24435APPLICANTTO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification -
Building Address:
�eF,v��_ grip
PERMIT N24435 O
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nen arse: hone:
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1 '<(�. i '�U ►� P�A
"TYOFCUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
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1
c d Lie. No: -
BUILDINGELECTMCAI.PLUMBING-MECHAMCAL.
CATEGORY CONTROL -
Arehltect/Engineer, Lk. No:
Qn 11 ELECTRIC PERMIT F1313BUILDING
PERMIT INFO
Address: -
BLDG ELUL] PLUMB Mk�ff
LQ
Ej rM ❑ ❑
PIRMITISSUANCE ��
LICENSED CONTRACTOR'S DECLARATION
I hembyaffirm that l am Beensd under provisions of Chapter9 (commec
ingwlth Section 7000)of Divi i..3ofthe Busl...a dPmfesio.Code,and my
Ii... Ie in full force and effect.
Licenseckm Lk.a
APPLIANCES-RESIDEMTAL
JOB DFSCNITfON
P,
PANELS
'
Dale Contractor
ARCHITECTS DECLARATION
I understand my plane shall be used u public records.
' �. S4-6— 1 1
201-IOWAMIS
OVER IODO AMPS
SQ. Fr. FLOOR AREA $/SQ. FT.
SIGNS ELECTRICAL -
U ... d Professional
Spp-CIAL CIl2CUfT/MISC
OWNER -BUILDER DECLARATION
Ihereby af8rmthat l am exempt from the Contractors License Law for the
II {n� ® M
I gI
1 , ' ^�
1PN.P.METFROR POLE [NST. ` .r
POWER DEVICES iI h
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following reason. (Section 70315, Business and Professions Code Any dty or
countywhlch requires a permit mcorutruct, alter, Improve, dennlish,orrepair
anyswnure prlortoftsIssuance, also requlreslheapplicant for such permit to
file a signed statement that he 1s licensed pursuant to the provisions of the
ContractoesLicense Law (Chapter 9(commencing with Section 7000)of Divi-
s1oe3 of the 8u einem and Professlo. Code) orthal he k exempt therefrom and
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as �.�
A
- - 1•
SWR•1MING POOL ELECT -RIC
the bash for the alleged exemption. Any violation of Section 70315 by any
applicant fora permit subjectthe applicant to a dvll penaltyof na more than
OUTLETSSWI3'CHFSFIXTURFS
��—
"
NEW RESIDENTIAL ELECTR SQFT.
five E]1, as ownered of the pro their sole
❑1,as owneroftheproperty,orhe employeewithwages
STORIES TYPECONSTRUCTION
compensation, hework.andlhes Wended r for
od e:rehe Cmdact.eet
dile (oxes See,70Kto alnowner andf Licenced
KBu.tru Code:
sthreme law
I
property who or improves
dh.d tapplytoan i.lf.,th pgh who Wilda.y.m,p idhdthn, and
owns.
whoovementsa
OCC.GROUP RES. UMTS
improvements not howevep
If,hoe, however,
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ithmoneyearfcomoruk.If,
Improvement fesold wlthlnone year.fcompletloM thcowner-bu0derwillhave
deer ill have
'
ll)�rden of proving that he did not Wild or Improve for purpose ofcakJ.
u I, as owner of the property, em exclusively contracting with licensed
contractors to construct the perfect (Sec. 7654 Business and Professions Code:
QTy, PLUMBING PERMIT FEE
FLOOD7DNE, APN '
PERMIT ISSUANCE.
The Contractor's Limnos Law does not apply to an owner of property who
Wilda or improves thereon, and who contracts for such pipjeds with a
c actors) licensed pursuant to the Contractors License Law.
LJ I am exempt under Sec., 8 k P C for this notion
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ALTER -DRAIN &VENTWATER (EA)
FEE SUMMARY
BACK PLOW PROTECT. DEVICE
DRAINS FLOOR ROOF, AREA, COND.
FIXNRFS PER TRAP '
SANITARY Y N
RECEIPT a
Owner Date
WOR KMAN COMPENSATION DECLARATION
01 hereby affirm that I have a corli8cam of consent to self -insure, ora
ao(Workers'CompewHonl.urance oramrtlfied appy thereof (Sec.
