22029 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Proen Identification PERMIT NO.
9u11tling Address: /'I/"I
A6- pHye ,gp ,� G G O f")^
2 9J
ams: one:
p. Aj CITY OF CUPERTINOBUILDING DIVISION.
APPLICATION /PERMIT Y`/` C?/CONTROL N
A
c°est n^:• ame� /A 3 LIe.Ne:a - BUILDINGELECTWCAUPLUMBING-MECHAMCAL CATEGORY rchitect/Englomr. Lie No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addmm: - PERMITISSUANCE I�I ❑ ❑
LICENSED CONTRACTOR'S DECLARATION I�{
I hereby affirm that l son l:cmmd under Evens of Chapter 9(mmmena APPLIANCES RESIDENTIAL JOB DFSCRI'TI N
ingwlth Sedion7000)of Dlvlslon3ofthe sine an aCod
Jim Is in full f and effect. PANELS
LI LIc.N
Dale s.I�/ Contract
ARCHI ECLARATIO 701-IMOAMPS
q�qw&v ceO zpo Iunderstandmypkva
ARC;
used as public records. OVERIOWAMPS SQ.Fl%FLOORAREA S/SQ.FT.
6U� Licensed Professional SIGNS ELECTRICAL
�<661 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC
IF
Cella Ihemct
byaflmothe lam exempt the Contraor'•License Law for the
Eppppp following reason.(Section 70115,Business and Professions Code:Any city or
r,4 2 county which requires a permit in mmtmct,alter,Improve,demolbh,or repair TEMP.METGRORI'OLE INST.
qanystructure prior to its enuaret also requires the applicant for such permit to POWER DEVICES
t5 a file a signed statement that be is Bernard pursuant to the powtsloiu of the
O63qE. Contractors License Law(Chapter 9(commencing with Section 7000)of Divi. SWIMMING POOL ELECTRIC
sif)
pH�OJ on3o(the Bualneu and Pmfemlmu Codk e)°rthIo he exempt therefroVALUATlO
mand O D
g x.••.57777 the basis for the alleged exemption. Any violation of Section 7011.5 by any OUTLETSSWITCHESHXTURES 7, o
O O
�u
applicant fora permit subjemthe applicant to a civil penalty of not morctlun
Ove hundred dollen(¢801.
�n
F1 1,as owner of the property,or my employees with wages as their sok NEW RESIDENTIAL ELECTR SQ.FT. STEs TYPE CONSTRUCTION
C
compensation,will dothe work,and the structure E not Intended or offered for _
5 O role(Sec.7044,Business and Professors Code:The Contractors License Law
B does not apply to an owner of property,who builds or improves thereon,and OCC.GROUP RFS.!/NITS
W whodreaauchworkhimmlforthrough hieownempl°yees,provided that such ...
Improvements are not Intended oroffered forsale.If,however,the Wildingor TOTAL:
Improvementissold within oneyearofcompiMion,theowner-bullderwlll have
the burden of proving that he did not build or Improve for purpose of sole.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
F-1 L as owner of the property,am exclusively contracting with licensed ( PERMIT ISSUANCE
centractons to construct the pmject(Sec.7064,Bushes,and Professlora Code:
The Contractors License Law does net apply to an owner of property who PETER-DRAIN kVENTWATER(EA)
Wilds or Improves thereon,and who contracts for such pkajeci -
a with a FEE SUMMARY
c'gn(amws)Ilmnsed pursuant to the Centractora License Law. BACK FLOW PROTECT.DEVICE
t r i am exempt under Sec. B k P C for this reason
DRAINS-FLOOR ROOF,AREA,COND. SANITARY Y N
Owner - Dale RECEIPFN
WORKMAN COMPENSATION DECLARATION Oe 6
�I hereby affirm wFIXTURES.PER TRAP V SCHOOL TAX Y N that I have a certificate of consent to self-lnre,or O
At ale of Worken'CempeMation Wurantt ora ttrtl(kd copythereof(Sec. RECEIPT
3800,1. C1 ^ GAS F.A. M
A.SYST -I INCAOUTLETS PARK FEF. Y N
Policy 0 01 V4.-�C.�.oy LO RECEIPT M
CAS PASYSTEM-OVER 4 LEA).
