21830 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Projed Identifludm 1, PFRMIT NO.
BuMing Addma: FC 21830
n,oArt yr c o� G �I �o ��3 So
one: A
'G rty OF Lp U /� /tip CITY OF CUPERT[NO-BUILDING DIVISION
mtrarctm'a Name: pLlc.No APPLICATION / PERMIT \ 1
I/ BVl—�J B boy BUIIDINGFl,ECTRIULPI.LM 11 M LANTUL CATEGORY CONTROL
ArchRet/Fnglreer. Lie No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address/yg y i+', /S T+a�ia r,.y PFRARTISSUANCE ❑ ❑
LICENSED CONTRACTOR'S DECIARATION
I hereby affirm that l am Bnned under provutlmnof Ct pta,9APPUANCESRFSIDFNI7AL JOB DESCRExfION
Ingwlth Setbn7D0D)of DWIdm3ofthe Budnes'and ProfealonsCodp and
it.. Ch to o d f(,. 1 4) PANELSLloa
Daten�=7Z ��C admot.r .! .pw/:-SLIP TO ZOAKY, �J ` •/' `. V'" Imo``
AACMITECI'S DECLARATION M-10(K)AMPS Iurd..0 d my plan aha8 be used a public mounds. OVERI"AMPS SQ.E7.FLOOR AREA $/SQ.FF.
E ULicensed Profeabnal SIGNSELECTRICAL
6 OWNER-BUILDER DECLARATION SPECIAL CEtCU1T/MISC
71„ 3 IherebyafBrm Uutlamexemptfromthe CnmractoesL¢ eiawfmthe
pp .o tyngmason.(Sepl W1$Bualnu• ePr pm , Cade: h,o dtyor
F7. � IITVIP.METQr<OR POLE INST.
ountywhkh rcqu bna pemdtto mnalrud,dt Out.prove,t for eh,orordi,
Y any atmdureptemenlot bout,isluorryuPnsuant t the noauchpemtlte POWER DEVICES
C � flY•dgned datement the he b Ilnnscd Pursuant n the prwbbro of the
0 uu. Contract0e.1.1ceme law(Chapter 9(mmmendng with S-lon 7080 of DM- SWIMMING POOL ELECTRIC
I'll of",Bushes and P ions Code)orthat he Is exempt therefromand VALUATION
the haab for the alleged exemption. Any vldation of Seotbn 7m15 by any
OQ appllantfor a permit.ubjecta the.pp0cant tons civil penalty a not momtbao OUILETSSWITCH6HXTllR6
Ji
five hundred dollara%W.
F1 1,a s a owner of the property,or my employees with wagetheir ante NEW RESIDENTIAL EI.ECTR 9QFT. STOWfS TYPE CON'STRUCT'ION
compensation,will do the workand Natruoum It not Intended or offeredfor
5 ede I.7044,Bu noess and Prufedun Code:The Carimnora U.law
dm notappy to an ownerM propertywho builds or improves thereon,and OCC.GROUP RES.[WIT9
M whodoneuchworkhlmaeVorthwgh hisownemplgnwmA
e ,prlded that
Impmvemew are not Intended oroffmrd fmaale.If,however,the building or TOTAL.'
Impnvemerelas wlthinomyeaofcmipIMt mtheowner-WWwflihave
itA; unlenofpr gthdMddnat Wadorimpmwforpurpoaofade.). QTY. PLUMBING PERMIT FEE
LLj I,a xchN
owner of the property,am eueiy oontracting with Iberued FTfJDD ZONE APN
ounhaton to mvtruct the project(SM 7(161,Budneas ab Prefembro Code: PERMIT ISSUANCE
The Contractor.Linens Law don n¢appy to an owner d property who
builds or improve thereon, and wha mntracta for ndr pIllots with a ALIER-DRAW k VENT-WATER(EA)
gntpoctm(a)Imenaed ponuont to the Cmtradd.Limos Law. BACK FLOWI'ROTECC.DEVICE FEE SUMMARY
LJ I am exempt under Sec a fi P C for this resalesOUTSIDEFErs
Owner
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N
'O Date.=
WORKMAN COMPENSATION DECLARATION FDOURES PER TRAP SCHOOL TAX Y N
Of hereby afflontor"that I have•nttitlole of ceuent to opythnre,un a R2-�,g
M,rortiLaeo(Worker'Comprrunlminsuran¢ora¢nuied copythamaf sec. GAS F.A.SYSTEM-I INC4 OUTLETS PARK FEE Y N
Pam, ab CJ
Com Y CAS EA.SYM7EM-OVER4(EA) RECEIl'I'.
