23936 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALLPOINT PEN ONLY
Bundln Project Idmtlflution 7 PERMIT NO.
BaflAi ng AddressS� ��-1•CV tQC�r ` 23936
F7'Ii `7� CITY OF CU TI O- ILDING DIVISI
co do da x.No A ION / P T (�
Archttect/Engl Llo ECIRICALI'L BI AL CATIS,OAY C
Q E C E M FEE BUILDING PERMITINFO
i Add. - ❑
LICENSED CONTRACTOR'S DECLARATION
Ihemby allrm thatlam lfcenM order provWmsdChapter9(common (MLIGFSIDFNTIAL JOB DESCRIPTION
Ing Mth5ectbn7DOO)of Dvblm3ofthe BuelnmandP fn,lonC ,and my
Ibenm la In fu �and effect.
Llaruc � L{cI - _I O
D _(r. _ Cordndnr (/I� UP TO 200 ANI!S
ARt511TECT'S DEC ATIONAMI"'
q�q�+u'ce0 ]uMerataM myplaroahaBbeuxd aspublicremrds AMI'B.rI SQ.IT.FLOOR AREA $//SSQ.FT'
}i 4' Llavd Professional SIGNS ELECTRICAL
6�µ�l OWNER-BUILDER DECLARATION SpFLIALCIRCUIT/ML9C
Iherebyafflrmt)utI.exempt from the Contractor's License Law for the
following reason.5ectlm 70715,Business and Professions Code:My city or
Ir METER OR OIE INST.
Ir muntywh{ch rcrylrmapermktommtrun,alter,Impmve,demoWh,orrtpalr --`
anystnucturtpr{ceto ib•^„nee,oleo requke NeappBontfmach pem0t to
POWER DENEM------
o flb a signed statement tateent that he b licensed pursuant to the provisions of the
C. Lkeroelaw(C1upn9(mmmencingwM Scctlon 7000)d Dd- SWIhIMNG POOL ELECTRIC VALUATION
.p301 cion 3oftheBuebmard Pm(mlonCode)orthat heb exempt therefromaM x
p� .•77 the basis for the alleged eaemptbn. My WolaBan of SMbn 7m15 6/any �� �
` 0 appllont fora permd eub}act&thespplkanttaadvll penity dnu morsthan Iso-E7SSX77Cf76F1)<7!!R6 a
flue hundred dollars 055.
�I,as owner of the property,or my employers with wages as their role NEW RESIDENTIAL EI.ECIR SQYT. STOWFSJ TYPENNSIRUCDON
CC �^ mmpennatim,will do the work and the strutlure b rot Wended or offered for
5 O sale(Sac-70K Business and Profession Code:The Contractor&License Law ,
r$ don rot apply to an owner of property who Wilds or lmproees thereaR and
Occj $^ whodansuchwork hlmalforthrough hlsownemployeei,provided that vch :
Improvements are nal Intended oroffcmd(areale.If,however,the building or
impro ce Mbsoldwhhlnoesycarofcomplebmtbeawner-builderwWhave vP Li
rdenofpm"ngthathedid WBdortmpr fmpurpoaeofu .). QTY. PLUMBING PERMIT FEE
L n erty
eavear of the prop ,am exclusively contracting with Ilmnsed FLOOD7DNE
mntrettm to mMruct the pro}ct(See.70/1,Business ant Prdmlon Code: PERMIT ISSUANCE DTE { y Z
The Contractor's Lfreree Law does not apply to an owner d property who A1,TER-DRAM&VENT-WATER(EA)
Wilds or terprovn Merton,and who contracts for such p(o)em wish s
cqN(aetor(s)llaoid parsunet to the Contrsctal&Licene law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
UI am exempt under Sec B& P C for this renin
Owner Date
DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y_ N
FIXTURES.PER TRAP gECErT R
_ WORKMAN COMPENSATION DECLARATION TSp{pOL TAX Y_ IN _
❑1 hereby affirm that I have a certlffrate of consent to self-Iwre,or a RECD s
certificate o(Worim'Compenad.Insurance ma cert dropy thereof(Sec. GAS EA.SYSTEM-1 UJG10UTLEIS PARK FEE Y N
3800,lab G)
CoPolm, GAS FA.SYSTEM-OVER 4(EA) DING DIVISION
I'1
�Cy BUILDING DI V IBION FEES
CertlOcd ropy b hertby furnished.
