19539 x PLI�ANTTO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Bulldin Pra e<t ldenJfkatlan 1'FR.WT NO.
aa�bg"dd� 19539
ama: one: .
rs i -0t e4 'CITYOFCUPERTINO-BUILDINGDIVISION
Cnn o +Nam: Lb.Ne.. APPLICATION IPERMIT C
N BUILDING-ELECTR1CALPLUMBINGME MCAL CA Y CONTROL#
�ArdflM/Fsgireer Lo,Na
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address PERWTISSUANCE ❑ ❑ ❑
LICENSED CONTRACTORS DECLARATION
Thereby alflrm tlutlam licensed order provWons of Clupbr9(mnvnen APPLIANCESRE9DE1TAl JOBDESCRB'DON
ingwlth Sodton7000)of DIv1Jon3ofthe B,uJ/nmandPrePfeseran Code,and my
lice..is lob f L. feR H G O PANELS
LbnvceCbO G
Dale Co
ntactor �VJI�
ARCHITII PS DECLARATION IDI-1000 AMPS
X7QIuMentard_ey plan sluBbe used wpubllc records OVER I ODO AMPS - SQ.FT.FLOOR AREA $/SQ.FT.
G L ccose i Profmbvl SIGNSELECTRICAL '
5 LGu OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC
Z h., 1 herebyefirenthat l am exempt from the Contractor's License Law for the
following reser,(Section 70315,Buslnm and Profmbre Code:Any city or
O ti� TEMP.METER ORI'(R,EINST.
K� countywhich requlroapemdtto mrowct,alter,hnprove,demoibh,orrtpalr
0anykmmmpr wibb mu al mquWt eapptantf«sit permltto IN)y/gR DEVILS
fie a signed statement that he b Bue sed pursuant to the provalov of me
j u ContrxtoA License Law(Chapter 9(mmmendng with SeNnn 700D)of ad- SWIdh9NG POOL ELECTRIC
t..,�0< elon3 ofine Businmrort
and ProfmioCo1e)orthhely eaemp"herefromand VALUATION
Q !l2.--tt the bels for the alleged exemption. Any violation of Section 7015 by any ggNr1.IC}IESFUCIlJRFS
apphant fora mi
pert sub"the applicant to•civone
vil pelty of not nthan
Ove hundred dollars%W. NEW RESIDENTIAL ELECTR—SQ-FT. STORIES TYPE CONSTRUCTION❑I,as ower of the propony,or my employees with wain u their sok
comperuatim w81 dotbe work and thestvtlurc b not btende i or offered for
Osak(Sec 7014,Busbm and Profmbv Code:The Contractors Lloenee Law
doe not apply to an owner of propeny who bald.or Improve thereogand OCC.GROUP RES UNITS
0. who dmryv
chwork himselforthrgh hisown employee•,prwlde ithat such
Improvements are not Intended oroHertd foreele.If,however,thebulkling or TOTAL
Improvement bead wlthln oneyearofcmnplelbn,the ovner-bullderwW have
t4LIlurdeo or proving that t did not bund or improve for purpose of ask.). QTY. PLUMBING PERMIT FEE "
L,J L as avner of the Property,am excwfvely,contracting with Ileeraed FLOOD TONE AI'N \
contractee to mvtret the pmjed(Se,7014,Buebm and Prdmioro Code: PERMIT ISSUANCE
The Contractor's Liters,Law does net apply to an owner a property who
builds or improve thereon,and who corura"a for such p(oject,with a ALTER-DRAIN&VENT-WATER(EM
q tte,ter(s)uaraed pursuant to the Contractor's Lieve Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
Lf I am exempt order Sec B &P C for this rtawn
Owner Date DRAINS'FLOOR ROOF,AREA,GOND. SANITARY Y_ N—
WORKMAN COMPENSATION DECLAATION RF{m'fa
MR
❑I,hereby of hen that I have a a"iflate of consent to ul!-Twee or• FNTDRFS'PER TRAP SCIIOOL TAX Y_ N_
