24093 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMITNO.
Building Address: O �t �` 24093
ra amc:� hone:[
�U GVW M �J� QRZ aAPPLICATMITSUNVI'MAE=A
F r� CITY OF CUPERTIN0.6UILDING DIVISION
cony yyY "•_p7��'F� a ..Nth LO e." ' APPLICATION I PERMIT
BUILDINGELECTRICALPLUMBINGMECHANICAL CATEGORY CONTROL N
No:
Architect/Engineer. Lb.
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERM TISSUANCE ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby aftlrm that l am licensed under Immsiona°f Chapter 9(commenc- APPLIANCFSRESIDENTIAL JOB DESCKIVHON
Ine.ariSectfor7000)ofd effeon3 ofthe Buslnessand Pre(essionaCAde,and my I��KY
ae��y�
Bsnse le In full fors and effe<. PANELS `{�V `�^�
License Chas LIc.Y
Date Contractor UP TO 2DOAMPS
ARCHITECTS DECLARATION 201-1000A.MPS
7 I understand my plans shall be used as public records. OVER 1000 AMPS �,FT.F1�gR AREA f/SQ,Fr,
o ' 'nVa
Licensed Professional SIG NS ELECTRICAL �//��(�
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/M6C _� f^ T ■
L, Ihereby affirmthal l am exempt fromthe Contractors License Law for the � l
pp following reason.(Section 7071SeoT Businand Profeobns Code:M tl
OZ :3y ty°f TEMP.METER OR POLE INST.
r;o county which requinua permit to rovtruct,altep improve,demolish,orrepair
ATE
Zanystmn mpdartoits Lssaance,alsor"Nu atheappBsntforsuchpermitto POWER DEVICES
file a signed statement that he,b licensed pursuant to the provisions of the
Ce ntraRols License Law(Chapter 9(comnnndng with Section 7000)of Divi-
3 O SWIMMING IDOL ELECTRIC
the basis fo Busbne a dexemption.Code violation
n of exempt therefremany VALUATIQ;„
the bash for the alleged exemption. Any violatbn of Section 70315 by any Sb� ���.J C//CV�
<5 five hundred doerMtaubje tsthe applicant roti tivll pewltyo(nat more than UTLEISSWITCHFSFlXTIJIiFS
o five hurts owner
lars ofthe pro
1,as owner of list property,or h y employees n with wage as thele sok NEW RESIDENTIAL ELECTR SQFT. STORIES 7Y1'E CONSIRIX:TION
compensation,Business and Professions
Code:The
Lice Law
d for
�$ p sale ace. pl,to Business property Code:The or Imp vola License law
�'$ don nottruch roan temerofthroag hiswho
nemplrimprwvidedes toRand OCC.GROUP RFS.UNITS
a who esutsamnwark hlmselforthroffemdfwne.fiflu m,mrtbedildingeh
improvementsarenotintendedproffered pl cute.If,h ner-p deer ilI have
Improvemem u sold within oreycarolcompldiOn,the owner-bullderwlll have
te pLOpDppNp rdenofpnerng that he did not build or improve for purpose ofsale.). QTY, PLUMBING PERMIT FEE TTN
Lj L as owner of the property,am exclusively contraning--u—sou PERMIT ISSUANCE
contractors to mrealmct the project(Sec.704q Business and Profeniaru Cade:
The Contractors Limose Law don not apply to an owner of prepery who ALTER-DRAIN kVENT-WATER(EA)
Wills or Improvers thereon, and who contracts for such Ixojecte with a
�glllfaco r(s)licensed pursuant to the Contradorb License Law. FEE SUMMARY
LJ I am exempt under Sec. B k P C for this reason BACK FLOW PROTECT.DEVICE
Owner Date DRAINS FLOOR ROOK AREA,GOND. SANITARY Y_ N
WORKMAN COMPENSATION DECLARATION RECEIPT p
