21539 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro Identlfirati°n Ir32h9T NO,
B°Ba'n¢S iq �) ��� 21539
0 CITYOFCUPER1IN0.BUILDING DIVISION 'J // a
,me.
e ba Lk.No APPLICATION / PERMIT l t_ 1
n�tleax/�8'nar: Lk.Nm BUfID]NGELECTRICALPLUMBINGMDCHANICAL CATEGORY CONTROL
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address PERMITISSUAl,iCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby dfirmthat lam underprovblov of Chapter9(mmmmc APPLLANCES-RESIDFN L JOB DESCRIIIION
Ingwlth Seetbn7000)o/DIWtl the Bugnm dPrufnelauCode,and
Ibenee lain _
LDbaeense b Co
PANELS
LerCntacor
ARCHIN
AMPS
q�q�vu WOW'ZC I understand my plans x1ull a used as public moned> OVERIM0AMPS SQ.FT.FLOOR AREA 5/SQ.FT.
6:i U Lleemed Probeii SIGNSELECTRICAL
w� OWNER-BUILDER DECLARATION
I.., % Thereby afRrtn that l am exempt from the Contractors Llmrue law fee the SITLIALC[RCIIIT/M6C
%P-t'� following ream.(Section 70315,Buslnm and Prefubv Code:AnN
6 LX9 y city or TEMP.METERORPOL ST. -
F� muntywhkh rryuWa pemdtt°mnslrua,es Cheap Lewd for such
de a any-signertprte—rdtahat he I,aborryuUntheappllthe pm Eden,of tto
o MOWER DEVICES
C U foe•segued ice.La that he b Bmnsad pursuant to the pe.Ton f the
Con3affi.Lkevelaw(Clupte mC( e)orC g eistth Settlxampt hem0)d Dlvl- SWIMMINGPOO ELECTRIC
Ot' .lora 3dtho Butlnm and Pmfmbns Any vlothaheb therefrom and VALUATION
`FYI theblab for the alleged netathea Anyt to abn orS�^b 7031_5herrn mine,than af' aPPBont(ora permit ubjMath<appBantto•dvll Penalty other moretHn OILIER FIFSFIKTURFS
ee
flus ndeed ddlan ism. NEW ENTfAL FTF.CfR STORIES TYPE CONSTRUCTION11 W
I,as owner d the property,or my empbyen with wagn as their sole
eampevaHw,willdothewmkandtheswaum Isnot lmerded or offered for
��p sale(Sec 7014,Buelvas and Pm(mbns Code:TM Cantraaots Llarae Law
({ don rot apply to an vwnsr d pmpedy wed W Ilds or Improvn thereon,and C. ROUP RFS UNITS
E6• whodoessuchoma
work hlelfthmugh hisownernplgees,provided thatweh
Impcovemcnts art wt Intended mothered forsale.If,however,the W edit T
Improvement laaold wtthln ovyarofcomplabn,theowner-W Ilderwill love
fl. rdenofprovingtlut hedldro WBdorimpmver°rpurpmeofsale.). QTy PLUMBING PER MIT FLOODZDNE APN
L as owner of the property,•m exchutvely contracting with lived
mntracten to oot et the project(Sec 7014,Buslnm and Profmion Code: PERMIT ISSUANCE
The,Contractor's Llave Law don rad apply to an ownn d Property who ALTER-DRAIN k VENT-WATER(FA)
W 8ds or Improve+thereon, and who contracts for udt plokas with
oMlTactor(s)0cen.ed purawnt to the Contraeds Lleecus, BACI(FLOWI'ROIFLT.DEVICE FEE SUMMARY
U I am exempt under Sec B k P C for this rtnon
DRNNS FLOOR ROOF,ARF/n,CO SANITARY Y— N—
.�
Owner Dae RECEIPT N .
