22384 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY ✓
1101din Proerg Ideni fiaBon PERMIT ND
Bufding Add;
r -� 'y�o 22384
amr one:
CITY OF CUPERTIN6BUILDING DIVISION �7�. �� � �
SContracto/a Name: 1Jc.No: APPLICATION I PERMIT
BUILDINGS.ECTRI PLUMBINGhfECIIAN1CA1, CATEGORY CONTROL.
Arddtel/Enginesr. Lb.Na
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add. PE),11TIS'UANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby afflmntlut lam lkerixd urdrrprvvbimre of O�aper9(mmmm
APPLIANCES-RESIDENTIAL t JOB DESCRIITI N
ingwith Secibn 7000)ofDo,Wm3 ofthe Butlweand MRIMUQTAI o e,and my
Ilam le In full fgloe d effc . PANELS I r I p)e�
LkerweCh� L L{c Y_ ej��
Dale CoMnno 4UP TO 2DOAM5P b
AR 'has&DECLARATION E AMPS
M
0 Zp Iuentand my plans'had]
i-uB be used mr
public rcds OVER 1070 AMPS 'SQ.aFT.FLOOR AREA 5/SQ.FT.
to L U LEensed Pmfesional . , - SIGNSELEC RICAL
(n< OWNER-BUILDER DECLARATION SPECULCEiCUIT/MLSC
F• 3 Ihmbyaffirm lh.t lam exempt from the Comraclor's Llo=rue law far the (�
7 9 following reason.(Section 70715,Business eand My city or Profession,Code:
TEMP.METER OR POLEINST. Qe1^m4
��� munty wF rh rtquirnapemdtmmmwn,alter,lmpmve,tlemoBahorrtpalr
anystucturt prb to lte feeuaregsborryulmtheappBantfor such pemdc to POWER DEVICES
O fib a signed statement that he 6llmrued pursuant to the provblom of the )
3ua� Contnnoh Lkenr l�w(Chaper9(mmvrcntlng with Section 9000)of Dlvl-�� Bbn3ofthe Bus.mdPrdmb CWe)orNthebeumpttherermmaM SWB.fMING R70L ELECTRIC VALUATION
y.'Y, the basis lot the alleged exemption. My Ndatlnn ofSenbn 7015 by any
O<A appU.tforaplr .bj,cv ,.ppUcankt.a Wllpe.hy f.,.mtNo OUTLE�SWUCkES-FLXTURES'
�c fins hundreddollue( 00). ED i
NI,as owner of the property,or my employees with wages as their sole NEW RFSIDFARTALELFG7R TITS CONSTRLCTION'
C%6 compensation,will do the work,andthe structure bnot bderdedoroffered for PU'TE
p sale Ck,704,L Bueircuand Pmfesbrm Cmn
ode:The Coctors Umnse,Lew MOW
dm em.pp)y to an owner of property who builds or lmpmves thereon,and TIIJII5
0. whodoesum
ch work himseforthrgh hbowoemployees,provided that such x.
improvemawaremtlntendedoroffere fwaic lthowever,thebuildingor IOTA 'G
improvement bsddw hlnomyearorcornpletbn,the er-bullderw0lhave XMv -1
tlILIIurdenofpmvingthrt Mdld not build or Improve ro<purpa,e or Bale.). Qi . PLUMBING PERMIT FEE
u L as owner of the Property,am exclusively amtractlng with Il¢ved FT.00D ZONE APN
mntou,tora to construct the pmject(See 7044,Business aid Professions Code: PERMIT ISSUANCE
The Contractors Lberue Lew dm not apply W an owner of property who
bolds or Improves thaear, and who mntescts for such projens whh s ALTER-DRAIN&VENT-WATER MAI _
gal[w.r(l)limned pursuant to the Contractor's Limose Law. FEE SUMMARY
LJ I am exempt under Sec B&P C for this reason BAC:FLOW PROTECT.DEVICE OUTSIDE FEES
DRAINSFTDDR ROOF,AREA,COND, SANITARY Y_ N
Owner Date RECEIPTI
WORKMANI haw av'SATION DECLARATION, FI%7URFS-PER TRAP SC TOOL TAX Y_ N_
Lie
orrirm that I have•¢rtifiate d morn[to copy the
rt,or a RECEIPT a
mrtl to of Worken'Cornpevatlmlwnranor ora artlfk]m%the'of(See GAS EA.S-YSppA{-1 INC.4017[I,EfS PARK FEE Y N
380,LabC.)
