23481 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification - PERMIT NO.
Building Address:
23481
say
nen arae: one: p
dTY OF c P NO-BUOILD SION �•� �a�
connctal.Name: Lm. CATIONMITTNGELECTRICA GIIAMCAL CATEGORY CO L
ArchiteR/Engineer. Lie.Nce
E ERMiT FEE BUILDING PERMIT INFO
Address: P,0'. q, /30X '6 /O SIN/;1)?-r e f I P T CE
LICENSED CONTRACTOR'S DECLARATION
Iherebyalfirm that l am licensed under provisions ol Chapter9(mmmenc I RESIDE �IpBD�RRTION-
ingwithSect1On7000)O(Dlvisnon3ofthe Businnsand ProfesslonsCode,and my 115^JJ1
Breese I.in full fidy�and effect. / PANELS
Llceme Clam_p_Lie.R SO S 7 -
Date Cordractor TQ 7W A
ARCHITECTS DECLARATION 2BI-1
m0 Q I understand my plans shall be,used as public records. OV (S/SQ..FT.FLOOR
AREA a�f//SQ.FT.
Fi
Licensed Professional GNS I
< OWNER-BUILDER DECLARATION SIsFG / YYY
,.., a Ihereby afirnthat l am exempt fromthe Contractor's License Law for
.Ooo following reason.(Section 7011.5,Business and Professions Code:Any or
z TEMP.M LEINSf.
muntywhich
.pH.rlrcst.kama tocaorequi atheapravnkfor, c rrepairtto _
anyatncwre prior tent that
he,W eemad pursuant to the pmab oess of It a �pSygR DEVICES " Zj1.5O
K file a signed statement that M 611cenaed pursuant to the provllons e( the -
3µ Contractors License Law(Chapter 9(mmmenWg with Section 7000)of Divi- VALUATION
SOS aien3oftheBusinessand Profemnons Code)orthat helexemptlomahromand - q SWIs1MING POOL ELECTRIC Nf
6 the ba.l for the alleged exemption. My violation of Section 7031.5 by any V OUTLETS5W17CFlESFIXTUI4ES Q
O applicant fora permit subjects the applicant to a civil penalty,of net more than
five hundred dollarshepr. , NEWRESIDFMIALELECTR' SQ.FT. STORIES TYPE CONSTRUCTION
I,as owner of the a work,y,br my employees with wages r thele door
compensation,will latheworkandion,Code:
13 not Intended oroffered for
q sine(Sec.70Ket pply lbo,lto
owner
nsandf property
Cade:The Cld,or Improsas License Law -
�$ doe. en"such t rkhiw tforth pghhls ion mplolm pmimas thereon,and OCC.CROUP RES.UNITS
whodonduchworkhlmseaorthwgh hlsownemployen,provWed Natsuch
Improvements are not Intended oroffered for sale.If,however,thebullding or TOTA "LTS '
Improvement b sold within mayear ofeempletion,the owner-W Oderwill have -
t1tqkuNenof praying that he did net build or Improve for purpose of saley QTy. PLUMBING PERMIT ,FL'GE FLOOD ZONE , Appr
u 4 ae owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
conlracmrs to construct the project(Sec 7014,Baseness and Professions Code:
The Contractora License Law don out apply to an owner of Property who ALTER-DRAW k VENT-WATER[EA)
Wilda or Improves thereon,and who contracts; for such pko)ecta with a FEE SUMMARY
r'Mctor(U Beamed pursuant to the Contnctols License Law. ' • BACK FLOW PROTECT.DEVICE
C.
