24422 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT N24422 4 4 2 2
Building Address:
wn n ame� one. CITY OF CUPERTIN4BUILDWG DIVISION A
. cont ors rat D u No APPLICATION /PERMIT
ArchitM/Engineer.Rlw�
I BLEC
7LDING-ELECTMCALPLUMBINGMHAMCAL CATEGORY CONTROLG+CkbIr. N
QTY ELECTRIC PERMIT FEE BUILDING PERMITINFO
Address: PERMITISS(IANCE El El
CONTRACTOR'S DECLARATION
Iherebysffirm that!am licensed under provisions of Chapter 9(ommenc APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Inense Is ectlon force and offeon3 olthe Buslnessand ProtemlonaCade,and my
license is in i..force and effect. PANELS
License Clam LicN
Date Contractor LM TO 2DOAhMS / -
ARCHITECT'S DECLARATION 201-1000 AMPS
�q'+re0 O I understand my plan re
BLUE be used as public cords OVER 1000 AMPS p p R S/SQ.FT.
M Q U Licensed Professiovl SIGNSELECTRICAL P U T ER
6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC
Ihereby affirrnthat lam exempt from the Contractor's License law for the
pp following reason.(Section 76715,Business and Professions Code:An city
O71't� coon which requires permit rontmd,alter,im Yor TEMP.METER ORPOLEINST.
F� county qu pe prove,demolleh,orrepair _ r
g atanystruclum prior to its!nuance,ahorequlres theappllcant forsuch permit to
O file a signed statement that he is licensed pursuant to the provision of the POWER DEVICES
Contractors License Law(Chapmr9(commencingwith SeMion 7000).(Divi- SWIMMING POOL ELECTRIC
sion3 of the Buvnesaand ProfesslovCode).rebate helaexempt thore(romand VALUATION
y.' the basis for the alleged exemption. Any violation of Section 7031.5 by any
�ppapplicant for.perMtBubjects the applicant to a dvil pevltyof na morethan OUTLETSSWHCHESFIXTIIRES _tee
c, �c� five hundred dollars(S500). NEW RESIDENTIAL ELFC7R —� O
�n
r7 1.as owner of the property,or my employees with wages as their sole eSQFT. STORIES TYPE CONSTRUCT ION
compensation,will do the work and the structure Is not intended or offered for
O role(Sec.70K Business and Profession Code:The Contractors License Law
S� doesnmapply to an owvrof propertywho Wildsor improves then.Rand
whodeessuchworkhimself orthrough hisownempleyees,providedthat such OCC,GROUP RES.UNITS
Improvements are not intended orolfered forsale.If,however,thebullding or TOTAL:
improvementbs ldwith!noneycarofcomplet ,theowner- gderwBlhave
t rdenotprovingmat he did notbuildorimproveforpurposeofvle.). QTY. PLUMBING PERMIT FEE FLODDZONE APN
�I,as owner of the property,am exclusively ontrading with licensed 1'FRMI7155IlANCE
contractors to construct the projM(Sec.7094,Business and Profemlom Code:
The Contractor's License Law dont one apply to an owner of property who
buALTER-DRAIN&VENT-WATER(EA)
Wilds or improve thereon, and who contracts for such pi ejects with a
�q¢L[ador(s)Ilcenaed punuanttothe Contractor'sLkrnse Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec. B &P C for this reason
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y— N
OUTSIDE H
Owner Date RECEIPT#
WORK MAN COMPENSATION DECLARATION FIXTURES-PER TRAP SCI{OOLTAX Y— N
❑I hereby affirm that I have a cert7ficate of consent to pytheure,ora RECEIPT#
certificate o(Workers'Compenatlonlnurance oraorti(kd ropythero((Soc. GAS•EA SYSTEM-1 INCA
Policy
CJ PARK FEE Y N
Poliry tl RECENT X
C CAS EA.SYSTEM-OVER 4(EA) BUILDING DI V ISION FEES
Ified copy is hercbyth the city
CREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECKFEE
Certified ropy la filed with the sty Inspmlon divlNon.
CERTIFICATE OF EXEMPT ION FROM WORKERS' CREAS'ETRAP PAID
COMPENSATION INSURANCE
(Thlsu ionneeanMb complee Btheper tLaforovhundreddollars SEVVER-SANITARY-STORM E.A.RIOFT Date Reoel t#
(51less.)
ImmWATER HEATER W/VENT/ELECTR ENERGYFEE Y N
!certify that lathe performance.(the work"which this permit is issued, N—
I shall not employ any person in anY manner eo n to become subject to the WATER SYSTEM TR
Workers'Compensation laws of California.Date / �n'� PAID
O Z Applicant
Z O NOTICETOAPPLICANT:If,after making this Certificate of ExempOon,you NEW RESIDENTIAL I7MB. SQ,FT, Date Recei t#
Hshould become subject to the Worked Compevatlon provision of the Labor TOT
WVI Code,You must forthwith comply with such provision orthis permit shall be a`
> seemee revoked, BUILDING FEE
CL C CONSTRUCTION LENDING AGENCY !ELECTRIC
SM!BING
E
Ihereby amrmthat them baconstromon lending agency for the perform. TOTAL: FEED Z ance ofthe workfor which this permit is Issued(Sec.3097,Civ.C.)O I<nder§Name MFEELL h Lendera Address QTY. MECHANICAL PERMIT FEE CHAL FEEOW Icertdythatl have read[hisapplicatlon and statethatthe above lnformatlon6 hcormd.l agree to comply with all Mtyand county ordinances and state laws PERMIT ISSUANCE S} relating to building ontmetion,and hereby authorlm representatives at thiocity to enter u Pon the above-mentioned#rope for ivpedion purposes. ALTER OR ADDTO MECH.
(We)agree to save,indemnify an d lees rmieas the City of Cuperino DReceipt#
againtilabilltl ,lodgments,ones and ex which ma nywayamma AIR HANDLING UNIT(TO IO,ODO CFM) SUBTOTAL,
agalnt Bald C In co gapience of t of thio it
AIR HANDLING UNIT(OVER IQDOOCFM) CONSTRUCTION TAX
Sig core of pplFIA2A RDOUSiont/ConractoMATERIALS DISCLOSURE r Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
ill the
plicant
ng
Wialas Spred b the
ertino Municipal Code,
hapten lc havardous F{FATINC UNIT(TO 100,000 BTU) Date
material as defined by the Cupertino Munidpal Code,Chapter 9.17,and the RCCC
QYes11rallhand SrfMy Cod c,Scnoon 25532(a)? HEATING UMT(OVEF(t00,0006TU) •FO `
Will the applicant or❑future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management District? BOILER-COMP OHP OR 100,000 BTU)
Yes ❑1�No m A
have read the hazazQinornnterials requirements under Chapter&95 of BDRER-COMP(OVIR 100,000 BE U) V' W D
the Ca lifomW Iiealth&Sa tett'Cade,Sed Ionia 75505,25$33 and 25534.I
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.PT
responsibility to rad ify the occupant of the requirements which must be met ' ����
prior to taints s race of a Certificate of Occupancy.
Owner or authodzeaagent Date CIIY OF CUrtrl I11vtI
TOTAL: ISSUEDBY:
OFFICE COPY