Poalya _ —Z.•. 49 OB - RECEOTI—
Com y ` �y /✓HA CAS EA.�EM-OPER4�`) BUIL DING DI VI SION EE ES
Certlll�py 4 led Mth ed, Oe' T GRE&SE/INDUsrnL WA INTTRKRPTOR PLANCHECK FEE
CertNed ropy bfL4d with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS GREASE TRAP PAID
COM P roopl TIONhe p1noV:CE SEwFR-SANTrARYSTORM FA NOFr. Date RCOei [#
(Dda I..) need matbucompleted Bthe p.mdt b(worehundred dollar
(SII orless.) WATER HEATERW/VENT/E.ECTR ENERGY FEE Y N_
I orrtlfy that b the pedormna of the work ran which ete xt suh b Issued,
1 sha0 raw employ any Peron in any manner at n to bemme subject to the WATER SYSTEM/TREATING
O ^wltiean'Cwnpenvtbn levee olGWornb. Date PAID
Z NOTICETO APPLICANT:11,after making tNS CertBlate of Exemption,you NEN'RESIDEMIAl.PLMB.—SQA. Date Recti t#
should become subject to the Worker'Comperuatlon provisionsof the Labor TOTAL:
CCN Code,you must fodhwLLh comply with such prwbloro orthls FarmN shall be
W > deemed revoked. BUILDING FEE
0 CONSTRICTION LENDING AGENCY S I MIC FEE
a 1 hercbyarflrmtluttFertba mmtunlm kodbgageney for the perform ELECTRIC FEE
7 = aore of the workrorwhkh Nb pemdt b Issued LSee 3097,Chr.C.) TOTAL'
02 IeMeraName PLUMB WG FEE
IL — Lenders address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
I oertlfy lhatl have mad thba
appltbn and statethat theabwe InformatiInformationoInformationO W
bmrrect.lagmetocamp)yw aUdtyaM=ntyordlnanma dstat.laws PERMIT ISSUANCE FEES PAID: n
NNatingtobulldingmmtuctlm,and hrnebyauthorlu rcprerntatWes of lhb Ks-ll q
F z city to enter upon the above-mentioned property for Wpectlon purposes. ALTER OR ADD TO MECH. Dale Recel (#
V — (We)agree to save,bdemN fy an d keep hunt.the City or Cu pertiro
g.�)iabNfios gmenb,aubfthe grvmlrigdW pemdt nywayacwe ARt HANDLING UNIT(TOIO,000CFM), SUBTOTAL:
yl� a. 7AIRHANDENGUNrr(OVE210,000CLND CONSTRUCTIONTAX
Sigrawrtaf am/c nor !7—�tem EXHAUsrklOOO(W/DUCT) CONSTRUCTION TAX PAID:
HAZARD US MATERIALS DISCLdSURE
WWtheapplla Nm furs ading.pantnoreorha Ichuardous HEATiNGUNIT(T01W, 10BTU) Date ReCel t#
mmerbl as defined by the Cupertlm M.Ndpal Code,Chapter 9.17,and the
I leallh and Safety Code Section 75532(8)1 HEATING UNIT(OVER 10,000 BTI!)q Y. TOTAL:
No
l the applhnt tune building occupant use equipment or xis VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
whkhemdthavrdousalr tambaueasdefinadbytMBay Area Air
• Quality Managemcm lHar4t7 BORER-NMP OkE'OR IW,IXD BTU)Y. No
have read the
Health
�matde,3requbemr5,2553erChapter.1 of BORER COMP(OVFT210,00 BTU)
the Cahfoula Heabh&SafetyCods oteum25505,25533andt,that 1
usp.r.oudyt.. ldythethat fithe ding due of the mentlyhanr.wham,rust It bony NEIVR®DFN77AL ME(7i. ;QFT
iuponeibddy tofja�lfy the wcupart dthe
pancy. remeda7 hkh must be met
Pn rti tc of ��
wast//' ag t ISSUED
TOTAL — -
C r OFFICE COPY