21924 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY 19 2 4
BuildingProject Identification PERMITNO.
Building Address: 21924
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woe s arra. one•
—*q CITY OF CUPERbNO-BUILDING DIVISION � �^
• ntntter Lie.N°: APPLICATION I PERMIT
14 BUILDING-ELECTRICAL PLUMBINGMECHAMCAL CAIFGORY CONTROL N
Areh act/ ®neer. Lk.No:
Q'rT ELECTRICPERMIT " FEE "BUILDING PERMIT INFO
Addrcsc BLOG ELECI PLUMB MUCH
PERMITISSUANCE ❑ .:❑ ® ❑
LICENSED CONTRACTOR'S DECLARATION
whereby ion7(that laiv licensed under provbionsof Chapter9de,and e- APPLIANCES-RESIDENTIAL JOB DESCRIPTION
lice..
Section 7000)o(Dlvislon3ofthe Buainemandlhefemlona Code,and my
license is tofu f d tied 2 2 PANELS p
LkenxClam ,Lk.N (... —odic
Date Contractor UP TO 2DO AM2S
ARCHITECTS DECLARATION 201-1000 AMPS
00' (understand my,ides shall be used as public mounds. OVER 1000 AMT'S
SQ.)T.FLOOR AREA $/SQ.Fr.
�j Licensed Professional SIGNSELECTRICAL
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC
7 Iherebyaffirmthat l am exempt fmm the Contractor's Llmnx law for the
following reason.(Section 7031.5,Business and Procession.Code:Any city or
t. which ir TEMP.METER OR POLE INST,
county primrequtela pertNttomrurectoltruct, sthe apmve,demsuch,ormit to
$ any atmcturepriereto ntehat he
lice sed pursuant t the moisior hpermlte POWER DEVICES
L5 O � the a signed statement that M la licensed pursuant to the prov0lov of the
Gp�16In Contractor'.License Law(CMpter9(mmmench,"ith Section 7000)of Dlvl- SWIMMING POOL ELECTRIC V LUATION
E, Mon3 ofthe Business and Profemlona Code)orthat hen.exempttherefmmand
the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETS.SWITCHFSEXTURES
�� applicant fora perMtsubjecbtheappllnnttoa tivll pewkydnm morellun
five hundred delta.($SAO. NEW RESIDENTIAL ELECTR SQ.Fr.
�n F-1 I,as owner of the property,or my employees with wages as their sole STORIES TYPE CONSTRUCTION
compensation,will do the work and the structure Is not intended or offend for
Osale(Sec.70K Busnness and Profemlons Code:The Contractor's Llttme Law
does not apply to an owner of property who builds or improves thereon,and OCC.CROUP RFS.UNITS
who does such work himself orthneugh hlsown employees,provided that such
Improvements are not Intended orotfered forsale.If,however,thebullding or TOTAL;
improvemenibsoldwithin oneyearotcomplelion,the owner-bullderwiil have
tf,Ukurden of proal^g that he did nm build or Improve for purpose Mutts.). QTY. PLUMBING PERMIT FEE
U FT.(70D ZONE APN
4 as owner tt the property,am exclusively..Ad ng with licensed PERMIT ISSUANCE 1`l
theconContra to mnswct the project(Bee apply
Bu.iness and Iof prA eat Code: L h C
TM Contractor's es the Law does oat apply to an owner m property,who ALTER-DRAIN&VENT-WATER(EA)
builds or Improve thereon,and who contracts for suchse,L w.ojects with e ,
offld=eBcent under See.
