23432 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Project Identification PF7(.MIT NO.
,. `Building Address: 23432
_ t t I-t0 5 0 5 t-t-
lw1n�er�a
1T�•rY O .dL 4"i 3-^ Z71�ad CITY OFCUPERTIN I NG DIVISION a
Cont,actor'eName: LIc.No: APPLIC TI N / PERMIT � � I ,
! BDILDINGELEC A UMBINGM C CATEGORY CO rO VZ
C.
rehired/Engineer. Lic.No:
QTY RIC PERMIT VjFEE BUILDING PERMIT INFO
Address: rq I ONCE 'r^QQ I
LICENSED CONTRACTOR'S
pr DECLARATION L(-�
[hereby affirm that!am licensed under provisions re Chapter9(co an PP ANC SI L •JO DFSC
ingwith5ection 7000)of Dlvlslon3 ofthe Buslacasand Pro(culansCode,
Rcense is in fail force and effect ANELS J 1�
Mcenac Clan Lk:.1' I
Date Contractor - A� O
ARCHITECTS DECLARATION 201-IOOOAM
1 ce0 Z I uMerstand my platy sial be used u public rerorda OVERIODOAMBS SQ.FT.FLOOR AREA S/SQ.FT.
ZLicensed Professional SIGNS ELECTRICAL
�Q^q
OWNER-BUILDER DECLARATION
I asBrmthat I exempt Contractor's License Law forthSPECIALCIRCUIT/M15C
folio Business �� .La Orwingr5actim70313, dProfAny city '{pQT
V
OgH� TCMP.METEROft OLEINST.
F�
county rcqulmapemdt toconstruct,alter,improve,demolish,or -
ggql1 any structure prior to its Issuance,also requires the applicant for such permit to POWER DEVICES
" C file a signed stateomM that he is limned pursuant to the provisions of the
O �' Contractor's License Law(Chapter 9(commencing with Section 7000)of DI i- SWIMMING POOL ELECTRIC
30 t sion 3 of the Business and Prfealons Code)mthat he t,exempttherefromand VALUATION
the bast,for the alleged exemption. Any violation of Section 7WIS by any I OUTLETSSW[TCFiESF[KTURES —� Irl
applicant fora permit subjectatheapplkanitoa civil penalty does morefluto sD !.J/•\Jl.
live hundred dollars($500). NEW RESIDENTIAL ELECTR STORIES TYPE CONSTRUCTION
GGG777 I,as owner of the m or memployees with wages as their Bole �'�'
7Q compensation,wllldothe work dth my
t,not intended or offered for
,❑
sale(See 7044,Business and Professions Code:The Contractor's License Law
$ does not apply to an owner of property who builds or Improves thereon,and
who doaeuch work himself orthmagh his own employees,provided that suchOCC.GROUP RIS.UNITS
Improvements are not ntended orof(ered for sale.If,hawxwe the building or TOTAL: �^
Improvement t,soldwllhln oaeyearo(compieloq theowner-bunderwillhave
OW-IlArden of proving that he did not bund orlmprove forpurpose ofsale.). QTY, PLUMBING PERMIT FEE FLOOD TONE nrN
Lj I,as owner of the propety,am exclusively contracting with licensed PERMITISSUANCE �D If
contractors to construct the project(Sec.7644,Bualnces and Professions Cods:Code: V
The Contractor's License Law does not apply to an ownerof property who ALTER-DRAIN&VENT-WATER
or Improves thereon, and who contracts for such pSojects with a OW
cgaB(2cton!)licensed pursuant to the Contractor',License Law. FEE SUMMARY
1_I I an jaxempt under Sec. B k P C for this reason BACKFLOW PROTECT.DEVICE OUTSIDE FEES
DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y N_
Owner_ Date RFCIII'T p
WOR KMANO A F2 TION DECLARAT N pp(TURES PER TRAP SCHOOL TAX Y_ N_
❑I hereby affirm that I have a mrtl(iate of consent d pythn re,ora RECEIPT Y
