26418ICl'1'YOFCUPERTINO APPLICATIONIPERMIT PI•umxinr-niF�c;,n Cni. rnovmt,�,r' nt_+/1q p
BUILDING DIVISION BUILDING PROJECT' IDBNTIFICAI ]ON G v 4 1 O
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STORIES TYPECONSTRI
L IN 1
R13. UNI'
P esu t
N. APN
FEESUMMARY
UT. IDE I I:ES
SANITARY YN_
RIiC1i117 p
SCIIOOLTAX YN_
RECEIPTN
PARK PEE YN_
RITCCI IT
BUILDING DIVISIVN FEES
PLANCHECK FEE
GRADING FEE
SOILS FEE
ENERGY FEES
PAID
to Rxeiptx
TOTAL.:
BUILDING ,E ' 0�
SEISMIC FETE
ELECTRIC FE
PAID
Dam Reaiplif
k;
Nr
ISSL ANCE DATE
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CI lY r ' ' •
ISSUED BY:
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CONTACT':15;WJ.6.Q, PHONE :
'^ 297-546
�I�LI%H�L Y�rHot�usr�y P)2C-rSI/ieA_i`1-
QTY. ELECTRIC PERMIT
PERMIT ISSUANCE
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( LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed anderprovisionsof Chaptert)(commencingwith
Section 7(psd M13M,eon3oflha Bminaolmd//Popoll,,ions Code, and my license is in
fall to effect CSI
APPLIANCES - RESIDENTIAL,
PANELS
<LV{,
cse Clad Lic.p (07�
Lien
UP YO 200 AMPS
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Date Conlramm
201 -IOW AMPS
A CIIITECTS DECLARA" N J7C//! 2
I undemm�d my plans sM1all be used es public re nMs.
OVER1000AMPS
SIGNS ELECTRICAL.
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Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from Ibe Cmnmema's License Law for The
following reasnn.(Senion 7031.5,Busines� and Pr.fessiom Code: Any city.. county
SPECIAL CIRCUIT/MI
TEMR MEf-R OR PCE IN'
which requires a permit to c,ndmal, aheq improve, demolish, or repair any structure
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prior to its issuance, also Taxi the applicant for such permit to file a signed statement
POWER DEVICES
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'aXo�i
Thm he is licensed pursuant to the provisions of the Cormuclor's License Law (Chapter
9(commencing with Section 7") of Division 3 of the Business and Professions Code)
SWIMMING POOL ELECTRIC
W_y
�=
� $
a
or that he is exempt therefrom and The basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant a civil penalty of
nm more than five hundred dollars (SSW),
❑ Lrtenwneroftheptnperty, ormyemployces with wagesustheirsolecompemati.n,
will dmbewofk, and the structure isms intended oroffead for safe (Sm. 70kI. Business
OUILEI'S-SWITCHES-PIXY FS
NEW RFSIUIiNT1At. ELELTR
and Professions Cole: The Contractor's License Law does not apply to an owner of
property who builds or improves Thereon, and who does such work himselfor Through his
own employees, provided that such improvements am not intended or offered for sale. If,
TAL
however. the building crimprovement is sold within one year ofc.mpletion. the owner
builderwlll have the burden of proving that hedidnol bulldorimprove farpurposeof
QTY. PLUMBING PERMIT
[1e')'
❑ Las owner eonwractoro
y,am exdusivdycomracabours
jet, (See 7 C de:) Th Contthereon.
menu the project (Sec. oano Business and Professions Code:) improves
property who d
Licensntrawdaasmhiresit apply loanmwnolarmac
mi.rupid
PERMIT ISSUANCE
sedIT.his
arCiamon,and
who contracts for such prnjats wiTh a conmaor(e) licensed pursuant to the Cnnvactor's
license Luw.
ALTER -DRAIN&VENT - WATER (Ii)7
_
❑ I am exempt under Sec. , B & P C for this reason
BACK FLOW PROTECT. DEVICE
Owner Date
DRAINS- FLOOR, ROOF, AREA, GOND.
WORKMAN COMPENSATION DECLARATION
❑ Thereby affirm thallhaveacmifcam mf consent mself-in sure,... anificamof
orkcri Compenxinion Insummceora ecnifed copy thveof (Se..3800. Lab C.)which
FIXTURES - PER TRAP
GAS - FA.SYSTEM-I INCA OUTLETS
covers .11 employee's undef This at
Policy N
GAS - VA. SYSTEM -OVER 4(EAU
❑mCcnifcA copy is hereby famished.
