24188 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification - PIik.WTNQ,
Building Addma: Z
?LC7�0 S�ilf5
Da ante: one: APPLICATION SUBMIL LAE DAlT
`..� CITY OF CUPERTIN0.BUILDING DIVISION
coetracher'i N.me: LIc.No: APPLICATION I PERMIT gas, g-jen
k.Fi Y `r. R •' 42D 9 9BUILDING-ELECTRICALPLUMBING-MECHANICAL CATEGORY CO
Architect/ gmeer. Llc.No:
`32 QTY ELECTRIC PBRM FEE BUILDING PERMIT INFO
Address: tA, ed MELEE
"9'55'1 �C L7 1�.C,Ce1-t.V-JPERMTISSUANCE IV ni �� �{ ❑
LICENSED CONTRACTOR'S DC: RAT] N 537
Thereby affirm that l am licensed under provla na ofOuiplerg(rommenc APPLIANCESRESIDENTIAL JOB DFSCRfI'DON
Ingwith Section7W0)of Dlvielon3oflhe Bupnemand Profesal...Code,and m
lineae b in full f and dfect. PANELS `
License Chm Lictl _g $S'7
ate Contractor_ F`i f a e CT
ARCHITECTS DECLARATION 1 PS
µQS m0 O I undereland my plana shall be used as public records. V AMPS SQ.FT.FLOOR AREA S/SQ.FT.
E Llcenwd Pmfmloml SELFCTRIC S
OWNER-BUILDER DECLARATION SPLCIA
Z F'�G ]herebyaffimn that lam exemplfromthe Contractor'iLkense Law for the
OZ1:�pp foilowing remon.(Sc«Ion 7 t to,B ms d and Pmfeasions Code:Any dty it
TEMP. O LE]NST.
Pmaountywhkh rcqulreaa isaggelocomrwe,esthemprovmtforslhh,or repair
q e atwcturetatemenits haaeat ahoregWmouset t the (orminsof tto
o POWERD CES
3 0. 01e a signed statement that he h Iicemed pursuant to the provisions of the
u, Con 3.fthe Llcenae Law(C emio 9(commencing with Section hemf of DWI- 54VA16gNG TOOL ELECTRIC VALUATION A.w
SOS the beg)fo Bupnnsand Profeseion.0 Any violation
f exempt therefrom and ^
the begs forthe alleged exemption. Anyt tolacivi a(nalty o 703L5by reany UH,CTSSWITCHFSHXTURLS {/
C
applicanthudranrapeemi(S500)n.the applicant los dull penalty of not mare than v YlJ
five hundred dolowner
of he pr.
NEW RESIDENTIAL ELECTR
❑I,as owner of the properly,or he employees Is real
with wages as ffer dole �'FT• STORIES TYPE CONSTRUCTION
7 In CS,,tion,will dotho Bealuesited k.and thestm a:Thnotintendedoroffered far
k o sale(Sec 7014,to alnow and Pro(mbm Code:The Contncto/s LIceae Law
S$ don not apply to an owner of property who builds or improves thereon and OCC.CROUP RFS.UNITS
EEE whodoeLidsa not Intended
edoorthrough hleownemp,however,
thating or
Improvementsarcnot Intended earofco for ale.If•however, ilderwdingve
Improvement hwld within oneyearrftomplHlon,the owner-bullderwllihdve
it�j ordenof provingthat he did not mildor Improve farpurposeof sale.). QTy, PLUMBING PERMIT FEE
8 Las at of the property,am exclusively contracting with licensed FLOOD 7pNg ApNpggM1775511ANCE
ron,idem to construct the Project(Sec 7014 Business and Profesalom Code:
The Conn trectoe.License law doact apply to an owner of property who ALTER-DRAIN VENT WATER(EA)
Wild.or Improves thereon,and who contracts for such ptojects with a
m•B)(anor(s)Bcemed pursuant to the Contractors License Law. BACK FLOW PROTECT,DEVICE FEE SUMMARY
Ll l am exempt under Sec B&P C for this reason
OUTSIDE FEES
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_
Owner Date RECEB'T g
WORKMAN COMPENSATION DECLARATION
Of hereby affirm that I have a certificate of consent to self-hare,or a /t RES]ER TRAP 100L TAX Y N—
certBiote of Worken'Comperuation Insurance ora certified copythersof(Sec. RECEEPT tl
38001Lab C.) tG EA _
1 C.4 PFEE Y_ N_
Policytl GAS -0VER4(EA),j .. - RECEIVEN
Co^' c - , BUILDING DIVISI FIX
❑CertNed copy is hereby famished. - __ . f
❑Certified copy is filed with the city inspection division. GREASE/INDUSTRL WASTE] EPT R N4Da �Recel
CERTIFICATE OF EXEMPTION FROM WORKERS' GR SE TE. P ID COMPENSATION INSURANCE SEWER-SANCCARY-STORM EA.7AOFT. aa�
(I'hlssection rootlets be completed If the permit h forone hundred dollars
($1ea..)
