20102 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pruect ldentlficelon PERMITNO.
Bui�gsa , 2010230
w'9Cra• a'r'c. �� one: q
/!G/,4�/C�LV-x /aet� —a�0/ CITY OF CUPERTTNO�BUILDING DIVISION � ���C�O
CoVnd°'''Name: LIc.No: APPLICATION I PERMIT / �•�
Architect/Engineer Llc.No: BUILDING-ELECTRICALPLUMBING-MECHANICAL CATEGORY CONTROL NSq' 1
QTY ELECTRICPERMIT FEE BU&VDING PERMIT INFO
09
Addmu:3vr Sr (1, PERMITISSUANCE ❑ ❑ El
CONTRACTOR'S DECLARATION
I hereby affirm tial l am licensed under provisions of Chapter9(mxmnm APPLIANCES-RESIDENTIAL ]OB DESCRR'IION
Ingwith Sedbn 7000)of Dlvlelmn3o(the Buaineuand ProfesNons Code,and my
license is In full fpycand d(ed. PANELS �� Iv�
License Cis 1� Lk.N L _
Dale' C."u's or (-yjIUP TO 200AMPq
I ARCH14 TSI RA ON 201-1000AMPS
9 Z I umnestand ery placeshallbe tt d u pu cords. OVER IODO AMPS SQ.Fr.FLOOR AREA 8/SQ.Fr.
O
Licensed Profcmlonal SIGNSELFLTRICAL r�
6 OWNER-BUILDER DECLARATION
In]� SPECIAL CIRCUIT/M1SC
s" Thereby afOmnthat lam exempt from the Contractor's Llcenm law for the
Op following mason.(Section 70315,Business and ProfmloNCcde:An d or
' Zb'u9 county which requires a permit tocorutrar ,alter,improve,demnWh,or repair TEMP METER OR TOLE INST.
4n, anystructure priortolts Issuance,also requimslhe applicant(orsuch permit to
S Ole a signed statement that he b licensed pursuant to the provision,of the POWER DEVICES
3wContractor's License Law(Chapler9(commencingwlthSection70M)o(Divl-
O
In SWIMMING POOL ELECTRIC
Won 3 ofthe Busineuend Pradmat aCode)mthat he is exempt therefromand VALUATION
I 'S the bash for the alleged exemption. Any vlolatlon of Section 7031.5 by anyB C.2
OUTLE7SSWITCH6FIXTURES r�
<� applicentfora permlbubjedstheappecanitmadvll pevltyofnd morelM1an �( o33e
o Ove hundred dollars(g5D0). NEW RESIDENTIAL EL TR SQ.FT. STORIES TYPE CONSTRUCTION
0 Fj I,ae owner of the property,or my employees with wages as their sok
C compensation,wllldolhe work and the stmdure is not intended or offered foraTQ -
5' 0 ale(Sec.7614 Buelneea and Profeuloru Code:The Contractors License law
does not apply to an owner of property who builds or improves thereon,and • OCC GROUT' RFS UNITS
MM who does suchwork himself or through hlsown employees,provided that such
Improvements are not intended oroRered forsale.If,howeve,lhebuliding or TOTA
Improvement Issold withlnoneyearofcompldlogtheowner-budderwlll have
ilMurdeo of proving that he did nM build or improve for purpose of sale.). QTY, PLUM PERMIT FEE FL5DD7vNE APN
u 4 es owner of the property,am exclusively contracting with licensed
contractor to construct the pmjed(Sec.7054 Business and Professions Code: P SSU N / -- -
The Contrsdorb License Law does not apply to an owner of property who IN WATER(EA)
builds or Improves thereon, and who contracts for such ptojeds with a
"gR(Tador(s)hmowd pursuant to the Contractor's License Law. BA WP CE FEE SUMMARY
LJ I am exempt under Sec- B k P C for this reawn a
S ROD ODND. SANITARY Y N_
RECEIPT
EES
Owner Date RECEIPT N
WORKMAN COMPENSATION DECLARATION TRAP SCI{— TAX Y N
1-11 hereby affirm that I have•certl(Icate of consent to self-Insure,ora RECENT N
mrtlOrateo(Workars•Compematlan Insurance ora unified copythereof(sec. S -1 IN .4 PARK FEE Y N
3800,IabCJ
Policy N RECEIPT N
Cam any AS F.A. V ) BUILDING DIVISION FEES
ffCertlRed copy is hereby furnished. IGREASE/IVDU L A NTFRcrrroR NCHECK FEE
Certified ropy b filed lith the city Inapedlen division.