BUILDING DI V1810NITES
mfled copy b hereby furnished. GREASE/INDUSIRL WASTE INTERCETOR PLANC14ECK FEE
�CertNed copy b filed with the city Irupectlon division.
CERTIFICATE OF EXEMPTION FROM WORK ERS' CRE'A'SE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 200FT. Date Recel tU
(This melon need notbecomplMed B the permit b for ora hundred dollars
($10Borlem.) WATER HEATER W/VENT/ELEC'TR ENERGY FEE Y N
l certify that In the performance of the work forwhich this permit is issued, N—
I shall not employ any person In any manner an an to become subject to the WATER SYSTEM/TREATING ,J 0
Workem'Compensation laws of Califomk.Date PAID
z Z NOTICE NEW RESIDENTIAL PLMB._SQFT. Date ApplicaRCcel t#
Z Q NOTICE TO APPLICANT.If,ager making the Certificate of Exemption,you
should become subject to the Workers'Compematlon provisions of the Labor TOTAL:
P:
N Code,you must forthwith comply with such provisions or this permit shall be BUILDING
IL j deemed revoked.
a C CONSTRUCTION LENDING AGENCY SEISMIC FE•
Thereby affirm that there bammtmction lendungagency for the perform U ELECTRIC FEE ,1�{ /
Z ance°fihrw.rkf.rwh1chtht,permit bbsued(Sec.3097,C1v.Cd TOTAL: D.0
U O F<nder's Name PLUMBING FEE
LLF= Lenders Addmm QTY' MECHANICAL PERMIT FEE MECHANICAL FEE
OW lmrtlfythatI have madthb appllcatl°nand nate thattheabove Information
S 6comect. remto comply with all city and county ordinances and state laws PERMITISSUANCE FEES PAID:
N rclatl o Ilding mmtmctlon,and hereby authorize ntailvesofthb
H Z city enter Pon the above. est red property for o_P.
purposes, ALTER OR ADDTO MECH. Date RCtei til
(We)a re to an d keep bar em th Ity of Cupertino P
V abatl Illd d ta, sand n whic yin anywayaccme AIR HANDLING UNI't'(TO IO,Wp CFM) SUBTOTAL: .7
gels aIdC I o the sPermit. AIR HANDLING UNIT(OVER I0,000CFM) CONSTRUCTION TAX
gra reof Appllcant/Contractor Date IXHAf15'FHOOD(W/DIX:7) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the appBcantor futum building occupant store or handle harardoas HEATING UNIT(TO 10),000 BTU) Date RCCei 1N
material as dented by the Cupertino Municipal Code,Chapter 933 and the
I lealth and Safety Code,Section 75532(a)7 HEATING UNLIT(OVER 100,000 BTU) TOTAL: 111.0,10
Ill the applicant oruture building occupant use equipment ordevices VENTILATION PAN(SINGLE RESID) ISSUANCED TE
which emit haramous aur curunm ants as cleaned by the Bay Arca At, P/A I�
�
ityMawgement b ct7 BOILELCOMPOHPOR100,000BTU) /9s
Vex N
haveread the somalerials requirements underChapter6.95 of BOILFR.COMP(OVER 100,000 BTU) 1991
the California Health h Safety Code,Sees tons,75505,25533 and 25534.1 r7✓
understand that iflhr WildleScime not currently have a tenant,that it lsmy NEW RESOENTTAL MECH. SQFF
responsibility to notify the occupant of the requircnrnts which.,the mot a.�j a�a,'�ry:��1ry'EsasK
priortoimuanm ofa Certlficatco(Occupancy. Olt.W ^�_uo
Owner or authorlud agent Date TOTAL: ISSUED BY: 1/CU
OFFICE COPY