the Contractor'sLk&PLaw. BACK FLAW PROTECT.DEVICE _FEE SUMMARY
LL1l[em exam,under Sec. B&P C for this reannnOUTSIDE FFES
Owner - DatDRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N
e RECEIPT N
WORKMAN COMPENSATION DECLARATION FIXTURES.PER TRAP SCHOOL TAX Y_ N
❑I hereby atiirm that I have o Insurance
of aon di l to seytheure,ora RECID7 N
certill380D,L.bC.cste Worker%Comperoation l�uunntt ora mrti(kd copy thereo((Sec. GAS E.A.SYSTEM-1 INCA OUTLETS PARK FEE Y N
I'MCom N GAS EA.SYSTEM-OVER DECEIT,
�y BUILDING DIVISION FEES
6ertified copy b herebyth the cid. CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
❑Certified copy b flied with the city inspection tllvlelon, "
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWERSANITARYSI'ORM EA 20Or1' Date Rccei t#
Rhbxss.) need not Mcampleted IftM permit b(Drone hundred dollars
a100)orty that
- WATER HEATERW/VENT/ELECTR ENERGY FEE Y N
(certify that Nthe performance ofthe work forwMrh this permit 1.blued,
I.hall nm employ any person In any manner so m to become mbod to the WATER SYSTEM/TREATING
Workeri Compensatlen California
of Califo
ZZ Applicant NEWRESIDENTIALPLMB. SQ.Fr. Date Remi t#
O NOTICE TO APPLICAN.If,.he,making t his Certificate of Exemption,you
should Moms subject to the Workers'Compensation provislona of the Labor a seer- TOTAL:
c N Cede,you Most forthwith comply with such provbloro oath'spermilshallM V-/x' B DI •E
W > deemed revoked.
CL G CONSTRUCTION LENDING AGENCY SEISMIC FEE
'Thereby affirm that there As a mmtmction lending agency for the perform TOTAL: 1 Ly ELECTRIC FEE
7 Z an ce ofthe work for which this permit is bsued(Sec.3097,Civ.C.) l -`ate �^
O O Lender's Name - PLUMBING FEE C.1/
IL I— Lendre.Addrem QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW Icertifythatl have read thbapplirationand matethatthe above Information
a bmrred.I dgreeto complywith all dtyand county ordinances and state law. PERMIT ISSUANCE FEES PAID:
} relating to building comtmcuo^,and Mreby authorize repreaentatives of this
r city to enter upon the above-mentioned property for inspection pu rpox.. ALTERORADDTOMEC
Z H.
(We)agree to save,I nlenuufy an d keep harmless the City of Cu peMno Date Recei t#
V a liabilities,jug nb,rortsand expenses which may In any,way accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
a ale aid
in on ance of egranling of this geDnl���
2J 1(11 AIRItANDUNC Un1T rovER 1B,BBocnM) CONSTRUCTION TAX
Slgnxm.MApplicant/Contractor I Data FxHAusrIIOOD(W/DUCT) CONSTRUCTION TAX PA ID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupantstore or handle hazardous HEATING UNIT(TO 100,00 BN) Date Recei t#
meterbl as deflned by tM Cupertlno Municipal Cod,Chapter 9.12 and the
ITeahh and Safety Code Section 25532(a)? HEATING UNIT(OVER IDg000 BTU) TOTAL:
❑ Yea fi�j No
Will theappllont M locule building part use equipment or devices VENTILATION rAN(SINGLE RESM) ISSU� DATE
which emit hanardou.air mntsminanb as defined by the Bay Area Air �.�
Quality Management District? BOILER-COMP OHPOR 100,0W BTU)
I Yrs No
have read the haze ou.matedab requlrcmenh uncierChapter6.95 of BOILEi-COMP(OVER 100,0008'ITn O()� as 6A
the California l lealth&Safety Code,Sections 25505,25533 and 25534.I w��l r
understand that If the building does mi currently have a tenant,that It Ls my NEW RESIDENTIAL MECH. SQ.Fr.
maporuibility to nalfy the o pant of the requirements which must be met es{ IR
prior to Issuance of a Certificate of Occupancy. 573 ,„--,-
Owner m authorized agent Date ISSUED BY:
TOTAL:
OFFICE COPY