IJI am exempt under Sm. B k P C (or thio mason
nllyqtnl
DRAINS FLOOR M
eru
ROOF,AREA,COND. .. SATARY Y N -�
Owner ' Date - RECEIPT If
WORKMAN COMPENSATION DECLARATION FATURFS PER TRAP SCI IDOL TAX Y N'
Ltrrhemby er(Irm that 1 have o lmumne of consent d py tnwre ora RECEIVE M
rertlfiab of Worken'Compensatlonlmurance oracertlfled mpythereof(Sec. CAS F.A.SYSTEM-1 WC60UTLEES: PARKITR Y N
Policy
Isis CJ
Policy M GAS EA.5YSEEM-OVER 4(EA) DING DI M
Cam any BUILDING DIVISION FEES
,ffCerttiled copy is hereby fumidhed. GREASE/INDUSIRL WASTEI EPTOR PLANCIIECK FEE
ncerllOed ropy is filed with the city Inspection division. - L x7 1
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE
(Thissectlen need eat W completed if the permit L furors hundred dollars ' SEWER-SAMTARY-5'TO EA.20oFf. Date RCee) t#
($100)cr Isess.) WATERHEATER ENT/ELECTR ENERGY FEE Y N
1 cectbfytbat In thapeAm
eunce of the work forwhlch this permit is Issued, ,
I shall not employ any person,in any manner w as to became subject to th. WATO4 SY /TREATING /
Workers Compensation Laws of California.Date - PAID '�7 l7Ug
PP Date Recei t#
Z 0 NOTICE TO APPLICANT..If,after making this Certificate of Exemption,you NEWR ENTIAL PLMB._SQFT.
should became sub)ect to the Workers'Compensation provisions of the Labor TOTAL:
N Code,you=at forthwith comply with such provisions orthla Noreen hall be BUILDING
FEE
W > deemed revoked. -
a O CONSTRUCHON LENDING AGENCY _ SEISMIC FEE
IhembyafOrm that there la cansttuction lendiegigeory forth.perform ELECTRIC FEE 'L
MZ ance of the workfor which this permit is issued(Sec.3097,CIv.Q .TOTAL:
V O' Lenders Name PLUMBING FEE
LL F Lsnder.Addmes QTY. MECHANICAL'PERMIT FEE MECHANICAL FEB
OW I amifythat l have read thlappllationand statethat theabovemumamm, ��
1 Is correct.l agree to complywithall etyand muntyordimmea.ed state laws PERMRISSUANCE I FEES PAID:
:i_ 0.
relating to Wilding canstruction,and hereby authorlu representatives of this _
F Z city to enter upon the above,mentloned property for inspection purposes. ALTER OR ADD7OMECH.' Date 'Reeei t#.
— (We)agree to save,indemnlly an d keep harmless;the City of C.NMI. - P
agalnatllabilliies,judgments,caateandexpenses which maybe snywayaccme - AIRHANDLING UNIT 1f1p00CFM) SUBTOTAL:
aS.I tai ty In c...ryuencsyf the granting of this permit. - -
� L' q L AIR HANDLING UNIT(OVER 10,000 CEM) CONSTRUCTION TAX
51thtoofAppiba /Contactor Date EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
the applicant orfuture building occupant store or handle hacadous HFATING UNIT(TO 100,000 BTU)
1. defined by the Cupertino Municipal Code,Chapter 9.1$and the _ Date Revel t#
and Safely Code Sectlon25532(a)7 HEATING UNIT(OVER tf10,000 BTU) - TOT
❑Yes No t
Will the applicant or future building occupant use equipment or devices VGMDLATION FAN(SINGLE RFSID) ISSUANCE DATE
which emit has mdous air contaminantsas defined bythe Bay Area Air
-� Quality Management District? BOILER-COMPOF]POR100,0001ITU)
4 Yea No BOILER-COMP 100,000 BTU) M P A I D
have read the hada oua material requirements under Chapter G95 of
the California IlealthhSafety Code,Sections 75505,25533 and 25534.1 '
underetandthat if the building does not currently have a tenant,that it is my NEW RP51DFNTIAL MECIL SQ'FT APR 23
rdponsibiva tonotifytheonvpantoftherequirements which must be met 'Il1Q/,1��—'1
pdoHoissuance ofdy the
eOvatea(t of the
eq - Is7J\�`a1ea�//i
CIT tr
Owner or authorized agent Data ISSUED 0Y:
OFFICE.COPY 5