21347APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification
Building Add
Address:
.I �1O PERMIT NO2.
��
wnera came one:
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CITY OFNPERTINaBUILDINGDIVISION
APPLICATION 1 PERMIT -
1,2.4/— 9d „
Cant ar'sNamo: Go. No:
.24 SSD f
BU[LDING-ELECTRICAL.PLUMBING-MECHANICAL
CATEGORY
CONTROL #
Architect/Engineer. Lle. No:
QT'!' `:' 1 EtifiCTRIC PfiR1G1IT }-IEEE Pt;
'"BUILDING PERMIT INFO
r
Address: i,.
PERMITISSUANCE
❑ ❑
LICENSED CONTRACTOR'S DECLARATION
IherebysRlrmlh.11.mlcensedunderpro Wonsof Chapter9(mm m
ingwith&coon 7O 0)ofDlvlelon3ofthe BuYnessand PmfeaYom Code, and my
licenselsln (u o aeffect. 9
Llrenee.l.f cite 's'</.laa+/ :
APPLIANCES -RESIDENTIAL
- ]OB DESCRIPTION
.A
-
PANELS
Dale i.y7— Contractor Qno�,
UP TO 2DOAMPq_
201-1000 AMPS
ARCHITECTS DECLARATION"
'
OVER1000AMPS
SQ. FT. FLOOR AREA
S/SQ. FT.
'
I understand my plain shall be used as public records.
SIGNSELECTRICAL -
Licensed PrfesYaml
OWNER -BUILDER DECLARATION
I hereby afflrmthat l am exempt fromthe Contran orb License law for the
following reason. (fiection 7031.5, Business and Professions Code: My city or
county which requires a permit tommtmet,alter, Improve, demolish, or repair
SPECIALCItCU1T/MLSC
_
`
TEMP. METER ORPOLE INST.
any.tmcture prior to its Issuance, also require. the applicant for such permit to
file a signed statement that he is licensed pursuant to the provisions of the
ContraRorb License Law (Chapter 9 (commencing with Section 7000) of Divi-
Yon3 ofthe Busmeesand ProfessioneCadhOmthat he bexempl therefromand
the basis fora permit alleed exemption.
the basis forthe alleged exemption. Any applicant tolacivi of Section 7031.5 6y any
ptin.the Anyation of penalty of not room than
five hundred dollars ($.500).
. Q [, as owner of the property, or my employees with wages as their sole
POWER DEVICES
^
SWIMMING POOL ELE CERIC
OUTLEISSWITCHESHXTUR
�aVALUATION ..
vp / _ / W
/ r
"
NEW RESIDENTIAL ELECTR SQ.FT.
STORIES
TYPE CONSTRUCTION
compensation, will do the work and the structure is not intended or offered for
sale (Sec. 7044, Buslneas and Professions Cade: The Contractor's Licerae Law
does not apply to an owner of property who Wilde or Improves thermn,and
who does such work himself orthrough hisown employees, provided that such
_
OCG GROUP
,
HIS. UNITS
Improvements are not Intended or offered for sale. If, however, the Wilding or
Improvementismldwlthinoneyearofcomplelion,the owner-bulWerwlll have
IV TOTAL:
tfle�urden of proving that M did not Wild or Improve for purpose of sale.).
LJ L as owner of the property, am exclusively contracting with licensed
contractors to combatant the project (Sec. 7054, Business and Professions Code:
(27y;. B ERMIT
p(.pOD ZONE
APN
."FEE
""W"
The ContnRor's License law does not apply to an owner of property, who
Wild. or Improves thereon, and who contracts for such projects with a
,LLt{'+ctor(s) licensed pursuant to the Contractor, License Lew.
I [ am exempt under Sec. B & P C for this reasonOUTSIDE
ALTER & WATER (EA)
FEE SUMMARY
gAIX T. DEV
FEES
D R A COND.
SANITARY Y N
RFGEIPI' #
Owner Date
WORKMAN COMPENSATION DECLARATION
ereby affirm that I have a certificate of consent to self -Insure, oraMT*S
mddddddlflcate of Workeri Compereginalmammos ora certified
PERTRA�k
SCHOOL TAX . Y N
RECEIPT #
•SY -]
,OUTLETS
PARK FEE Y N
RECEIPT#
copythereof(Sec.
