20818 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project idenllflulim /�i y+ - PERMITNO.
Building Address: 1622 L VNA�Q C/ /1 O/1 (1
_.PCT C:, J j rwo CA 9:50%4' G �V{ ITJS
rte . me.
CITY OF CUPERT[NO-BUILDING DIVISION
Contractor.N..: Lk.No: APPLICATION I PERMIT C �l
BUILDING-ELFCTRICALPLUMBING-MF-CHAMCA
CAL TEGORYCONTROL(r
Architect/Engluer.
Lie.No: t
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address I'ERh9TISSUANCE ❑ 1:1 a
LICENSED CONTRACTOR'S DECLARATION
I hereby
fthe Bu ....nsof Chapter 9(mmmen APIrLIANCFSRESIDENML - ]OB DFSCRErrION
l�gMit... sInfull 7000)..4 elect Jotlhe Butlnessand Prolleal.neCode,and
license isle s force and efteci, - PANELS (
LlanseCkss Lk.N `
Date Contractor
—UP TO 2DO AMS
ARCHITECT`S DECLARATION 701.1000 AMPS
1Q+�reeO I understand my plans shall be used as public records, OVERIOJOAMPS r--�SQ.FT.FLOOR AREA $/SQ.Fr.
Iz LicensedPmfossloml SIGNS ELECTRICAL
OWNER-BUILDER DECLARATION SPECIALCIXCIJIT/M
2ti 3 Ihereby affirm that l am exempt from the Contraceorb License Law for the
following reason.(Section 7(1315,Business and Professions Code:Any city or
AN
F t'c� i c.untywhichrequlresapemdttommtmdalter,impmve,dem lLLh,orrepair p'MEfpIt ORPO E Sf.
.a anystmcture Intermit.issuance,also requienslheapplianl for such permitto
PDWER DEVICES /
�. file a signed statement that he Is licensed pursuant to the provlsloru of the
3w Contractors License Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELEC
�Oa sion3 o(the Business and Profeul.ra CodVALUATIONe)orthat he is exempttherefromand _
the bash for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWITCHESFI ES �—a L
t]
applicant for a permit subjectslhe applicanlm a civil penalty of net more than l/ J n
$ five hundred dollars($5001,
1,a.owuroflhe property, NEW RESIDENTIAL ELECTR SQ.FT. STORIES TYPECONSTRUCTION'
(^n p perry,or my employees with wage as their sole
compensation,70 Businessl do workand[..Cods:Th.
cm,nactoentended Loffered(or
k O due e.am apply
to Business adPro.[..
pmpssom who builds
Connimmesthe. law
$
who duas
l apply torn owner ofprough�ny whoemplrlmprovnthereory and OCC.CROUP RES.UNITS
w provemucb are nothimselfIntended
oro ffered ownale.It yeeverprovided buildbu.h
Improvementsarenot Intendedoroffemdfor to If,h nor-gthebuildingve TOTAL:
Improvement bwld within.neyearn(compltlorytheowner-bullderwlll have
X.
proving that he did not build or Improve for purpose of sale.). QTY, PLUMBING PERMIT FEE FLOODZONE _TPN_
as owner of the property,am exclusively contracting with licensed m to emntmct the project(Sec.7044,Business and Professions PERMIT ISSUANCE Code: _
' The Contractors License Law does not apply to an owner of property who ALTER-DRAIN k VFNL-WATER(E U
builds or improves thereon,and who contracts for such pipjets with a FEE SUMMARY
egIl[ia.torp)licensed pursuant to the Contractor's License Law. BACK FfAWPROTFfT.DEVICE
LJ I am exempt under Sec B k P C for this reason
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y— N_
Owner Date RFCEPr N
WORKMAN COMPENSATION DECLARATION
❑ mftarem pp(T()gpS.
PER TRAP SCHOOLTAX Y_ —
N1 hereby affirm that I have a nite,of consent to self-Insu , a RECm NN
mnitlateof Workers'Compematlonlm mmoraanifledmpythereof(Sec. GAS EA.SYSTEM-]INC.401JTLETS PARK FEE Y N
3800,Lab CJ - —
Pollq p RECEIPT'#
CAS EA.SYSTEM-OVER 4(EA)
Com any BUILDING DIVISION FEES
�Certlfled copy is hereby furnished. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
❑Certified copy is(fled with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID �1fA1�
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 70UFT Date Revel tin Li�"4
CTM.se tion need n.[be completed lithe penNt is for one hundred dollars
($1I cumless3 ENERGYFEE Y N
Iarti(ythat in the performance of the work forwhlch this permit is issued, WATER HEATER d
TER W/VENC/ [CTR —
I.hall not employ any person In any manner so as to become subject to the WATER SYSTEM/,TREATING
Workers'C.mpenutlon laws a/611fomla.Date PAID
Z Z Applicant - - NEW RESIDENTIAL PCMB. SQFf. Date Revel t#
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
Hshould become subject to the Workeri Comperuallon provisions of the Labor TOTAL:
tl3 Code,you at forthwith comply with such provisions or this permit shall beBUILDING.
FE
W > deemed revoked. -
0. c CONSTRUCTION LENDING AGENCY SEISMIC FEE 1
Ihembyaffihat there is a mrotrution lending agency for the perform ELECTRIC FEE
Z an.ofthe workfor which this permit he twed(Sec.3097,CIv.CJ TOTAL:
.U O lander.Name PLUMBING FEE
IL H Lender's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
0 W IcenlfythatIMa madlhbapplimtlonaMdatethattheabovelnformatlon
courmct.I agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE
C GEES PAID:
r relating[.building mn.Wtlon,and hereby authorize rcpresenlativea.(this -
N city to enter upon the above-mentioned property for Inspection purposes, ALTERORADDTOMECH.
? (We)agree to save,Indemnify an d keep harmless the City of Cu Fortino Date Reeei tR
L.I agairut lWbNHea,pdgmenb,c.etsend expense which may In anywayacerm AIR HANDLING UNIT(TO 10,000CFM) SUBTOTAL:
against said con uence ofthegrant7ngaftNeperm11. ,,
---°�� AIR HANDLING UNIT(OVER I0,000CFM) CONSTRUCTION TAX
PAiCONSTRUCTION TAX PAID:
S
.hm,1xffApootra?tmVto EXHAUST HOOD(W/DUCT)
HAZARDOUS MATERIALS DISCLOSU
Will the applicant or future building occupant store or handle haurduos HEATING UNIT CFO 100,000 BTU) Date Recel tin
materials.defined by the Cupertino Municipal Code,Chapter 912 and the -
. health and SafetyC ion 25537(.)7 HEATING UNIT 100,000 BTQ TOTAL:
❑Yes No
Will the applies nt or tum bu llding occupant use equipment or d strives VENTILATION FAN(SINGLE RISID) ISSUANCE DATE
which emit harurdous or
ronlan inns as defined by the Bay Ama Air
Quality Management D'ut t7 BOILER-COMP DID OR 100,000 BTU) �p yy
4 Yn . P—A
have read the Fazar oM mode,Se requirements under M3aChaple4.1 of BOILER-COMP(OVER IOO,000BN)
the Callfomk Health& din Code,Sections25505,2M3have
a tenant,
d7fihat it AUGmpunderatanity to if the the ocgdoe not erequire artsw which
that it mot NEW RESIDENTIAL MECH. SQ.FL " 81990
roporuibility to notify the occupant of the requlrcmenta which muslbe met
prior to a g6LCvjt1ficote ofOcapancy,
a o sad ag Dat ISSUED BY: r i1
TOTAL:
OFFICE COPY