CERTIFICATE OF EXEM PTION FROM WORK ERS' CREASE PAID 4-e.,clo
COMPENSATION INSURANCE Al smnhf EA,zOOF]'. Date Recd t# 1{.r
(This section need not be completed Bthe permit Is for one hundred dollars
(s100)m1ass.) WATERHFATFR /VENT/MECTR ENERGY FEE Y N
I mdifylhat In the performance of the work forwhlch this permit to issued,
I shall not employ any person In any manner so as to become subject to the WATER SYSIEN/TREATING 1 y'6
Worker'Compensation laws of Califomla. Date - AIDL -jb
O Z Applicant NEW RESIDENTIAL PLM B._SQ Fr. 7 C DatC Recti t# &3.C"
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
Fshould become subject to the Workers'Comparaatlon provisions of the Labor TOTAL:
V7 Codqyoumustfodhwlihcomplywlthauchp.v4 ..rthbpermltshallbe 4BUILDING ' s470
47
W 5 deemed revoked. a
CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL Z Ihercbya(Orm that there ts a construction lending agency for the pcdorm- TOTAL' ELECTRIC IEEE ),
7 ance of the workfor which this permit ts Issued(See.3097,Civ.C.)
02 Landers No PLUMBING FEE
LL H Lender's Addmss QTY. MECHANICAL PERMIT FE MECHANICAL FEE
Icedlfythatlhave read this applicallonand statelhat theabove informationO W
0. Is correct.l agree to comply with all city and county ordinances and date laws PERMIT ISSUANCE FEES PAID' -
N relating to building construction,and hereby authorize rcprceentstivea'!this 7 f 0 'z;6:2/9
Z
it to enterupon the sbov.mentioned propeny for Inspection purposes. ALTER OR ADD TO MECH.
— (We)agree to save en d keep harmless the City of Cupedlno Date Recei t#
agalrotllabllltic men e,cost and expenses whichmaylnanywayeccrue AIR HANDLING UNIT GO 10,000 CPM) SUBTOTAL:
against nc sae a granting o(thls pemnit AIR HANDLING UNIT(OVER IO,IXIOCFM) CONSTRUCTION TAX
S w7dfl�dby
ant/ ontradorDdre F7(HAUSr HOOD(W/D[JCT) CONSTRUCTION TAX PAID:
AZARDOUS MATERIALS DISCLOSURE
Wlllnt or tutumbuildingoccupant store our handle hazardous HEATING UNIT(TO 100,000 BTU) Date Recei t#
mated' the Cupertino Municipal Code,Chapter 9.1 2,and the
Health and Safetyton 75532(a)I HEATING UNIT(OVER 100,000 BM TOT
❑Yes o
Will the applicant oruture building occupant use equipment or devim VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
which emit M1aczrdous air contaminants asdefined by the Bay Area Air �A.�
Quality Management D���biaa111ct7 BOILER-COMP DW DR100,IXp BTU) n.epv
4 Yes ac. No
havernia tcalth& coarse matd Senis uircmentsunder
andChapter 253 .1 of BOILER-COMP(OVER100,(100 Bill)
the understand
t Health le ss! Code,Stolon,7550x,75533 and 25537.] srr V as
understand that It)halo ng ano[c�rrently haveatenan4 shat it is my NEW RESIDENTIAL MCCH. SQ.FT. u
responsibility to i 1 eo pant of the requirements which moat be Tran, 2 syL
+ prior to lu a :am to parry. Q y((�/
�/ n• o �Pn►ttnn
vgero ulhorim gen Data a �I
t
TOTAL: r 7y ISSUED BY:� .
a OFFICE COPY