GREASEUSDUSTRL WASTE INTERCEPTOR
❑ Cambial copy is fled with thecity inspection division.
CERTIFICATE; OF EXEMPTION FROM WORKERS'
GREASE TRAP
COMPENSATION INSURANCE:
SEWER - SANI'T'ARY - STORM EA. 20017.
CTbisacetion necdnot becompletedifumpernit isforonehundfNdellars($100)
or less.) t
WATER HEATER W/VBNT/RLECTR
I eciifythm in the perfo.occuf The work far whi,h.hispcman is issued, Ishall
so
nor employ itoy person in any n as to hecmme subject to the Workers'
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Compensation Lawsof Califomia. Date
Applicnnt
NOTICE TO APPLICANT: If, after makiagthis Cerifteme of Exemption, you should
WATER SYSTEM/1'REATING
NEW RESIDENTIAL PI,MB. SQ. FT.
(• CO
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OF
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become subject o the Worker's Compensation provisions (if the Labor Code, you most
fonhwith comply with such provisions .,,his permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby afftrn thea There iso mtundio on lending agency for the perfnrmancc of
par
the work for which this nit is issued (Sec. 3197, Civ. C.)
Lender's Name
-
TOTAL:
L's Address
arch
QTY. MSCI IANICAI. PERMIT'
1 certily that 1 have read this application and state That the above informinn is
correct. l agree to comply with all city and county ordinances and state laws existing m
building ecuxlructlon. and hereby auThodu minasenlmives of This city to autocrats. the
PERM IT ISSUANCE
ALTER OR ADD TO MECH.
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above-operaimned property for inspection purposes.
(We) agree m rive, indemnify and keep harmless the City of Cupenlno against
liabilities,judgments, costs andexpenses which may in any way.ecrue against said City
AIR HANDLING UNIT(TO 10,000 CPM)
icons arca of The grami g.f This pernil.
tI
AIR UNIT'(OVIiN 10,000 CFM)
543/ 6j
-5431164
v 7
'ignamre of pplicanUQtmmn.r Dte
EXHAUST HOOD(W/DUM
HEATING UNIT(TO 1M." BTU)
HAZARDOUS h ATBRIALS DISCLOSURE
Wil the applicant er fuwre bu' ding acupam store or handle hazardous material
as defined by The Cupenino Muni al Code, Chapter 9.12, and the Ileahh and Safety
11E7ING UNIT' (OVER 100,000 R 11
Csae, Section 25512(e)1
❑Yes ysivIs; '' u
VENTILATION VAN (SINGLE RISID)
BOILER- COME LIHP OR 100,0(11 BTU)
Willthe applmi
icant or future building occupant use equiprremordevieca which et
BOILER - COMP (OVER 100,000 BTU)
.
harmCous air coal. nan6 as defined by [be Bay Area Air Quality Management
tonal?
.
❑Yat ❑ Nn
NEW RESIDENTIAL MECH.SQ. FT.
1 have read the hapardous materials requirements under Chapter 6.95 of the
'
Cc ... n,nia ll.lth & Safety CWe, Sections 25505, 25533 and 25534. 1 u ulardend Nal
if the building does not currently have a tenant, that it is my responsibility To notify the
.ccvpant of the acquirements which must be mel prior to issuance of it Ceniftcate of
Occupancy.
Owner of amhoriud agent Date
TOTAL:
10
r•ER
Frr:
0
STORIES TYPECONSTRI
L IN 1
R13. UNI'
P esu t
N. APN
FEESUMMARY
UT. IDE I I:ES
SANITARY YN_
RIiC1i117 p
SCIIOOLTAX YN_
RECEIPTN
PARK PEE YN_
RITCCI IT
BUILDING DIVISIVN FEES
PLANCHECK FEE
GRADING FEE
SOILS FEE
ENERGY FEES
PAID
to Rxeiptx
TOTAL.:
BUILDING ,E ' 0�
SEISMIC FETE
ELECTRIC FE
PAID
Dam Reaiplif
k;
Nr
ISSL ANCE DATE
P°lp�
CI lY r ' ' •
ISSUED BY:
0 