WORKMAN COMPENSATION DECLARATION FIXNRFS PFR.IRrVs SCI{OOL TA% Y_ N
reby affum that I have a mrti0ate d(sure to mV-Insure,or• RFLFBI'.
eo(Worheri Cron va/t/lon mate a(•eklrfed ropy thereofpec. GAS FA.SYSTEM-31Ne40 PARK FEE Y— N_
3800,Lab ,�,L�l S 3���II-�/
^r�i e byfu >—/-s(A�V CAS EA.SYSTEM-OVER ) BUILDING FEES
GertlRedm b1'dt the ced. GREASE/WDUSTRLW INTERCEPTOR PLANCHECK FEE
ed ropy b rued with IM city inspection alwbl°n.
CERTIFICATE OF EXEMPTION FROM WORKERS' GitEA¢TRAr PAID
COMPENSATION INSURANCE $EWER SANITSTORM EA.700FT Date RC i t#
(I'hlssectbn need not he eemplaed tithe Permit Is foram hundred dollar
(S100)mlm.) WATER(IFA w/VENT/E1.UZER ENERGY FEE Y _ N
Illnor clashthe pe arson IadlMwak so as to thlapemdlabued, —
I shall m'employ any penin In any runner at u m bemnn subject to the WATER /TRFATINC
O Amikecaurd, wtbs Laws of California. Date PAID '
PP NEW ENTiAI.PLMB, SQFE Date Rece1 t#
_Z 0 NOTICE TOAI'PLICAM:H,aRerers'Co thea at ich aleo(Exrmptetz
should
e,yb nrubjh totheWorkethCo perualomorbbv of the labor TOTAL:
W N_ Creamed r rtuat fanhw4h comply with uch pmNabns orthie perMtehdl be L
� > deemed rtwked. '
W
p CONSTRUCTION UlNDING AGENCY SEISMIQ FEE
I hemby amrm tlext there la.mnstrualon lend ng.gency for the perform_ ELECTRIC FEE
= anaoftheworkforwhkhthlapermltls WuedlSec30Y/,CIv.C) TOTAL:
02 I,ender•Na^.e - PLUMBING FEE
LL E- I.endee,Add. QTY. MECHANICAL PERMIT FEE MECHAMCAL FEE a
O W IartlfythelUvemadtN appllotbnaMr tethatheabovelnromutlon ,f
Isconert,lagreetocomplyw".UctyaMm ntyordlnanmando.t law. PERMIT ISSUANCE 2rV FEE$PAID.
>_ N relaiingto I lding mvlmctloo.M Mreby.whorL mproentatWn°f Chir ,
F Z dty to en upon the abovo-mentbnrd pcoperty Tonins n rposea. ALTER OR ADD TO MECFL Date Recei t#
save
,Indemnify an d keep harmless,the By of Cupertbm
agalw bdgnrnb,mats expenx.which In• ywayacvue AIRHANDUN'CUNTTCTO10,000CFM) SUBTOTAL:
against d m^aequ noo granting dthia
AIR HANDUNC DNTT(OVER 10,000 CPM) CONSTRUCTION TAX
Ngvtumof Appel nt/Contrier Dat EXEIALTSTHOOO(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the epph"m orlottere WBdingoaupantste, orhaMlehavrdous HFATINGIINIT(TO100,000 am Date Recei t#
materials.de0vd by the Cupertino Municipal Cade,Chapter 9.17,and the
Health and Safety Code Sectlot 25537(,)7 HEATING UNIT(OVER IM,000 BTU) TOTAL: ,QS
I I Yn _ q No
althe appllantm tort Wilding oe(fine use ehe flay Area
it VENTILATION FAN RINGER RFSID) II(.'E PATE
whkheMahagemet airrlet? his as defined by 1M Bay Arca Ab
Quality Management D-1 No BOn cR-COMP DENDR 100,0(q BTU)
Yn ❑No
��gl
4have rwdthe
ealth&rdfvtyCoerlabryulremenbW3and25534.1 BOR FROOMProvFR100,000eTn Al 10
the California Health k Safety Coda SMbv 25505,25537 and 75534.I H�"k
undesLaM that tithe Wilding don not currently have,tenant"that it la my NEW R6DEN'EAL MEC31. SQFT ly'si�
maponsmWty to notify the oreupant d the requirements which must he met
Prior to beuance d a Certirlate dOnvps my. WI
00
Owner or authodoed agent Date TOTAL ISSUEDBY:���a/tom
OFFICE COPY