20462 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Project IdentificationPERMIT NO,
Building Address
�,d 8 F �� 2046 2
aro Name:
one: p A
tVA Ne 2fj�)^ C17Y OF CUPERTINQBUILDING DIVISION
. Co ischrsNimes: Lte.N. APPLICATION / PERMIT
Qf% P�UM l G BUILDING-MECTRICAL-PLUMBING-MECHANICAL CATEGORY CONIROLN
Arch /Engineer. Lie.No:
QTY ELECTRIC PERMIT FEE BUILDING,PERMIT INFO
ddress:s 2 �Uft//4Z U S - PERFITISSUANCE �(j ❑ ❑ ❑
LICENSEDCONTRACTO 'S DECLARATION �LV
I hereby affirm that l am licensed under provisions of Chapter 9(commene- APPLIANCES-RESIDENTIAL JOB DESCRIPTION
ingwith Section 7000)of Division 3 ofthe Business and PmfessionsCods,and my
Itrenae is In full force and effect �y PANELS
License Cli ss� b? Lic.N Z �—O
Date?'!r3 contnctur�/PZ52 F1 ,'��M�. UP TO 200 AMPSp11000AMPS R�Dvr BI�wE '- TtCf
ARCHIiECPS DLtLARATiON
07. I understand my plarvisballbe used as publicescords. OVER 1030 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
O
Licensed Professional SIGNS ELECTRICAL
IN
OWNER-BUILDER DECLARATION
In Fn SPECIALCI4CUT/
L, G owinghereaffirm hat tato 7 31.5,B fromthe d Professions
Code:
forehe
F O F. following reason.(SMI.n 70415,Badness and I'rofevlov Code:My city or TEMP.M R OR POL• ST.
county which requires a permit to construct,alter,improve,demolish,or repair
Y1 any structure prior to its Wua ace,a[so requires the a ppBcant for sucM1 ,.nrdtto POWER CFS
sr file a signed statement that he is licensed pursuant to the provLstov of the
Contractor'sLicense Law(Chapter9(mmmencingwRhSeedon7000)ofDWI-
30�n don3ofthe Budnessand Pro iovCode)orthathe Nemm thefmmand 'win ECTRIC VALUATION
a Fb Sn the bests for the alleged exemption. Any violation of Sectiont m7MI-S by any OUTLETS HESH
applicant fora permit subjects the applicant to a civil penalty of not more than
five hundred dollars(¢500). NEW RESID AL ELF R
I,as owner of the SQ.FL STORIES 7YPE CONSTRUC'T'ION
property,or my employees with wages v there sole
,7a compensation,sound.the work,
rofmithe struneure is de:The ontractor or License
d for
Law
,08 doe(Sec.apply
Badness and Professions Code:The Contractors Ucense law
p ($ whodoes tapplytoan owvro(property
rough who Wlld,or mploy mproviii ovided thereon,and hat such— OCC.GROUP RES.UNITS
c.S whadoementsa notintelfedorofghhisownemp,howev ,theb building
or
improvementsarenot Intendedprofferedfor sale.ILh nen-gtheerwilI have
TOTAL:
improvement'sapid within oneyearofcompletbMtheowner-bu0derw111 have
th *rden of proving that he did not build or improve for purpose ofsale.). QTY.I PLUMBING PERMIT FEE FLOOD 7ANE APN
Lf L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec.7044,Business and Professions Code:
The Comraaor's License Taw don not apply to an owner of property who ALTER-DRAIN 6 VENT-WATER D:NN
Wilds or Improves thereon,and who contracts for such p(ojects with a FEE SUMMARY
c9tiLictor(s)It...dpu..art to the Contractors License Law. BACK FLOW PROTECT.DEVICE
LJ I am exempt under Sec B& P C for this reason
DRAINS.FLOOR ROOF,AREA,COND. SANITARY Y_ N_
.
Owner Date RECF]PT N
WORKMAN COMPENSATION DECIARATION FIXTURES-PFR TRAP SCHOOL TAX Y_ N_
.J
hereby affirm that I have o mrtNra c o consent to op therm,ora RECEIPT N
3800,last,
Compensation Insurance ora certified copy tM1ercof(Sec. GAS PA.SYSTEM-1 INCAOUTLE75 PARKFEE Y N
polis lab C.I RECFSPI'N
Conry N GAS EA.SYSTEM-OVER 4(EA)Com any BUILDING DI VIS ION F'EGS
Certifled copy is hereby furnished. GREASEANDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
pl
Certified copy is filed with the city Inspection division.
Y' CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEINER-SANITARY-STORM EA ZOOF I' DBIC RCCCI tH
(This section need not be completed lithe permit a for one hundred dollars
(Sl(0)or less.) WATER HEATER W/VENT/ELECTR ENERGYFEE Y_ N_
I certify that in the performance of the work for which this perm Is Iward,
I shall not employ any person In say manner w as to become subject to the WATER SYS.TBM/TREATING
Workers Compensation Laws of California.Date PAID
O Z Applicant NEWRFSIDENTIALPLMB. SQ FT. Date Reciti tq
Z O NOTICETO APPLICANT:ILaftsr nuking this Certificate,of Exemption,you
should become subject to the Workers'Compevatlon provisions of the Labor TOTAL:
2 N Code,you must forthwith comply with such provisions or this permit shall be I BUILDING FEE acx
LU j deencd revoked.CONSTRUCTION LENDING AGENCY SEISMIC FEE L
CL E I herebyafflrmthat there is a construction Icedingagenry forthe perform ELEC'T'RIC FEE
7 Zan"
of the work for which this permit bi Issued(See.3097,CN.C.) TOTAL:
00 lender's Name PLUMBING FEE
LL H Lenders Address QC( QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW Icertifythalhave mad this appliat ...it stmothattheaboveinformatlm
4 Is mnect.l agree to comply with all city and county omdinanm and date laws PERMIT ISSUANCE FEES PAID:
>. 9L to building construction,and hereby authomm representatives of this
f.. Z city to enter upon the above�menRnn,d property for inspection purposes. ALTER OR ADDTO MECH. Date Receiptq
_ (We)agreeto save,indemnify..d keep harmless the City of Cu penin. AIR HANDLING UNIT(IPO 10,000 CFM)
against liabilities,judgments,costs and expenses which may,in any way arems SUBTOTAL:
age last said City in sen once of the granting of this pnermit.
a. AIR HANDUNG UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signature of Appiant/Contractor i Da� EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applla nt or future building occupant store or ha ad Is hazardoes HEATING UNIT CIO 100,OW BT" Date ReceiptA
material as defined by the C.penlno Municipal Code,Chapter 9.1 Z,and the `
Health and Safety Code Section 2SS37(a)7 HEATING UNIT(OVER l00,ON BTN TOTAL: L t )o
0 Yea !III No
Willthe applicant. future building occupant use equipment or devices VENTILATION PAN(SINGLE RESID) I 'DATE
which emit haaardom air contamivsds as defined by the Bay Area Air J
• Quality Management District? BOILFR.COMP QHP OR 100,000 BTU s
YesNo it
[�
Thivereadthehasrtlousmaterials requirementsunder Chapter 6.95of BOMER-COMP(OVER 100,000 BTU) i j4�J
the California Health k Safety Code,Sections 25505,25533 and 25534.I
understand that lithe Wilding does not currently have a tenant,that it Is my NEW RESIDENTIAL MECH. SQ.FT. Mir
responsibility to notify the occupant of the requirements which must W met
prior to isuanceocatco e. an —�L
Owner or authonud agent e, Date ISSUED BY:
TOTAL:
OFFICE COPY