22964 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building project Idendflotlen PFIAgT W.
BeBabg mare,.:rrz () 2) 22964
re � me: ,
CITY OF CUPERTIN6BUILDINC DIVISION / /(^���(
Caritrades Na me: _ Lic.No: APPLICATION / PERMIT
BUR.DINGELECMCALI'LUMBINGMFLHANICAL CATCGORY CONTROL 1
l Armbea/Pngtvrr. 1Jr.No:
Add- 7q
QTY ELECTRIC PERMIT FE BUILDING PERMIT INFO
AddreeK L QC-11PERMITISSUANCE ❑
LICENSED CONTRACTORS DECLARATION
Thereby a fflrmthatl,mlbmaeduMerpm Wovol Chaptm9(mmmmc APPLIANCESRERDFNTIAL BD N
ingwith Sedbn7000)dd dim.3ofthe Bu,YrrmandPro(esslmeCode,and
iocve b in in.tome and died. PANELS
License Cos Lk.F i
Dale Contractor
ARCHITECTS DECLARATION
P
qflq�u, I uMentaM ery phv,hall he used as puisne oda (� XYMIMOAMPS �. S/SQ.FI'.
k Fj I.Icevcd mfmbvl 9GNS ELEC7RICA(, 1 I
OWNER-BNLOER DECLARATION \.1 the SITMLCIRCUIT/MLSC
'�I7,-'/� Ihertbyal0rtntlut lamexemp fromthe Comm sorb Llwrue l�wf t
OmQ UT
following,aeon.(Sedlm 7015,Bu[Ineoard Pmfmbv .Codr.And or
Qg n which besa tomvru alter,lm Any
ty TEMP.METER ORPOLE INST.
r,�� cnu ty pc Perr^It d, Prove,demsu&pe rep o
anya signed tearrent he he e,,bo sed pursuant
t lfmtfwaum pemdt a POWER DEVICES
!ik•signed statement that k b licensed pv.vnt to the provisbv of the
OaG Centraette"Lkeve Law(Chaper 9(ce.eing with Section 7000)o/DIA- SWIMMING POOL ELECTRIC XVALUATIQy _
05 den3afthe Bueinns and Prdmbv Code)orthrt hebeaemptherefromard
12 the basisfor the alleged exemp on. Any vloWlon d SeGbn 7015 by any
n
p ppH..tfor,perutauhItcte the.pp".t too dvli pevlty dnd nn,tHn OUTLEISSV.TTCHESFTXTTJRES ( � �
Bred doll..%W.
'9..' see owner of the Property,or my ompbym with wages as their sok NEW RESmQJMLELBCIR 9QFp. STORIES TYPECONSTRLGTION
mpewHm,will do the work,and the struetu,is not imerde l or offered for
$ Oja le Gee-71M,Bueinm and Prdrsbv Code:The Contredors License Law
$ docs not apply to an owner of property who builds or improveithereen.and OCC GRO[JI' RFS UNITS
who does such work hlmeeU athrough his own emm
pIcy ,provided di
that u
impmvemems are,not Intended proffered!weak.If,howeser,the building or TOT
Improvement beokl wlthlnaneyerefcompletion.tkowner-bullderwlll haw[ -
t Menofpmvingthatkdldrntbuudor/mpr fwpurpoaaofeale.). QTY. PLUMBING PERMIT FEE
L owner of owof the property,am excl uhrly mntrading with Ifmne[A FLOOD ZONE APN
contractw-to mvtruct the pro(ed(Se,70K Business and! m
Prefbm Code: PFRhtTT ISSUANCE
The Contractor's License Law don not apply to an owner of property who ALTER-DRAW 4 VENT-WATER 0�
builds or Improve thmon, and who mmnda for wch p,,ints with a
��ctor(O hawed purwnt to the Contractee Lien.Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
IJ I am Hemp under Sec B k P C for this reason
Owner Date DRAINS FLOOR ROOF,AREA,COND. - SANITARY Y_ N_
WORKMAN COMPENSATION DECLARATION RECENT F
❑I hereby af(hm that I have a.matte of consent to self-Wure,or a FDn`URESPER TRAP SCHOOL TAX Y_ N_
anlnoteofwnrken'Compe mInsuranceovamnifiedcopythereof(See RECEIPT'S
3800,Tab C) GAS EA.SYSTEM-I 1NC4 OU1.E15 PARK FEE Y_ N_
�ma CAS FA.SYSI'FM-0VER4(EA) R➢CEaTY
y BUILDING DIVISION FEES
Certiie!ropy b hereby furnished. GREASE/WWSIRL WASTE INTFRCFPTL7R PLANCHECK FEE
Certified copy h filed with tic my Inspection dlvWm.