I onmniceices.at N the performance of the work forwNch tNs permit is JawWATER HEATER W/VENT/ELMTR Eed, —
I shall not employ any person In any manner to as to become subject to the WATER SYSTEM/TREATING
Workers Compensation Laws of California.Date P
z Z ApplicaNOnCnt i. you NEW RESIDENTIAL PLMB. SQ.FT. Da Recel t#
Z O NOTICETO esubjettothe mkrrakingthh..it.provisions
should become subjecttothe ply with
Lab or TOTAL:
~ M deemed Cod,you
coked.forthwith comply with such provhlom or this permit shall be BUILD] �
LU j deemed revoked. SEIS?
S C FEE �'
CONSTRUCTION LENDING AGENCY
- IherebyafBmn that there is a construction lending agency for the perform TMHANICAL
IC FEE
Zanceofthewmrkforwhichthhpemdrhhwed(See 309],Civ.C.) TOTAL:
V O Lender'.Name NG FEE
LL F bender's Address QTY. MECHANICAL PERMIT FEE FEE
OW I certlfythal l have read this application and pate thattheabove Informationa incorrect.I agree to comply withal)cityand county nettlesome and pate laws PERMIT ISSUANCE ID:
). relating to building[nmtanion,and hereby authomm representatives of thin
Zcity to enter upon the above-mentioned property for Wpection purposes. ALTIRORADDTOMECH. el f#
V — (We)agree to ave,led madly an d keep harmless the City of Cu pen[no AIR HANDLING]IMT(1'010,f100 CFM)
spat liabilities,judgment,costs and expenses which may In any way accrue SDBT L'
aga ;said City In con ern of the grant in$of this permit.
AIR HANDLING UNIT(OVER 10,000 CFM) CON UCTION TA
—ll CONST CTION TAX PAID:
of Applicant/ContractorDare IXIiAlJS'C fI00D(W/DIKE)
HAZARDOUS MATERIALS DISCLOSURE
Will the appllcant or future building otxvpantnmre or handle haaardous HEATING UNIT(TO 100,000 BTU) Date .Reset t#
material as defined by the Cupertino Municipal Code,Chapter 9.1$and the -
Iinith and Safety Code Section 25537(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑ Yes No
Willlheapplicent or Lure building occupant use equipment ordevices VENTILATION FAN(SINGLE RESID) ISS CE DATE
a
which emit harurdom air contaminants as defined by the Bay Area Air
Bry Management District? BOILFR-COMP OHP OR 100,!X10 BTO
�.
Yes ❑No
have read the hitt crus materials requlremenh under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU)
the Californla Health&Safety Code,Sections 25505,25533 and 75534. I (S�n •I
�011�
understand that if the building does not currently have a tenant,that It is my NEW RESIDENTIAL ME CH. SQ.FT. k7 1' al
h apomibility to notify the oc vpant of the requirement which must be met Vx7
prior to issuance of a Certificate of Ocw pa ney. Cl ry,ur�y��(\
Owner or authorlud agent Data ISSUED BY:
VV Y= Llrl Ib,
TOTAL:
OFFICE COPY