20948APPLICANT TO FILL IN INFORMATION WITHIi N RED LINES - USE BALL POINT PEN ONLY
Building Project Identification
Building Add mss:
9'y0U 0,5 ►-e � S � ��O
PERMIT NO.
2094.8
Owner ante: - one,
�{X
CITY OF CUPE RTI NO- BUI LDING DIVISION
APPLICATION / PERMIT
8'Zq-Q6
prliractor.sName: Lle. No:
e Y
BUILDINGS.ECTRICALPLUMBINGMECHANICAL
CATEGORY
CONTROL p
Firm/1'sgln r. Lk. No:
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Addrcsc
❑ El 1:1LICENSED
PERMITISSUANCE
CONTRACTOR'S DECLARATION
I hereby afflrmthat laivsim3licensed heunder Busi errand Pro ChionsCo e,and m-
Ing with Section 7000) of Dlvlsion3 o/tFe.uslness and ProfesslonsCode, and ory
license Is In full rce d dim 6 0
Limn C=sat k.N
APPLIANCESRESIDENTIAL
J .DESCRIPTION
'
PANTELS
Date Contnssor
ftt!5
201-1000 AMPS
ARCHITE G LARATIO�N —
OVERIOOOAMPS
SQ, FT. FLOOR AREA
E/SQ. Fr.
lunderstandmyplarusha. beusedaspublicrecords.
SIGNS ELECTRICAL
Licensed Prdesalovl
SPECIALCRRCUIT/MISC
OWNER -BUILDER DECLARATION
I hereby af.rmthat I am exempt from the G mtramnea License law for the
'
TSdP. MFTLROR POLE INST. 4�
fo.owing reason. (Section 7mlS, Business and Professions Code: Anydty or
muntywhich requires a permit to construct, alter, improve, demolish,oreepair
any simAure pdorto Its bsuance,abo requireatheappllonifrn each permit to
Ole a signed statement that he Is Ifecme i pursuant to the provisions of the
POWER DEVICES
/I
SWIMMING POOL ELECTRIC 13.
OUTLETS -SWITCHES SXTURES L
Contractor's License Taw (Chapter 9 (commencing with Section 7000) of Divi-
Bion3ofthe.uslnessand ProfessimuCode)orthab he is exempttherefr°mand
the bash for the alleged exemption. Any violation of Section 7031.5 by any
appBantfor e permit subjects the applicant toacivil penaltydnetnnretha
VALUATION
6
NEW RMDEN71AL ELECTR SQ.FT.
five hundred owner of thepro
❑ 1, as owner of the property, or my employees with wages as thele sok
S I TYPECONSTRUCTION
d for
cele Ike. Hon, w.Idothe ass.rd k.and the stmctnore e:TheC ContraIntenctors
sae (Sec. ainow and Code: The Law
License Law
TOTAL:
apply to f property of Improves
docs not apply loan owner offprough who buinempor impravathcrcoryand suchO
who does msuch
nts amwork hlmse dedorough Neownempered for safe. , hoxwa eprovided th that or
Improvements Intindneyear fcomplefoNthemneep deer ilI have
improvement 6soldwlthln oneycarofcomplelion,the owner-bullderwlll have
\
'
Rlrri. UNITS
/
th,c*rden of proving that he did =build orimproveforpurposeofuk.).
L_j I, as owner of the property, am exclusively contracting with licensed
contractors to mnsHuss the project (Sec. 7044, Business and Prdessions Code:
QTY. PLUMBING PERMIT FEE
PERMIT ISSUANCE
\ ,
APN
'Ilse Contractor's Limnse law does not apply to an owner of property who
builds or improver thereon, and who contracts for such p(osss with a
je
,5ador(s) Ilcensed pursuant to the Contracted License Law.
c IJ I am exempt under Sec. B & P C for this reason
--
ALTER -DRAIN &VENTWATER (EA)
�.pa
-
gpIX FLOW PROTECT. DEVICE
FEE SUMMARY
QIITqIDL
DRAINS FLOOR ROOF, AREA, COND.
