21286 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
building Project Identification I10MITNO.
Building Address; (�/I /�^ n
i 3 6 5o St��l4 h�' G I G 8
ners
one: p
Wayne- Scirce2 Cog)9�3 '/�y4 CITY OFCUPERTINOBUILDINGDIVISION D ��a
c°^trsQ.r'.Name: No: APPLICATION I PERMIT
N R• rLI.. D BUILDING-FLECTRICALPLUMBING-MECHAMCAL CATEGORY CONTROL
l 4chimet/Engimer. Lie N.
I� QTY ' ELECPRICPERMIT FEE BUILDING PERMIT INFO
Add.. PERMITISSUANCE 1:1 ❑ 1:1LICENS ED CONTRACTOR'S DECLARATION
KI I hereby affirm that l am licensed under provisions of Chapter 9(cemmmc APPLIANCES-RESIDENTIAL JOB DESCRIPTION
ingwith Section 7000).(Division3ofthe Businnsand Protea•IonsC°de,and my
license is le fullform and effect. PANELS
L1mme Clas - Lir.Y 5174
Data Contractor
ARCHITECTS DECLARATION 701-1000 AMPS
q�q�uu 0 CTO I understand my plate,shall be used a public records. OVER 1 ODO AMPS B SQ.Fr.FLOOR AREA S/SQ.Fr.
}i Licensed Professional SIGNSELECTRICAL a
�dd6 OWNER-BUILDER DECLARATION SPECGLr IRCUI MISC
7t. G I hereby affirm that l am exempt from the Contractor's License Law for the
qq following. ...(Sectlon70315,Busineaand Professions Code:Any dtyor
Fs'ry countywhlchrequlre•apermittoc°rohua,alter,improve,demoll•h,orrepalr �MP'MEfQt OR LE INSf.,
X77 anystrurntre priortolta issuance,also requlresthe applicantforsuch permit to D ,� .�
c, file.signed statement that he is licensed pursuant to the proal ions.f the —
Oµi. Contractor's License Law(Chapter 9(commencing with Section 7000)of Divl- �VA(.UATIOp( f,
30J •Ion3ofthe Buslnna and Profeelme,Code)orthat he h exempt therefromandii SWNIMING POOL ILECCEC D oo V
k5�n.••77777 the bash for the alleged exemption. Any violation o!Secti.n]0315 by any • /
QOS applicant lora permit subjectsthe applicant to a civil peentyan.t m.rettom OlJ'ILETS TCIi6F1XlVNES y
$� five hundred dollars($500). r
NLrW.RESIDEN`AL ELECTR SQR.
7 6 ❑I,ac owner of the property,or my employees with wages as their Bole SIO FS TYPE CONSTRUCTION
compensation,willdothe werk.andthe structure h not Intended or offered for
O sale(Sec.7044,Business and Professions Code:The Contractor'•License Law _
don not apply to an owner of property who Wilds or Improves thereon,and OCC.GROUP RFS.UNITS0.0. who d°essuchwork hlmselforthrough hlsownemployeeaprovided that wch
Imprevements am not intended oroffered forsale.l4 however,the W ilding°/' TOTAL:
Improvement usold withinoneyearo completi.n,the owner-builderwill have
tjc�uSden of proving that he did not build or Improve for purpose ofsale3. QTY, PLUMB( PERMIT. FEE FLOOD ZONE AVN
LIas owner of the property,am exclusively=trading with licensed PERMIT ISSUANCE
centnctors to ceatruct the project(Sec.704C Business and ProfessionsCode:
The Contracture License Law don not apply to an owner d property who ALTER-DRAIN&VENT-WATER(EA)Wilda or improves thereon,and who contracts for such pw*U with a
ry¢I(+ctor(s)licensed pursuant to the Contratt.ri Licana Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
U I am exempt under See. B h P C for this reconOUTSIDE FEES
Owner pateDRAINS FLOOR ROOF,AIUiA,CON*. SANITARY Y_ N
WORMAN COMPENSATION DECLARATION RFCEIP--- Y
K
Of hereby affirm that I have a certificate of consent to Self-In ante,ora FIXTURES PEN TRAP SCHOOL TAX Y N
RFOE 7Y
nrti(inte.(Wo et 'C at.n an San ed hereof l5ec' GAS EA.SYSTEM-11NC.40[IILEfS PARK FEE Y N
3800,[ab CJ
Policy Y GAS. A.SYSITM-OVER 4(FA) RECI]I'T M
Co'm�nny BUILDING DIVISION FEES
t�Certified copy b hereby furnished.
