Cupertino Municipal Code hapter 9.12,and the
Health and Safety Code Section 25532(a)? HEATING UNIT(OVER]0,000 BTU)
F-1YenM No IOTA
Will the applicant orhoure building occupant use equipment or devices VWnLATION FAN(SINGLE RESID) ISSUANCE DATE
which emit haaarcious air contambanta as defined by the Bay Area Air
Quality Managencnt Distad? BOILER-COMP 0HPOR 10,000 BTU) I� /y 8
m4 ad
No N
have read the hazy ous materfab requirements under Chapter 6.95 of BOILER-COMP(OVERIW,OW BTU)
the California I lealth h Safety Code,Sections 25505,25533 and 25534.1 OCT
understand that ifthe building does not currently have tenant,thatitismy NEWRESIDFNTIALMECH
res . - SQ.FT 1992
ponsibility to ndify the occupant of the nyuimwnta which must be met
prior in Issuance ofa Certificate.!Ocapaney. CITY L!r '
<�ayY)`U/r1J
Owner.nauthoressd agent Date
TOTAL: ISSUED BY: y/�iiE#•la'
OFFICE COPY