¢niRrote of Work,,'Comperottiw Insurance ora ce"fled copy thereof(See. RECEIPT
MW,lab C.) GAS PA.SY9'TFM-1 INC4 OUTLETS PARK FEE Y N_
pdk,4 RECEIPT a
Com y GAS,FA.SYSTEM-OVER 4(EM BUILDWG DIVISION FEES
Certified copy Is file dl furnished. GREASE/1N)USIRL WASTE INITFC.-FPTOR PLANCHECKFEE
"Ned copy is filed with the city lropectbn division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATIONceMfft NpeR bfE gEIVER-SANITARY STORM FA aX1FT Date Rceel 1#
Rhux sess.) need oat Mcompletedith<pemdt b(more hundred doliam
a1003orfe.) WATER NEATER W/VENT/EFZTR ENERGY FEE Y 'N
Iartfy mat tithe peAomunm of me work forwNchtw pemW is issued, —
I shall not employ any person In any manner to ars to becoma subject to the WATER SYSITM/TREATING
kcr
Wora'Compeneeino lawn of California. Dm PAID
O Z NU710EApplicanNEW RESIDENTIAL PLMB SQFT Date Recel tit
2 O M7TICETO APPLICANT:to
ftermakingtw Celan pro of Exemption,you
shml,y.. subject Work en'comprevhonprovhispermlons thall�be TOTAL
LU y deemed remusi(a"hwLLh comply with such prvvbbro or this permit shall be
W deemed rtwked. BUILDING FEE
CONSTRUCTION Is a oN,LENon kn AGENCY 5 I IC FEE
O. = Thereby aork(orthat t hihc mrutructionkrding ,Cl for the pedorrtr TOTAL: ELECTRIC FEE
Lenge .N.mek for which[w permit b lesued f$ee 309'/,CIv.CJ
O O Ledve,Add PLUMBING FEE
LL ~ IeM,re naarta, QTY. MECHANICAL PERMIT FEE MECHANICAL FEE d
O W unitytha lha ercadtw appBa lona d btetha theabo logo ma ion
bmrrt".L.grt,mrronplywlthaudty,ndmunryardlnanmanasiatel,ws PFRMrr1$IIANGE Z_OU FEESP IU rad
} N rebtingtobulldingcavtmdiw,and mbyauNarb eprmnutiveoftw !t / ,r 3493
Z cay toenter upon the above-mencbvd property for inspection purposes. ALTFRORADDTOMECH.-
(We)agree to save,indemnify an d keep harmlm the City of Cupertbo Date ReceI t#
V agaW BabiBtie,aidgmenb,coesedl expenses which may lo anywayaccrue AIR HANDLING UNIT(TO IO,OW CFM) SUBTOTAL:
agamar said City In consequence of the granting a this permit.
AIR HANDLING UNIT(OVER IO,=CFAD CONSTRUCTIONTAX
Igv Rof po
nnt/Contractor Date RUST HOOD(W/DUCT, CONSTRUCTION TAX PAID:
HAl R DOUR MATER IALS DI SCLOSU RE
Will the appllantnefuture Wilding mvpee score or hand le havrdoue HFATING UNIT(TO 1WODO BTU) TF-0 Date Recel [#
mrterlal a deneed by the Cupertlm Muradpol Cade,Chapter9.1],and m,
❑t ao Safety Codlrer SextJIm2Sri,77G17 TINGUMT(OVER100,0WBTIp TOTAL: • DD
Y. No
Wdltheappeantaruturcbuilding.pentueecquipmentardevim
VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
4 QualRy Marogement Dierict? advntsudeRvd bythe Bey Arce Alr B0BFR{OMP(31IOR 100.OW BTU) PAID
4Ye No
lavoread m,Heharimw•mater,Sbre lremenbunderChapter695of 0 FRCO.HPOVSIDO,000BTU
the CalfMtn Health&Safety Codas ntlyh1 a and IAM. # JAN 02 175U
underabrd that if the lou Uding tan not currently have+tenant,that ltbmy NEW AESiDEVTIAL MECH. SQFT
resporobll LLy to ratify Rha occvpatd of the ragalmmanb which avast be and ,
Prior to Lsnre d.uaa Cenllkeb of«cvparuy. Cir, ff Nnortinn
0Rer or elihortredagent Date 1. I,
TOTAL (% ISSUED BY: V
OFFICE COPY