rtBlcalea(Worken'Compensation Insurance oracertl(Ied copythereo((Sec. GAS EA.SYSTEM-1 INC4 OUTLETS PARKBER Y N
800,lab C.) t
laolky Y � V a RECEIPT M
Com an CASEA.SYSTEM-OVER 4 EPA)
•_-Jt y BUILDING DI VISION FEES
Certified copy is hercbyth the city GREASE/INDUSIRL WASE INTERCEPTOR PLAN HECK FEE
❑CertiRed copyt,(iled with the city Inspection division. ryr� —C 1 CJS
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRM PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200FT. RCCCI t diad r r
(Thissection need not be completed tithe permit is foram hundred dollars
(S100)ar less.) WATER HEATER W/VENT/FI cr.I.R
nsENERGYPEE Y N
I mrtifythat in the performance of thework forwhlch this permit is issued,
I shall not employ any person In any..an,so as to become subject to the / WATER SYSTEM/TREATING . n p PAID
Workers'Compensation Laws of California.Date
O Z Applicant Date Re i t
Z.0 NOTICETO APPLICANT:[(,after making this Certificate of Exemption,you NEW RESIDENTIAL PLMB. SQFT,
should became subject to the Workers'Compensation provt,lom of the Labor TO AL:
LO Code,you=at fors hwith comply with such provisions or this permit shall be
> deemed revoked. D N FE
17.1 C CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL [hereby a(firm that there ls a comitmctlon lending agency for the perform- ELECTRI
Z anmoftheworklor wIdchthlsperno1skamd(See309'/,CIv.C.) TOTAL:
U O Lenders Name PLU EE
LL F Lenlce.Adder. QTY, MECHANICAL PERMIT •,. . FEE
O W ]cedlfy that i have read this application and statethattheabove in(omutlon ) C [CAL E .Q
1 Boarmct.lagreetocomplywfthalldtyandcountyordlnanmandatatelaws / PERMIT ISSUANCE pQ F• AID:
} relating tobuilding ronstruction,and herebyauthorize aprexntativaofthis
7 city to enter upon the above-mentioned property for inspection purposes. j ALTERORADDTOMECH. DO Date Recel [#
� — (We)agree to save,Ind crucify a a d keep harmless the City of Cu penin
against liabilities,Peignmah,"sand expenses which may In any wayacmte AIR HANDLING UNIT(TO 10,000CFM) UBTOTAL:
against said City In consequence of the granting of this permit.
AUCHANDLING UNIT(OVER 10,000CrM) CONSTRUCTI TAX
s Slgruhrm of Applicant/Contractor Date EXHAUS"FHOOD(W/DUCO rL PAILLe'er
HAZARDOUS MATERIALS DISCLOSURE I v
Will the applicant or future building occupant store or handle hacadom HRATINC UMT(TO 100,000BTU) Date RBCeI t#
meerlaI as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health and Safety Cade Section 25532(a)7 1NG UNIT(OVER 100,000 BTU) 00 TOTAL:
F1 Yea ri No
Wnl theapplicam orhimm buildingoccupant use equlprreht or devices VENTILATION FAN(SINGLE RESID) ISSUA\CED0TJ,which emit hanrdous air comamlnsntsasdeMed bytc Bay Area Al, f'Qu Ihyy.ManagMent D❑lsMct? BOILER-COMP OFR'OR 100,000 BTU] l* M No
haveread ealth a fctyC d,Setions 2mO5,255dcrChapter.1 of BOILER-COMP(OV[R 100000BTU)
nGTtardtaattith bSfetyCde,Seccuruntlyh veatenan33 and 25537.1 `JUL19
understand that tithe building dote not currently haveatenant,that it Is my NEW RESIDENTIAL MSCI-I, �.Ff.
responsibility to notify the occupant of the requirements which must be met
Ion yiIssuance of aAaupce I
CITY Of CI
nt
ra s4AAVV
DataISSUEDB2ixI
TOTAL:
OFFICE COPY