24044 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pm ea ldemi(kalon � PEIN9TN
Building Address; YR
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CITY OF CUPERTIN0.BUILDINGDIVISION
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APPLICATION /PE �'�3
In BUILDINGELECTMCALP UMBING IANICAL CATEGORY
. Ae / glneer. �Ic.No:
QTY
ELEC14Ck6MIT FEE BUILDING PERMIT INFO
Address, T o ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
(hereby afford that lam licensed haunder BuabddaW ad ofChapterod.,% n C EMIAL JOB DESCRIPDON
Ingwlth Section7000)of Dlvldonlo(thegutlnessand ProfessiovCode,and my _
license is In full f�.ro and died. 'j�1//� A
License Cls® P LICN , /iO
Date Contractor
' ARCHITECTS DECLARATION 20I-1000 AMPS(
90Zp I understand my plans shall be used a,public records. OVER IOW SQ.FT.FLOOR AREA S/SQ.FT.
TyZ�j Licensed Prolemlovl SIGNS ELEC SemJOIFIFU
<¢� OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MLSC a a�(Q
p [a-6 1hembyaflred that[am exempt from the Contractor's License Law for the
✓'o following reacted.(Section 7031.5,Business and Prefesbv Code:Any city or
O]F TEMP.METER OR POLE INST.
Pp countywhkh requiresa permit tororuhuct,alter,Improve,demolish,orrepalr
a anystmu mprtortolts Wuance,alsorequlrestheapphantforsuchpermitta POWER DEVICES
rN1 n.V file a signed statement that he Is Ilmnsed pursuant to the provisions of the
3µ Contractor's Liceme Law(Chapler9(mmmendngwlthSett1on70W)ofDivl-
O SWIMMING POOL ELECTRIC
,lon3of the Buelnessand ErafembvCode)orthat halo exam Ihercfromand ALUATI
<�, the basis for the alleged exemption. Any violation of Section 70115 by any OUTLETS-SWITCHES-FIXTURES'
applicant fora permit subjects the applicant loa civil penalty of net rrore than
live hums owner
the W). - NEW RE9DFNTIAL ELECTR SQ.FT. STORIES TYPECONSIRUCTION
7 ❑I,a ower i the property,or my employes with wages r their door
compenutiogwlll dolheworkend theatrudure Is not Intended or offered for
� sale(See 7094,Bushes and Profesaions Code:The Contractors License Law
OD does not apply to an ower of property,who Wilds or Improves thereon,and OCC.CRO P RFS.UNITS
who dos such work himself orthrough hlsown employees,provided that such / 1
Improvements are not Intended oroffered for sale.If,however,thebullding or TOP L:
improvementbwldwithinovyearofcompodloNtheowner-bu0derwillhave - -
Illebunlenofpmvlog that he did not Wildorimpwvef°rpurpou ofule.). QTY, P UMBING .BR' rT I ^AE FLOOD ZONEApN
L
J L as owner of the property,am exclusively contracting with licensed P IT ISSUANCE
rontractwe to construct the project(Sec 7014,Business and Professions Code: C
TTe Contractor's Limited law dos not apply to an owner of property who AL -DRAT
builds or improved;thereon,and who contracts for such ExTiects with a tE FEE SUMMARY
Inaft licensed pursuant to the Contractor's License Law. BAIX FT-OW PROTECT.DEVICE
LII am exempt under Sec, B A P C for this readers
DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y N
Owner Date RFGF7IsTN
WORXMAN COMPENSATION DECLARATION F1X`rURFS-PER TRAP SCI TAX Y N
❑I hereby affirm that I have o lmumne of consent to pythemo(ora RECEIPT N
certifiate of Workers'Compensati°nlvuacnce ora certified copy themof l$ec' CAS EA.SYSTEM-1 INC4OUTLETS PARK FEE Y N
3gW,7ab C.) /aQ?6 /Y RFLERPI'N
Polley X CAS E.A.SYSfQd-0VER 4(FA)
Com BUILDING DI VISIONFEES
�Certltl copy Is herebytehed. CREASE/INDUSTRL WASTE INTERCEPTOR PLANGHECK FEE
Certified copy b filed withh the city inspection division. a�
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAJD� L �1Id �rAr3a
COMPENSATION INSURANCE SEWER-gANq.LARY-SNRM EA 2(IOFT Da[C �'ltit�eCC�I 1—# V
(This section need not be complded If the permit Is v forohundred dollars
(f100)orteu') ENERGY FEE Y— N
I cemlythat In the pedormanceofthe work forwhich this permit is Issued, WATER HEATER W/VENT/ELECTR
I shall not employ any perwn In any manner w"to become subject to the WATER SY5IFM/TRWTING
Workers'Compensation Laws of California. Date PAID
-
0 Z Applicant NEW RESIDENTIAL PLMB. SQYT. Date Recei t#
ZO NOTICE TO APPLICANT:If,after making l his Certificate of Exemption,you
Hshould become subject to the W°rkers'Compensation provisions of the Labor TOTAL:
f/9 Code,you=at forthwith comply with such provblov or this permit shall be T
W j deemed revoked.
CL c CONSTRUCTION LENDING AGENCY SEISMIC PEE
]herebyafflmtthat there Is a construction lending agency for the perform- ELEC'T'RIC FEE
Z ance ofthe work for which this permit Is Issued(Sm.3097,Civ.C.) TOTAL:
V O Lenders Name PLUMBING FEE
LL 1— Lender's Addma, QIY. MECHANICAL PERMIT "E MECHANICAL FEE
O W ImAifythatlluvercadlhisapp11ationando.tethattheabovelnforruti°°
IL brorect.Iagree tocomply with all cityandcounty ordinances and gate laws PERMIT ISSUANCE FE �a lg 6 big"
} relating to building construction,and hereby authorize representatives ofthis—
F 2 city to enter upon the above-mentioned property for inspection purposes. ALIERORADDTOMECH.
L) — (We)agree to save,Indemnity an d keep harmless the City of Cupen ine, Date Recei t#
ago but lbbWticsjudgments,mnsand expenses which may In any wayamus AIR HANDLING UNIT(TO 10,OW CFM) -SUBTOTAL:
against uld City In consequence of the granting of this permit.
AIR HANDLING UNIT(OVER 10,020 CFM) CONSTRUCTION TAX
Signature of Appllant/Contractor Date EXHAUST I IOOD M/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE.
Will the applicant orfunded building occupant store or handle huardous HEATING UNIT CID I00,000 BTU Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the -- _
Health and Safety Cod�ction M32(a)7 HEATING UNIT(OVER 1 W,000 BTU( TOTAL:
n Yes No
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) bLSSlJ,1AuNCE DATE
which emit hazardous air contaminants as dell tied by the Bay Area Air w
Quzldy Management Chish��Q ff��V7 BOILRWCAMP(3HP OR IW,OW BTU) �(f
4 Ys aaLrcMn°
have mad the rtaterlab mryircmenhunder Chapter 6.95 of BOILER-COMP 1W,000 BTI)) +,{!
the Callfomla Health k Safety Code,Sections 25505,25533 and 25539.1 ^! 6 '(�[>tNA
understand that lithe building don not currently have a tenant,that it Is my NEW RFSIDENDAL MECH. SQ.F7 4 a919Z
responsibility to not fy theompant of quimmems which must be met Uh
priort°issuanceofaCartl(late if `Urrff///Vu
ze a _� _
Por authorigent to ISSUED BY: -_F
�-
TOTAL:
OFFICE COPY ,>