❑Certified copy It filed with the city Inspection division. CREASE/1NDUSIRL WASTE INTERCEPTOR PLANGHECIC FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY.MRM PA 200Ff Date Re i tM
(fhb section need not M completed If the permit b(or.ne hundred dollars
($100)orfy that
WATER HEATER W/VENT/ELBCTR ENERGYFEE Y N
]certify thatlnthe proun,In ny .work for to become
permit Is honed, —
I shall not employ any person In any manner n a to become subjett to the WATER SYSTEM/TREATING
WopComp.neatlon Laws of California. Data PARD
C! Z Applicant NEW RESIDENTIAL PLMB. SQFr. Date Reuel tin
Z O N077CE TO APPLICANT.If,sitar making this Certificate of Exemption,you
Hshould become subject Rothe W.rkem'Compensation provisions of the Labor TOTAL:
CC W Code,youmust forthwith comply with such provisions or this permit shall be
> decmad revoked. BUILDING -Ob
W F3 CONSTRUCTION LENDING AGENCY SEISMIC FEE 3"
a Iherebyaffirm that there b a censmodlon lending agency for the perform ELECTRIC FEE
7 Z ante of the work for which ti r�Itis issued(See.3097,CIv.C.) TOTAL:
02 Lender',Name /(} PLUMBING FEE
LL 1- Lenders Addrca fr QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W lartifythatl have read thbapplicattonand m
statethattheabovelnforatlon
1 bcermet.lagreetocomplywlthallcilyand ceuntyordinancesand slate laws PERMIT ISSUANCE FEES PAID:
relating to building cemmicdon,and hereby authorize repreaenalives of this
H Z city to enter upon the above-mentioned property for Inspection purposes. ALTERORADDTOMECH. Date ReCei tin
_ (We)agate to save,indemnify an d keep harmless the City of CupeMno
.gamut BabiWies,judgme^b,cesband apes.which may inanywayacems AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
sgsiatsal nconxy ertnl a (thle p
i9�ago j��b /9 \ AIR HANDUNG UNIT(OVER I 0,000CFM) CONSTRUCTION TAX
Signarbire o Applicant%C ntractor / Date o EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the apphcant or future building occupant store or handle harardou• HEATING UNIT(TO 100,000 BTU) Date ReeCl tin
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health and Safely Cade on 25532(x)? HEATING UNIT(OVER 100,000 BTU) TOTAL:
F1 Ye. , Ijj N°
Will the pplicant or future building occupant use etulpmont or devices VENI LATION FAN(SINGLE RESID) ISSUOIs1 -DATE
which emit tiara rdous air c°nta mbsnta as defined by the Bay Area Air r�Y
Qua lity Ma ugereent District? BOILER-COMP OHP OR 100,0(*BTU)
4Yes �No 55 OCT 19 1990
have read the haze ous rtuterlabrerequirements under Chapter 6.95 of BOILER-COMP 100,000 BTU)
the Gltand that imla f
ASafetyCode, oteonntlyluv..t25SOS,25533 and.ettha4. I
understanddthat notify Ile ocgdoesnotcurequoment,tenant that It me, NEW RESIDENTIAL MCCH. SQ.IR.
rriorto ilitanceofifytheoccupa the requlrerrentawhichmustberret of.Cupe�lrto
prior to ance of 0catp O City. {i
�.a
� OA
email nor u'�t�orimd ISSUED BY:
i TOTAL: I —
OFFICE COPY