FIXTURES. PER TRAP
SANITARY Y_ N_
RECEET 0
Owner Date
WORKMAN COMPENSATION DECLARATION
711 hereby affirm that I have a certificate of consent to self -Insure, ora
mdiflmteofWorker'ComNe tionlmumnmoramnBkdmpythemmf(Sec
3800, Lab CJ
SCHOOLTAX Y N
RECEIPT M
GAS EA. SYSfFM-1 INC.60I1TLETS
PARK FEE Y N
p
p
GAS EA. SYSTEM -OVER d (RA)
Coliry
Cm any
DING DI
BUILDING DIVISION FEES
[�Cer copy is RrIRrt.ied ropy b filed with the city herebyfurnished.the city Inspection division.
GREASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE
CRE'ASETRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thlraesslon need not be completed if the permit Isfrn one hundred dollars
(5100)orless.)
le 'sexed,
I cent em t oyin anyhe Performanceinany mornerhe work w as to becomeIn this subjrmitect
I shall rs employ any person In any manner so m m become subject t° the
Workers lawn of California. Date
PAID
DatC RCCCI IN
SEWER -SANITARY -STORM FA, 200FT.
WATER HEATER W/VENT/ELEGTR
ENERGY FEE Y N
PAID
WATER SYSTEM/TRFATING
ApplicaNOTICE
NOTICE co APPLICANT; a after nuking this Certificate is Exemption, you
subject it the Workers' such pruatlon orthloruoftheail be
Code,shoulyou
Code, you must forthwith comply with such proWlons orthb permit shall be
doomed revoked.
Date RC i t#
NEW RESIDENTIAL PLMR SQ.FT.
-
TOTAL:
BUILDING FEE
TOTAL:
SEISMIC FEE
ELECTRIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lendlegagenry forthe perform-
anm of the work for which this permit Is bested (Sec. 3097, Civ. C.)
Lenders Name
Landers Address
I cenl/ythat I havemad this application and state thattheabove Information
Lamrmn.I agree to comply with all dtyand muntyordlnanasand 4atelaws
QTY, MECHANICAL PERMIT - FEE
PLUMBING FEE
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID
relating to building comtmction, and hereby authodze repremntatives of this
'
city to enter upon the above,mentioned property for inspection purposes.
(We) agre to save, Indemnify an d keep harmless the City of C.per t..
ALTERORADDTOMECH.
-
Date RL'Ceipt#
SUBTOTAL:
against habyrtlfs, judgments, moo and ex which mayl..eyw.y..e
against t4, inconsequence he gr Ingdth permit
AIR HANDLING UNIT (TO 10,0W CFM)
AIR HANDLING UNIT(OVER 10,000 CFM)
CONSTRUCTION TAX
SigmAundomppTicant ontra W I Data
IXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HARD ATERIALS DISCLOSURE
HEATING UNIT HO 100,000 BTU)
illtheapp.cent or futu Ildlegoccvpantstoreor M1andleha:ardous
tedalasdefined by the Cupertino Municipal Code, Chapter 9.12, and the
V^
RCCCI tic
HEATING UNIT(OVER 100,000 BTU)
aate
' TOTAL:
D�
Health and Safety Ion 25532(a)7
F -1 Y.°
Wllltheappllcant future building occupant use equipment ordevices
whkhcmit havrdom Ir contaminants as defined by the Bay Area Alr
VENTILATION FAN (SINGLE RESID)
91990 ISSUANCE DATE
BOILER -COMP PHP OR l00,lXq BTU)
BOILER-COMP(OVSR 100,000 BTU)
Quality Marugemen Dlstrict7
4M1Yea o
ave rcadlhehaza wmoudah requirements under Chapter 6.95 of
the California Flcalth & fety Code, Sessions 25505, 25533 and 2x536. I
sIQ (Mrar11'�
NEW RESIDFNTIAL MECH. SQ.FT.
understand that lithe ulldingdoesnotcur otlyheveatcnant,that It bbaab�y
responsibility to heoavpaet of the quire. to which must besr�t
P to issuan of a III icate Oc cy.
r�
er aur raced age Date
ISSUEDBY:
TOTAL:
I� OFFICE COPY