21671 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project ldemiflcation PI?IIhllT NO.
B.ildmgAddre.s:.22160 Wqjof brtv'( Cl,-pe,t''fi %&) Cit 956fY 21 671
y08- 43 - GI
waer ane: one:
CITY OF CUPERTINOBUILDING DIVISION
Contractor°Name: LIc'Ne: APPLICATION 1 PERMIT
BUILDING-ELECTRICALPLUMBINC-MECHANICAL CATEGORY CONTROL If
Architect/Engineer. Lic.No:
X58 y dean a r, et( R� S� Qry ELECTRIC PERMIT FEE BUILDING PERMIT INFO
ress
Add : Va PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACT'OR'S DECLARATION pSd
IherebydfUm that lam Bcenudundsrprovidonspf Chapter9(comman APPLIANCES RESIDENfIAL JOB DESCRIPTION
ingwith Ecd1on7000)pf DlWslon3ofthe Buel and PrefesslansCode,and my
Ilcense bin full force and d(ect, PANELS TS _
Llcenss Chu Llca IIr(
Date Contractor - UP TO TOO2DDAh
ARCHITEC?'S DECLARATION IT FLOORAREA S/SQ FT
q�q�uu
Mx: I un nnster l my plans shall be used u public records. OVER TODD AMPS -
SQ
6i Limned Professional SIGNS ELECTRICAL
GGGG OWNER-BUILDER DECLARATION
SPECIALCItCU1T/MIST
O R T hereby um.(tut ne 7031 mot from Me d Professions
License LawAny farcit or
qqqqqq following remora.6ectlon 7UI1S,Business and Isro(esslpm Code:Any city or
Fs'v{ countywhichrequbesapermdtWmmtmdalter,lmproedemnlbh,orrepalr TEMP METER OR POLE INA.
45 a anystm umpeorto B.Wuame,alcorequlrntheapphmntfmsuchpermltto
6 9 0. file a signed statement that he b llmnsed Pursuant to the provialom of the POWER DEVICES
3 w Contractor.License Law(Chapter 9(commencing with Section 7000)of Dlvl- SWIMMING TUOL EL C
H OS ebnloftle Bu.ine dPr feu mCade)orlholhehexemptlhtrefromand VALUATION
the baeis for the alleged exemption. Any violation of Semon 7031.5 by any
�A OUTLE TCHFS ES
aPPIlan fora permit subMcte the to a civil penalty ofnet more than
12 O 01 V9
..CL R1undred dollars%SftE. NEW RAL ELLC S
Q I,as owner of the property,or my employees with wages as their sale Q.17. STORIES TYPE CONSTRUCTION
compensation,will do the work and the structure Is rot Intended or offered for
sole(Sec.70/4,Business and Professions Code:The Contractors License Law
$ don not apply to an owner of property who bullds or Improves thereon,and OCC.GROUP' RES.UNITS
who does suchwork himvel or through hlsown employees,provided that such AV A
Improvements are not intended proffered ferule.If,however,thebullding or U TOTAL:
Improvement bsold withN oneyearofcomplction,the owner-builderwllt have
t rden of proving that he did not build or improve for purpose of sale.). Q PERMIT FEE FLOODZONEApN
as owner of the property,am exclusively contracting with It...d
ronPERM AN
ntcton to construct the project(See.7614,Business and Professlom Code:
The Cont ractpr',Llcenss few don not apply to an owner of property who INA VENT WA )
build.or Improves thereon,and who contracts far such pfujecis with a FEE SUMMARY
cgp)laon,(.)heresed pursuant to the Contractor',License Law. B W OTECT.D E
1�I am exempt under Seo B A P C for this reason
D SFT.00 BOO, SANITARY Y_ N_
• Owner A aM Date T RECEIPT a
WOR AN 'O SA ION DECLARATION SPER SCHOOL TAX Y_ N_
01 hereby affirm that I have a nrtl0rate of consent to self-Insureor,A RECEIPT 0
certificate ofworkeri Compensation Insurance oraartl(k:d copythereof(5ec. GAS EA. -1 NC.