3�� bC.�Cf%'�0%iO3
C EA. -0164 �`)
Co�m�0000any 6i1 !.�
BUILDING DI VISION FEES
I ICertlfled copy bhereby .(umlehed.
I�.i�-Vrrdfled copy b filed with the city inspection division.
CREASE/ sTTiL WASTE INTERCEPTOR
PLANCHECK FEE
GREASE
CERTIFICATE OF IXEMPTION FROM WOR KERS'
COMPENSATION INSURANCE
(Thb.eneed notWm
copd i(
letelhe permit btorose hundred dollars
PAID
Date Recel t#
SEWER -SANITARY -STORM EA. 200Ff.
WATER HEATER W/VENT/ELECTR
ENERGYFEE Y_ N
N—
PAID
(8100)orless.)se.)
Icertllythat in the performance of the work far which this permit le blued,
I shall not employ any person In any manner so as to became subject to the
Workam Compensationlaws of California. Date
WATER SYSTEM/TREATING
Applicant -
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you
.hould become subject to the Workers'Comperwtion provW ofthe Labor
Date Recei t#
NEW RESIDENTIAL PLMB. SQbT.
TOTAL:
Code, you mu at forthwith comply with such provisions or this permit shall be
deemed revoked.
-
U G FEE
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
Iherebyaffirm thaltherebammtmction lending agency for the perform-
ance of the work for which this permit b issued (Sec. 3097, Civ. C.)
TOTAL:
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ELECTRIC FEE
QTY. - :' MECIIANICA(PEkMIT "' FEE'
PERMITISSUANCE
PLUMBING FEE
Iendar, Name
Lender's Address
Ice rtlfythatlhavereaathbapplicati ... dg.teth....... veirmnroatlon
ismrrect.lagreeta complywilh all cilyand county ordinances and Yate laws
MECHANICAL PEE
FEES PAID:
relating to building construction, and hereby auNorize representatives of this
-
citytoenter upon the above-mentioned property for Inspection purpose..
' (We)'agree to save, Indemnify and keep harMeas the City of Cupertino
ALTER OR ADD TO MECH.
Date RCCei t#
SUBTOTAL:
against b111tles,judgments,cosmande nses whichmaylnanywayac'rnm
again Id Ci in conaaen it anHngoflhisperrnit.
AIR HANDLING UNIT (TO 10,000 CFM)
-
AIR HANDLING UNIT (OVER 10,000CFM)
CONSTRUCTION TAX
Slicnitureof pppplliicca`-et//CoetmaorDate
E)(FIAUSTHOODM/DUCT)
CONSTRUCTION. TAX PAID: •
HAZARDOUS MATERIALS DISCLOSURE
'
HEATING UNIT (TO IOD,ODO BTU)'
Will the applicant or future building ommpant atom or handle hazardous
material as defined by the C9upertmo Municipal Code, Chapter 9.1Z, and the
Date RCCei t#
HEATING UNIT (OVER 100,000 BTU)
iTOTAL.
HealtYed Safety Cod Non 25532(a)7
❑
- VENTILATION FAN (SINGLE RESID)
ISS TE
Willtheapplimnt future building occupant useequlpment ordevices
which emit hazardous ab co taminants as defined by the Bay Area Air
(�J Management Dl 7
gOR.ER-COMP OHPOR 100,OIU BT U)
Yea o
DEClty
AJ A
'S q
BOILER-COMP'(OVER 100,000 BTU)
Ihave read the baz do.. materials requirement under Chapter 6.95 of
the California Health Safety Cade,Sectlora25505,75S33and25534.I
understand that if the building does not normally have a tenant, that It Is my
retponsibilitytorcal themnopant a requirements which must be met
"'V aft �!�pjPAta.�
NEW RESIDENTIAL MECH. 5Q.FT
prto Earn ce of a aifi to of c any,=S!Pj
Qvneroraulhorired agent Data
ISSUEDBY: V fir, U�
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TOTAL:
OFFICE COPY