22466APPLICANT TO FILL IN INFORMATION WITHIN RED LINE POINT PEN ONLY
' Building Project Identification I�f . 1- LQ '--1
BuBdingAddreay�+l` �! i•
- PFRhllT NO.
Y 22466
CITY OF CUPBRTINO-BUILDING DIVISION
APPLICATION / PERMIT 4
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C, era r ' ue.N :
Architect/Engineer. Lk. Na:
BUILDING-ELECTRICALPLUMBINGMKHAMCAL
CATEGORY.
CO=
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{(OObb CC77
QTY ELECTRIC PERMIT "FEE
BUILDING PERMIT INFO
Addrcm: " r
5 Y
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PIRMITISSUANCE "'
LICENSED CONTRSDECLA RATION
Ihereboi.E70that lam B.e3.funderpemand mfmsioiChapter9de,aAd e-
under
7000)o.d effl.n3o(the Bustnemandl'rofesslmsCode, and my
)i.e.h in
Lt nm la In full farce and d(ect.
Llanx CWm Lica
APPLIANCCSRESIDENTIAL
JOB DESCRII'IION
L ,
n
PANELS
Dale _Contractor
s
201-1000 IS
ARCHITECTS DECLARATION
I understand my Alam shag be used as public records.
OVER 1000 AMPS
. FT. FLOO EA
$/SQ. FT.
SIGNS ELECTRICAL
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby afflrerthat I am exempt from the Contractor's License law fee the
following reason. fSectbn70315, B.M....ed Professions Code: Any city or
cmntywhkhmqulresaper ttocomtrud,aller,impmvgdennlbh,orrepalr
p TN
-
anydructure pdorto its issuance,aho requirmtheappllcant for uch permltto
file a signed statement that he is licensed pursuant to the provisions of the
Contractors License Law (Chapter 9 (commencing with Section 7000) of Dlvi-
�sion3o(the Bualnessand Profemlom Code).rthatha W..empttherefrom and
.
S G LL
ALUATION
the basis for the alleged exemption. Any violation of Section 7031.5 by any
applicant fora permit subjects the applicant to a civil penally of not rrorethan
five hundred dollars ff50N.
❑ 1, as owner of the property, or my employees with wages as their sale
c mpensation,wBldo the work and the sinecure isnot Intended or offered for
[1TI ETS
TYPECONEIRUCJ
_
NEW RLSIDENTTALE TR SQ'r'
sale (Sec. 7014, B.dread and Profession Code: The Contractors License Law
does not apply to an owner of property who Wilds or improves thereon,and
who daessuch work hinueB or through his own employees, provided that such
R
RES. B
Innime ants arc not Intended oioffered!or sale. If, however, thebuilding or
improvement bwld withinoneyearafcompteloNtheowner-W IlderwBl have
T
tlItturdan of proving that he did not Wild or Improve for purpose o(mle.).
u I, as owner of the property, am exclusively mnlratting with licensed
contractors to coatmet the preject(Sm 7614, Business and Preffeadom Code:
PLUMBING
QM PLUMBING PERMJT FEE
FT,pODZGINE
APN
ISSUANCE '
(
The Contractors License Law does not apply to an owner of property who
Wilds or Improves thereon, and who contracts for such p(ojeche with a
cgDllactor(s) licensed pursuant to the Contractor's Llrense Law.
I_J 1 am exempt under Sec B k P C for thin reason
ALTER -DRAIN k VEM- WATER (EN
FEE SUMMARY
BACK ]II.OW PROTECT. DEVICE'
nu FI
DRAINS• FLOOR ROOF, AREA, CONI.
FIXTURESPERTRAP /
SANITARY Y_
RECEIPT a
SCI'IOOL TAX Y N
REC=N
Owner Date
C11 hereWORKMAN COMPENSATION DECLARATION
by affirm that I have a•ttrtlBmte of consent to self -Insure, or a
certificate ofWorkeW Compensation lmunnm or a certlfkd copy thereof &c.
3800, Lab C.)