3800,late C.) PARK ITE Y_ N
Policy GAS G.SY O d(U) RECEIPTN
Com any BUILDING DIVISION FEES
�CertiRed copy b herebyfamished. GRFASE/IVDU w sIE INTERCEPTOR PLANCHECK FEE
❑Certified copy b filed with the city Inspection dlve.lon.
CERTIFICATE OF EXEMPTION FROM WORK ERS' GREASETRAP PAID
COMPENSATION INSURANCE sEwE&SANITARY•S'CORM FA.2WFT. Date RCCeI [IF
(Thlssectlon need not be completed If the permit la forone hundred dollars
($10[fimless.) WATER HEATER W/VENT/ELECTS ENERGY FEE Y N
I oertlfylhat in the Performance of the work forwhlch this permit is blued,
1 shall not employ any person in any manner an a.to become subject to the WATER SYSTFSA/TRGTING
Workers'Compensation laws of Caidomla.Date PAID
Z NOTlicant
ICE TO APPLICANT:If,after making this Certificate of Exemption,you NEW RESIDENTIAL PLMB. SQ.FT. Date Recei tat
Hshould became a.bjtd to the Warke.'Compensation provisions of the Labor TOTAL:
tl3 Code,you muat forthwith comply with such prmtalons or this permit shall be IN DO
W C deemed revoked.
CL CONSTRUCTION LENDING AGENCY SEISMIC FEE r
I hereby a(Rmethat there b a construction lending agency for the perforrm ELECTRIC FEE
Z Anne ofthe work for which this permit is lasued(See.3097,Civ.C.) TOTAL:
U O lender's Name PLUMBING FEE
IL F Lcndcr.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW I certlfythall have need thlaappllatlon and statethatthe above Information
1 lacorrect.I agree to comply with all city and county ordinances and state laws PERMITISSUANCE FEES PAID:
N relating to building comtmcten,and hereby authortu representatives of this
F city to enter upon the above-mentioned property for inspection N rposn. ALTERORADDIOMECH.? Date Revel tit(We)agree to save,Indemnify an d keep harmless the City of Cu pertlno
V Aga Inst liabilities,judgments,mets end expenses which may In any wry accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL'
age Inst said City In con ence of the grantingofthe.permit. �i1
y �I
Aa r.a�a�yAA�e9 I—/4 Tf AIR HANDLING UNIT(OVER I0,000CFM) CONSTRUCfIONTAX
SignatureSignaturepf APpl rat/ ontractor Date — EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
ZAR DOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle haaardaus HEATING UNIT(TO l 00,00D BTU) Date RCCCi t✓w
material as defined by the Cupertl no Municipal Code,Chapter 9.1 2,and the
I and Safety Code,Section 25532(x)? HEATING UNIT(OVER 100,000 BTU) TOTAL
❑Ye :
Will the applicant or❑future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) Ify,"DATE
which eMt hamrdous air contaminants as deOnaA by the Bay Area Air
Quality Management District? BOILFR-COMP DEEP OR IM000 BTU)
4Y. n No �pQ
havcreadtealth& afetyC de,Ssreorn25Sntsundeand255r6.95o! BO LER-COMP(OVQt100,OOD BTU)
the erata d t Health A Satiny Code,Sections 2550.5,have
a tenant,,that.1
undecaporlandthat ifthe ntify the ingocc tlom of to rently uiremnts whichthat It be sot NEW RESIDENTIAL METH. 5Q.Fr.
rmor to lauace motifytheoccupantoftherequimrmniswhich at be neat r:af(�F�.^"1e�lfd►
prior to Lssuanre of a CertlMate of Occupancy. S:.nf,W L:.L+�;.VC�.aS
Owner or Authodud agent Data TOTAL: ISSUED,,4,
OFFICE COPY