Y BUILDING DI VISION FEES
CeniBed ropy b hereby fumldmd. GRFASC/WOUSIRL WASTE WI'HY_FPIOR PLANCHECK FEE
CenNed ropy b Ned with the dty inspection dlvleim.
CERTIFlUTE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION WSfIRANCE SEIVER- STORM STORM FA EDFT Date Ift
(ITlsealbn need n¢be completed uthapermet b fa on hundred do8.n
atDO)nleeeJ WATER HEATER w/VENT/FI,EcrR ENERGY FEE Y
I¢nify that In th.pedomun¢Mthe work brwhlch tw permit I.bsuM,
1'hall nat employ any Peron in any runner n a to become subjet n the WATER SYSIIId/TREATING
worlen'Cmrpm-tbnlawaof Calumnla.Date PAID _
C' Z Applicant NEW RF3DFNMLPLNe. SQFI. D to 1 t
Z O NOTICE TO APPLICANT:u,after making this Certificate of Exemption,you
should become subject in the Worker:Camp.roation provbiona of the Labor pt.
~ U3 CW.,you in forthwith comply with such provblanorthla pend nhallbe *ELEFEE> seamed revoked.
W pCONSTRUCTION LENDING AGENCY aIherubyaf1 that them ba eonnnnlm lerding.geruy far the pedornFTOTAU� Z annofthe workfar wlch thio permit b ianed(Sec 3D97,Clv.C.)V Olender.Name E
U. r I<rd.randdma. QTY. MECHANICAL PERMIT FEF MECHA [CAL
O W bmI mnuythatl have read thio appllatbn aM state thatthe.hwe InformatInformationrm[.I.greetocomplywuhaBckyaMn ntyordln ad Y.telam PERMIT ISSUANCE FEES PA
NTN relating to Wilding mntructlm,and hereby authoebe representativnofthb
ofty to enter upon the.now-mentmna property forwpemon purpose,. ALTFRORADDTOMECR Date Ree tq
(W naw,Indemdy an d keep harondm the City of Cu Ino
Bawllt rea,mn.and upenrnwbkhmaylnanyway...e ADRHANDUNGUNR(TOID,000CPM) SUB TAE:
7 aPWflItheappluaintorfutom
1dC ecce of the geatirig of
pemdL
AIRHANDUNc uNTr rovFR lD,000cFhn CONSTRUCI7 AX
CONSTRUCTION TAX PAID:
of Appll t/Contracts Wte F7(ILAUST HOOD(W/DUCD
HA]ARDOUS MATERIALS DISCIASURE
WBdingomrportatomorhardleh—rdou. HEATINGUNITOO IOD,030 BTU) Date Recti tF
mnerial a.deBred by the Cupertino Mu Nclpal Code,Chapter 9.12,ad the
Hraahhard Safety Code 32p)i FffATING UNIT(OVER l00,ODD 8TU) TOTAL:
W Yes
alto.appBad or tore WBdingo define ua the Bay Ams devlm VENTILATION FANaWGLE RFSiD) ISSUANCE DATE
which eMl havedms air mntamW nee a defined by the Bay Area Ak
• Q_ia lay Management Osvle BOIIER-COMP QHPOR 1W,"RTU)
4 Yn ��Qn
havere H.hav mat ,S eequlre ,2SS33.d255U.95 of eO1LFRCOMP(OVERlo0,00o BTI!)
In.ennaM t Heaith fi Safety Code,Set tm 25505,25533 andt,that 1
uMerwrd that lith.WBdingdoes not mrremy have'tenant,tont ltbrtry NEW RESIDENTIAL MECH. SQFI'.
rapo yto not eocapaod M the requirement,whkh must be men
o ere aCe teofo¢vpany.
ora ori ag est Data ISSUEDBY y(JC'Q I`�/TOTAL:
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