CAS EA. SYSTEM -1 WC.40UTLEIS
PARK FEE Y_ N
Polley N
N
RECEGAS
FA. SYSTIMAVER 4 (EA) -
y
DING DT
BUILDING DIVISION TEES
CnAffect copy h hereby filed the city
ertl6ed espy h tiled with the city inspection division.
GREASE/LNDUSIRL WASTE INTERCEPTOR
PLANCHECK FEE
GREASE TRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
PAID a s�'y 7�rq( (-1'7(:P
COMPENSATION INSURANCE
(Thiseaction need nae be completed lithe permit b foram hundred dollars
($1I urly that
Irnrti(y that In the performance of lhework for which this permit is issued,
I shall not employ any person friary manner e, m to become sublect to the
Workere'Compematlon Lawsof Callfomla. Data -
Date Recti t#
SEW PR -SANITARY -STORM EA 200F1'
WATER HEATER W/VENT/ELECTR
ENERGYFEE Y 'N
/—�
^1 1 -TL �p.-� ry G
PAID I^ ✓I O
WATER SYSTEM/TREATING
-
AppNOTICE
NOTICETOAPPLICANT:e after making this .tion lum'61 o theLyou
Code,shoulbecome subject to the ply evu edech pmaisimprovhis p ofthe Labor
dramod umustforthwith comply with each provhlom or this permit shall be
deemed revoked.
Date Remi t#
NEW RISIDENTIALPLMB. SQ.FT.
TOTAL:
B E -
CONSTRUCTION LENDING AGENCY
Ihcrcby afRrtnthat there ha mmimdlon lending agency (or the perform
a.. of the work for which this permit is •^ml(Sec. 3097, Civ. C.)
TO
Q
Icnderb Name
LendersAddress
that l have read thhappllcat(onand statethat theabove information hcormd. I agree to comply with all cilyand county ordinances and state laws
QTY. MECHANICALPERMIT FEEIarelfy
OER
PERMITISSUANCE
4TAX
relating to Wilding romtrudion, and heraby authorize representatives of thincity to enter upon the above-mentioned pmperty for Wpecilon purposes.
Me) agree to save, Indemnify and ep learrNess the Clty of Cu Alm
agalmtlia lm,jodgments,cosrs a ex meawhlchmsyla accrue
xgelnae Ity conseque o he min fthbperml A
ALTERORADDTOMECH.#
AIR HANDLING UNIT (TO 10,000 CFM)
L:
AIR NOLING UMT ICVER l0,006CFM)
CONSTRUCTIO
y
—
'Iga of Appli.F Contract. Data
ExRAUSTHOODfw/DUCT)
CONSTRUCTIO TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
HEATINGUMT(TOI00,00OBM
_
I the applicant or future Wilding occupant store or handle hazardous
materhlasdefined bythe Cupertino MunicipalCode, Chapter 9.12, and the
Heallh and Safety Cade Section 25532(.)7
rl Yea MN.
-
•'
Date eeel t#
HEATING UNIT (OVER 10B000 BTU)OT
- '
�%
VENTILATION EAN(SINGLE RESID)
ISSUANCE DATE
'
Ill the applicant or future building occupant use equipment or devices
which emit hazardous air contami®nts as defined by the Bay Area Air
Quality Management District?
Yes No
BOILFR-COMP OHPOR 100,000 BTU)
BOILER-COMP(OVM 100,000 BTU)
have read the hazardous materials requlrcmenh under Chapter 6.95 of
PAD
B PY .
the Cel1lornh I Imlth 6 Safety Code, Sections 25505, 25533 and 25574. I
NEW RESIDENTIAL M[!CH, SQ.FT.
undenexpntandthat lithe the ing doesocupart not a rmatly have equirmnts whichl, that it met
rcspomiblllty to notify the aavpant of the requirements which must be mel
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iD
-
prior to Issuance of a Certificate of O.P. ary.
O t.
��-{(Tt U
ISSUED BY: `s
Owners authorized agent Date
`_
OFFICE COPY