22908 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES- USE BALL POINT PEN ONLY
BuildingProtect Identification PERMIT NO.
Building Add 22908,
wnera SVM%onu!: one:
CITY OF CUPERTINOBUILDING DIVISION
cyao�a� APPLICATION / PERMIT 7 —L
/— ld �^^ BUILDING.ELECTRICALPLUMBING•MECHANICAL CATEGORY C
Architect/Englnrer. Lic.Na
QTY ELECTRICPERMIT FEE BUILDING PERMITINFO
Address:
LICENSED CONTRACTOR'S
iTION PFRMTISSUANCE
IhbetIs.ncenvidon.oCh.pter9e APPLIANCSRE9DENTIAL
ingwithSdion7DOG)ofDlNelon3ofthe8uMnemandProfndonsCsde,andmy JOB DESCRIPTION
�
license le in fun f and effect. PANELS
Llcenec�Llc p�
Date Contncror
ARCHITECTSDECLARATION 201.1
OVER0ODOAM
mO Zp ]understand my phns ahalbe used espubllcrecoNs OVER 1(1!10 AMP5 .FT.ILOOR AREA f/SQ.FT.
(� Licensed Professional SIGNSELFCTRICAL
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC
Z thereby affirm that am exempt from the Contractor's Limnse Law for the
QQ following reaver.(&,mon7BI S,Bualnessand Professions Code:An ct r
Kt'uf muntywhkhmquimaper ttommhMalter,impmve,demollah,ormpair �MP 'hfEfIXORPOLE(NST.
g`'q 77 anystructom priortoits Issuance,alsorequirmtheappeeant fmsuch permit to
E file a signed statement that he is licensed pursuant to the prowisom of the POWER DEVICES CUUJ VYvr/
Ow 1- Contractor's License Law(Chapter 9(commenclogwith Section 7000ofDivi- SWIMMING POOL ELECTRIC
elon3a(the Businessand Professions Code)orthat bele exempttherc(mmand VALUATION '
•]] the basis for the alleged exemption. Any violation of Section 7031.5 by any "LE
appmmntfor a pemdt subjects the a ppllcant to a civil penalty a nm more than OUTLETSSWITCFIESHJ('IURES(ive FI L as ed owner of the pr. NEW RESIDENTIAL ELECTR SQ.Fr,�n ❑I,as owner of tM property,or my employers with wages as their mk SIRUCTION
compensation,wllldothe work,end/he strocture is not intended or offered forq sale(Sec.7044,Business and Professions Code:The Contractors License Law ■p�S docs notapply to an owner of property who build,or improves thereon,andSwhod. .®hworkhimselfmthroughhisawnemplayeea,provldMthatsuch
Improvements arena Intended arof(ered tarsale.Ithowevepthebulldingor TOT
t"Men of proving that be did nabu8dorimproveforpurposeo(sale.). QTY, PLUMBING PERMIT FEED
U L as owner of the property,am exclusively contracting with licensed
mntracerstomnatruct the project(Sec.7074,Businessand ProfessionsCode: T
PERMIT ISSUANCE
The Contractor's License Law don not apply to an owner of property who ALTER-DRAIN kVENTWATER(EA)
builds or Improves thereon, and who contact, for such p(ojeci -s with a s.re
cYpt,(ado,(,)11...d pursuant to the Cadractar,Lim.Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
I5 I am exempt under Sec. B k P C for this mason PEES
Owner DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N�
• Data RECEIPT N
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP as — SCI;OOLTAX Y_ N_
hereby affirm that I have a.cer iBnte of consent to self-insure,or a RECEIPT N
certificate a Workers'Comperuationlnsurance or a certified copy thereof(Sec. CAS EA.SYSTEM-1 INC.40UTLEIS PARK FEE Y N
3800,Lab C.)
Polley n RECEIPT M
GAS EA.SYSTEM-OVER 4(EA)
Y BUILDING DI VISION EES
Ce ed copy is hereby rtnled copy is filed withh the
tGREASE/INDUS*ML WASTE INTERCEPTOR PLANCHECK FEE eD
he city
Wpeatlon division.
GREASE TRAP
CERTIFICATEMPE SATIO IN PROM WORKERS' PAID
COMPENSATION INSURANCE
(rNsmctlonneMnabecompleediftMpermitis(momhundreddollan SEWER-SANITARY-STORM EA."Fr.
Date CCC! t
(f100)orlen.) WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
I certify that M the performance of the work for which this permit Is timed, —
I shall not employ any person In any manner so as to be o sub c the WATER SYSTEM/TREATING
Workers Compensation Lam of California. Date PAI
z Z Applicant Dale ReCel t#
Z NOTICETO MPLIGNT:If,eRer making this Certificate of Exemption,you NEW RESIDENTIAL PLMB. SQ.FT.
Hshould became subject to the Workers'Comperaatlan provisions oflhe Labor TOTAL:—
Ir
N Code,you=at forthwith comply with such provisions orthla pemdt shall be
jdeemed revoked. 1
W
C CONSTRUCTION LENDING AGENCY SEISMIC
Z Ihereby affirm that there I.a construction lending agency for the perform TOT �'� ELECT
� 0 anreof the work for which this permit is Issued(Sec.3097,Civ.CJ
11
U Lenders Name
U. F Under.Addren - QTY, MECHANICAL PERMIT FEE PL FEE
U Icertitythatl have read thbappllmtbnaM etatethat theabove information M ANICAL FEB
Q W boarreR.a agreeto comply with an city and county ordinances and mate lawn PERMIT ISSUANCE "'a" FEES PAID:
IL relating to building construction,and Mrebyautherim representatives ofthls
F Z city to enter upon the ahave-marooned property for Inspection purposes. ALTIRORADDTOMECH. �s
(We)agree to save,indemnify an d keep harmless the City of Cu pertlno Date ecel t#
V against liabilities,Judgments,mg.and expenses which may In any wayaccrue AIR HANDLING UNIT(TO 10,ODOCFM) SU TOTAL:
against said City In consnTuence of the granting a this permit.
AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION AX i
Signature of Applicant/Contractor Date EXHAUSTHOOD(W/DUCT) CONSTRUCTION AX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will theapplimmt or future building occupant store or handle hazardous I'[EATING UNIT(TO 100,000 BTU)
mamrialasdefiredby the C rtlno Municipal Cale,Chapter 9.17,and the Date cel #
Healthand Safcty Code Ion 75537(,)7 HEATING UNIT(OVER 100,000 BTU) TO
❑Yn No
Will theapplinnt orfuture building ompant use equipment or devices VFNDLATION FAN SINGLE RESID) I$SIIALJCE DATE
which emit haxardousaircoVentrantsa,de8ned bythe Bay Area Air t�4 �I 6J
. Quality Management Dstr}ef7 80ILF.R-COMP OI{I'OR IOO,IXD BTU)
4 Yn [ja{No OCT11
havereadlhals ous man ab requimmen a under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) b1 3+' 1991
the California Health k Safely Code,Sections 75505,75533 and 75534. I
understand that if the building don not currently have a tenant,that It is my NEW RESIDENTIAL MECH. SQFT.
respmuibility to naity the occupant of the requirements which at be met CRY UF�x L
priorb u . of A moo= L CIl l OF NUPLHI INV
26
(hv roc lh rise agent /O/ ISSUEDBY:
IOTA
OFFICE COPY