CERTIFICATE OF O(EIMP1'IO.NMOM WORKERS' GR�-'=TR'U� PAID-
not(rw-edbn neN COMPNSATION INSURANCE SIVMSNARY- RM
becmrpletei lithe permit bforons hundred defers Af
Date Recti IN �I
(Si0)alessJ
WATER HEATER W/VENT/ELD= ENERGY FEE Y N
l folly that In the pedornnna of the work(orwMm tw pemm b Wued,
1-hall not employ any person It,any runner so as to become subyd to the WATER SYSITM/TREATING
Wofluens Compewtbn Laws of California.Date PAID
Z ZO NOTICE TO APPLICANT:ILeter mating this CenBkatn of Exemption,you NEW RESIDENTIAL PLMB. SQFF. Date Remi t#
F y should become sobs to the Worl,eri Compewtbn proA-bv ofthe Labor TOTAL:
Code,you oust forthwith mmpiy with such proWsbv ortw perrtJt"It be
LU NG ^
CONSTRUCTION LENDING AGENCY
LU
j cleansed.1ced.O SEISMIC FEE e
(hereby firmorl,fothat rwthe,bam�utmmonlending 3097,Ch,.
perforrry ELECTRIC FEE
� Z once of the wohferwhkhfhb perMtb WuM bee](N7,CIv.C) TOTAL:
02 eller'-Nam PLUMBING FEE
LL h Teneer.Addreas QTY. MECRANICAL PERMIT FEE MECHANICAL FEE
O W
1 Irenlfy that l haw mad tthisappleemA and nate that the ab;ve formmon
bmneet.Iagreem
to comply with all dry and county onllnanre and state laws PERMIT ISIIANCE FEES PAID:
r rtluing to building rovtrumon,and krtby,utharke represen.tivrn dthb -
F = eity,to enter upon the above-m[ntbned property for lvpedton purposes. ALTFRORADDTOMECH.
(We)agree to ave,Indemnify an d trap heed.the Ctty of CupeAbu, - Date RBCei t#
V against WbWtks,ladgmens,mnsand eaperwa which nuybanywayamue AIRHANDL1NGIWIT(TOI0,000CFM) - SUBTOTAL'
agobut ity In arca ofthegraMln dtwpennit.
AIRHANDLING UNIT(OVER 1fl,ODOCFM) CONSTRUCTION TAX
Ilare of AppIleart/Contract Data EXHAUST HOOD M/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS ATERIALS DISCLOSURE
Wlllthc appliant or futumbullding oaupant store or haMk havrdoua HEATING UNIT(TO 10,ODO lfN) Date Recei t#
matcrlal as de0ned by the Cupertino Munldpal Cock,Chapter 9.17,and the
Hkallh and Sofeiy Code Soction25533(ei HATING UNIT(OVER 100,000 BTU)
No TOTAL:
I—I yes ?
Ill the apps®est serr ,tNo bulldingompantu,equipment wdevim VFN'IILATION FAN ESINGLE RESID) 1 U ATE
which cmlt havrdwe,Ir coutaMvnts as dared by the Bay Area Ab
Q+aIh y Ma ad then '! BOILER{OMP OHPOR10000BTU)n NOY -8 1991
ua Ya No
haif.a hufth& fky CMr,Sl .2SSnts under d25534695 of IgILLR{OMP(OVER 10,000 BTU)
the Callfa.la Heskh[a Safety Code,Sedbv]5505,75533 and 25574. I
under Mthlifthebuildingdoesw mntlyh,veatenam,tlutit6rny NEW RESIDENTIAL MECH. SQ.FT CITY Ulm GUYtHI[NU
reapovmDity to notify the ocvrpant of the,equlrcments which rrun be met 1[�
Prior to bounce of a Certificate ofOmrp.ncy. f
Owner or.whorl.d agent Date ISSUED BY:
TOTAL
OFFICE COPY