3800,ab CJ
Lab
SCHOOL TAX Y_ N_ -
RECEIPTNa
GAS EA. SYSTEM -1 INCA OUTLETS
-
PARKFEE Y N—
Poll M
P
RECEIPT#
GAS FA. SYSTEM -OVER 4 (EA)
Y
BUI LDING D I VISION FE ES
ehined. la herebyfurnished,the city
Certified copy V Ned with the city Lpectlon division.
GREASE/INDUSIRU WASTE INTERCEPTOR -
PLANCHECKFEE
GREASETRAP I
CERTIFICATE OF CC M. FFION FROM WORKER S'
PAID -
1.
SEWER -SANITARY -STORM EA. 200FT.
COMPENSATION INSURANCE -
(Dissection need not be completed lithe permit V furans hundred dolls.
Date Recel t#
I WATER HEATER W/VENT/ELECTR
ENERGYFEE -YN '
PAID
($1 I0)orle
[certify that In the performance ofthe work forwhich this permit is issued,
I shall not employ any person In any manner n as to become subject to the
Workers' Compensation Lawn of California. Date
WATQt SYSTFA7/TREA73NG
_
Applicant
NODCETO APPLICANT: R, after making this Certificate of Exemption, you
should become subiect to the Workers' Compensation provisions of the Labor
Date Recel t#
NEW RESIDENTIAL ['LMB. SQ.FT. -
TOTAL:
Code,you must forthwith comply withauch Em almismthla perndtahall be
deemed revoked.
BUILDING
-
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
Ihereby af8rmtlat there is a construction lending agency forthe perform-
ancoof the work for which this permit 1s Issued (Sec. 3D97, Civ. C.)
TOTAL: -
ELECTRIC FEE
PLUMBING FEE
Icnder'n Name
Lender's Address -
1 cadifythatl have read thisapplleatlonend state thattheabovelnformation
Is correct l agree to comply with all cityand county ordinances and state laws
QTY. MECHANICAL PERMIT FEE
MECHANICAL FEE
PERMIT ISSUANCE -
FEES PAID:
relating to building coretruction, and hereby authorize representatives of th]
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cilyloenterupontheab.ve-mentioned property for Inspection purposes.
(We) agree to save, Indemnify an d keep harmless the City of Cupedlm
against llabllltles,pdgments saandexpenses whlchmaylnanywayacaue
agal.t old Cl In cons nmpllhe gra s gor lhb permit
' I%
ALTERORADOTOMECH'
,. Date - RCCe[#
I P
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AIRHANDUNGUNIT(TOloDWCFM)
- SUBTOTAL:
AIR HANDLING UNIT (OVER IO,OWCFM)
CONSTRUCTIONTAX
V?/
antcre of Applicant/Coract. Dat i
HA2AARDOUS MATERIALS DISCLOSURE
EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID: -
HEATING UNIT CTO 100,ODO BTI])
Will the applicant or future building onv pant store or hand le hazardous
material ars defined by the Cupertino Municipal Code, Chapter 9.1 2, and the
Date Recti t#
BEATING UNIT (OVER I00,000 BTU)
TOT
Iieallh and Safety Cade Section 25532(a)7
❑ Ye No
VFNDLATION FAN (SINGLE RESID)
-
ISSUANCE DATE.
Will the applicant or future building occupant use equipment or devices
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management DlsMct7
4Yea ❑ No
havereadih.Ith&Sossa material, Cbanter &95 of
- �,,� - -
Bap
1J
BOILER-COMPOHP OR 100,W BTU) _
BOLER-COMP(OVER 100,00 BTU)
llu 255entsunder
25534.1
theersta dla H.Ithk building
Code, Soct10 entry have at tenant,
undnratandthat ullding does eft. requirments tenantthat it
N0V as
IV V a 1992
NEW RESIDENTIAL MECH. SQ.I•T
neally
r¢po.iblllty, to notify the occupant .(the requirements which moat be and
mot
priori. Issuance ofd Certificate.!Occupanry.
7 '
/.11 t, �.
V�..U�\T�/LU��r
.
c/r�/y�
ISSUEDBY: "�/a/ aV
Owner or authorized agent` Date
TOTAL:
OFFICE COPY