ertNed copy b flied with the city inpectbn divbim. GREASE/IJDUSIRL WASTE IMFRCEPTOR PLANCHEC
CERTIFICATE OF EXEMPTION FROM WORKERS GREASE TRA ]�
COMPENSATION INSURANCE gEWFR-SANTIARY SHAM E.A. ate RCOCI
(Thlssectbn need not be completed B the permit b forone hundred dollars
a100)or1m) WATER HEATER W/VENT/ELECTR ENERGY FEE Y_'�
1 mnot slut o the performanceof the wale for which co•permit r bored,
1 shag not employ any person In any manner m ae b become aublen to tk WATER SYSTEM/TREATING
Waken Compensation Jawad California. Doe PAID
Z Z A TICEt - ion,you NEW RESIDENTIAL P B. SQ.FT. Date Recei t#
ZO NDIICETOAsubjCANthe W. .'Comesation utesf FsempteLabo
` cN shunido musarhwitthe Workers'compematimpmwmnof rmit shall
IOTA
Cade,you Tux imthwlth comply with such provblon orthb permit shall be
� > domed revoked. BUI 12ING FEE Fa
do CONSTRUCTION LENDING AGENCY 5EISMIC FEE 1,VOU
Z thereby.fnrmthatflumbamwrudionbMmgagenty brthepedom+ TOTAL ELECTRIC FEE
7 arm of the wormfor whleh this permit b lowed Gee 309'7, lv.G)
61 O Lende .Name PLUMBING FEE
IL h LeMer,Address QTY. MECHANICAL PERMIT FEE MECHANICAL FCE
OW 1 certify Mat l have read this application a rd state that the above informant
a Ismrmct.lagrtetocomplyw aUcyandmunyord mandsbtelawa I'FRMIT'6SUANCE FEFS PAID:
} U) rey to enter
upongmmtroctlan,aM hertby auNorfureprexnhtivndthio
H Z cityWenteree to ave,Inve-mentl a.d property fmwpe Cit purposes ALTER OR ADD'R7 MECH. Date Reeci t#
(We)agree m save,Indemnifyyse d keep harmless the City y CupenW
U (We)
Balli Cityiojomequ, of
operon which may bony wayacvue AIR IdwNIXlNc UNIT TTO 1D,mo ant) SUBTOTAL:
agalntu dCity In enm of the gnntbgd It.
a—w�� AIRIIANDUNGUNIT(OVQtlo,000cFaD CONSTRUCTIONTAX
Sig of App t/ mirxtm Date EXHAVS7IIOOD(w/DUCD CONSTRUCTION TAX PAID:
fifiAZARDOUSMATERIALSDISCLOSUIE
Will the appllont erfuture building oavpant core or Fant le harardm& HEATING UNIT(TO 100,WO BTI)) Date RCC .
rmteda]as defined by the Cupertino Municipal Cade,Chapter 9.17,and the
I kalth and 1,Cade��—,Stledan 75537 fp)7 1-IFATING UNIT(OVER 100,()M SM TOT
T1 Yn n'No ISSUANCE DATE
�Ylll the appBant ar Lure Wllding amnpant use NulpmeN m device+ VFNfI IATION FAN(SINGLE RFSIO)
whkh emit haea dous air contaminants as deo rad by the Bay Area Air
Qua lhy Management D�MIrkti BOILER-COMP OM'OR 100,000 BI Iq
No
I Yn arardcuus P
HimmialheM1 materials requirements under of BOfLFRCOMP(DVER 100,0006fU) / y�
the Caldomt at 11 h building
Cade,SMlonmlyh ve.tand 2rthat.I Y
urdmsaMthat note the
of the requirmnts tenant,that itlsmy NEW RESIDENTIAL hfECH. SQFI
ytoissresponsibility.to notify the oaupard d the requirements whkh mu,t be met
Prior to issuanar a.Ccrllkate of Ocaparuy.
I
Owner mauthodaad agent Date —TO ' ISSUED BY: \VYsS.A/l f floc.
OFFICE COPY �I J