QI hereby affirm that I have a nSAT ON
of Concent to sell-Inwre,m a N z PER TRAP SCHOOL TAX
enl(loteofWorkers Compcv tlonlmunnsoramnifkd copythereof(Sec. RECEIPT
3800,Lab C.) GAS EA.SYSTEM-1 INCA OUTLETS PARKFEE Y N—
Policy Y RECEIPT N
'YT
y GAS EA.SYSTEM-OVER 6(TAI BUILDING DIVISION FEES
rtified copyb hercbyth the city GREASEANDUSTRL WASTE INTERCEPTOR PLANC14ECK FEE
CertlRed copy la filed with the tlty Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS GRIASETRAP PAID
COMPENSATION INSURANCE
MThlsscdion need not ecompleted ifthepermit lsforonehundead dollars SEWER-SANITARY-STORM EA.20OFT. Date Re i t#
(f1I orml - WATER HEATER W/VENT/RLECTR ENERGY FEE Y N
Isnlfythythat in the performance of thework forwhich this penult Is inured,
I shall eta employ any person b any manner so u to become subject to the WATER SYSTEM/TREATING
Workcri COmpensaU°n Laws of Glifornla.Date
O Z Applicant PAID
Z O NOTTCETOAPPLICANT:If,after making thisCertificate of Exemption,you NEW RESIDENTIAL PLMB. SQFL Date Remi t#
Fshould become subject to the Workers Compensation provisions,of the Labor
N Code,you nm at forthwith comply with such prevlsbns or this permit shall W TOTAL: y.
LU > deemed revoked. BUi DI G
ECE
CL p CONSTRUCTION LENDING AGENCY SEISMIC FEE t
= Z I herebyalirmthat there bacomtrunlon lendingagency forthe perform ELECTRIC FEE a�a
ance of the work for which tide permit Is Issued(Sec.3097,Clv.C.) TOTAL:
N�
U O Leaders Name PLUMBING FEE
Iy l— LenderaAddress QTY, MECHANICAL PERMIT FEE
O W Icerify that l have read this appOcatfon a nd state that the above formation MECHANICAL FEE
IL bmr -lagreetommplywithalldtyandmuntyonllnan ndstatelaws PERMIT ISSUANCE FEES PAID.
>. W velatingtobuildl mnstmetion,and by horizere wntaUvesofthis
r
Z city t u n the above.m n tis my for ion rposn. ALTER OR ADD TO MECH.
V — (We ve,Indemnify a ep harmi the Cd of Cupenbo Date Receipt#
agabutl llties,N ments on expense ch ran wayasree AIR HANDLING[IMT ITO 10,000 CFM)
agai id ity n a grant permit. SUBTOTAL:
AIR HANDLING IJNR(OVER tO,ODOCIN) fCONRUCTIONAXS' eta mofAppilcan/ nrano Dat EXHAUST HOOD(W/DUCT? RUCTIPAIDHAZARDOUS ATERIALSDISCL URWill the applicant or future Bdingoccupanlstom orhand le hazardous HEATINGUMT(TO100,(00 BTU) e
material as defined by the Cu enino Municipal Code,Chapter 9.12,and the " t#
Health and Safety Code Section 2S532(a)t HEATING UT(OVER 100,OW BTU) TOTAL•UNITYes Na .
Will the applicant or future building occupant use equipment or devices VENTILATION IAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Mawgement District? BOILER COMP OHPOR IDgO(O BTU) QS A B
?Yea No
have read the harath&Sal pus maleriab rcons 253 n,25333 Chapter.1 of BOILER-COMP(OVER 100.00)BTU)
the Gltandt Health building
Code, of comentlyh have
a fiand25hat it IjlIG j
understand that lithe Wlldingdces not currently havcatenanL that itis my NEW RESIDENTIAL MECH. SQ,pT 71 1(11(I2
reaponsibilily to notify the occupant of the requiremats which most be red CITY
pnmtOissuanreofaCenificateof Occupancy. CITY Ur I
� M V
Owner or aulhorlud agent Data ISSUED BY:
TOTAL:
OFFICE COPY