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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Pro'cct Identification
B°°ding Address
PERMITNO.
Oosa A1,11P d
23634
Phone:
jrAf�/De-Al [�Oi•�lPLfTCnd
CITY OF CUPERTTNO-BUILDING DIVISION
APPLICATION / PERMIT
Contracture Name: Lk. No:
IGIC e'a'4S1_ T/Z/}A/C
BMDING-ELECTRICAI.PLUMBINGMFCHAMCAL
CATEGORY
CONTROL#
Architect/Engineer. Lie. No:
ELECTRICPERMIT FEE
BUILDING PERMIT INFO
Address: `�/C) S0'P6f&` W'"' Yo
LES YO At
PERMITISSUANCE
(�A/I
❑ E] 1:1�
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am lkensed under provisions of Chapter 9(commenc
APPLIANCESRESIDENTIAL
JOB DESCRIPTION
PANELS
UP TO 2DOAMM
ingwith Section 7DXBrf Dwision3olthe Busmossand ProfsmionsCode,and my
It... b in full force and effect.
LicenseClassC=Z 0 Lic. # 4/o S6 S6
Date ,/3 oKContnctor
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records
�s L�; • • G^n
201-1000AM15
OVERI=MvI15
SQ. FT. FLOOR AREA
5/SQ. FT.
SIGNS ELECTRICAL
Licensed Professional
SPECIALCRCUIT/MISC
OWNER -BUILDER DECLARATION
I hereby.f(lton that I am exempt from the Contractor's License Law for the
�k
L` LED I
!l
TEMP. METER OR POLE INST.
following reason.(Section 7(31.5, Business and Professions Code: Any city or
cou my which requires a permit to construct, alter, Improve, demolish, or repair
f\ (I 1
anystrumm priorto its itsuance6
,ao requirestheappllcaut forsuch permitte,
Ole a signed statement that he is licensed pursuant to the provIsiom of the
POWER DEVICES
[V� V
SWATMING POOL ELECTRIC—
OUTLETSSWI7CFIESHXTURES
Contractor's License Law(Chapter9(commencing with Section 7000) of Divi-
.don 3 ofthe Rusinessend ProfessionsCode) orthat he Is exempt therefromandVALUATION
the basis for the alleged exemption. Any violation of Section 7WIS by any
applicantforapen isubjeMtheapplic.rsttoadvllpemltyofna.m than
t '
NEW RESIDENTIAL ELECTR SQ'FT.
five hundred dollars ($5M.
[]1, as owner of the property, or my employees with wages as their sole
STORIES—
TYPE CONSTRUCTION
compensation, wi ldothe work andthe structure 6 not intended or offered for
sale (Sec. 7NR Business and Professions Code: The Contractors Lt.. Law
does not apply to an owner of property who Wilds or improves thereon, and
whodoessuchwork himself orthrough hisownemployem, provided thatsrch
OCC.GROUP
RFS. UNITS
TOTAL:
improvements are nm intended proffered for mle. IL however the W llding m
improver ntuwldwithinoneysarofcmnplet Ntheowner-WWerwillhave
thLkprden of proving that he did not Wild or improve for purpose of axle.).
LI L as an, of the property, am exclusively det—c Ing with .... d
contra era to construct the project(Sec 70K Business and Professions Code:
QTY. PLUMBING PERMIT PEE
FLOOD ZONE
APN
PERMIT ISSUANCE
The Contractor's License law does not apply to an owner of property who
Wilds or improves thereon, and who contracts for such Objects with a
q¢Ranor(s) licensed pursuant to the Contractor's License Law.
d u I am exempt .under Sec. R & P C for this reason
ALTER -DRAIN & VENT -WATER (EM
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
e. .'e
DRAINS FLOOR ROOF, AREA, CONI).
SANITARYRECmPT#
Owner Data
WORKMAN COMPENSATION DECIARATION
hereby affirm that I kava a certificate of consent to self -Insure, ora
certificate of Workers' Compensation Insurance or a mrtifd!copy thereof (Sec
3800, Tab C.)
FICTURFS PER TRAP
SCITOOL TAX Y N
RECEIPT It
GAS EA. SYSIFM.I INCA OUTLETS
PARK FEE Y N
RECEIPT M
Policy #
om any
CEf
GAS PA. gYSTEM-OVER 6 (EA)
BUILDING DIVISION FEES
Ccrtified copy Is hereby furnished.
❑ Certified copy 6 filed with the city inspection division.
GRFASE/INDUSIRL WASTE INTERCEPTOR
PLANCHECK FEE
GREASE TRAP
CERTIFICATE OF E)cEM PTION FROM WOR K ER S'
PAID
SEWER -SANITARY -STORM F.A.200FT
COMPENSATION INSURANCE
(Thissectlon need not be completed I the permit 6 forms hundred dollar.
Date RCCCI t#
HEATER W/VONT/dpC.pR
ENERGY FEE Y_ N_
(s100).H.)WATER
I mnify that N the performance of the work for which this penult is Issued,
WATER SYSTEM/TREATING
I shall not employ any person In any manner w as to Wcome subject to the
WorkersCompensation Laws of California. Date
PAID
NEW RESIDENTIAL PCMB. SQ.FT.
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you
should become subject to the Warkees' Compensation provisions of the Labor
Date Rccei t#
TOTAL:
BUILDING FEE
Code, you mus: forthwith comply with such provisions or this permit shall be
deemed revoked.
coNsrgurnoN LENDING neencY
SEISMIC FEE
I herebyaffirmthat there Isaco®tructlon lendingagency forthe perform.
sure of the work for which this permit 6lvacd (See. 3097, Civ. C.)
Lender's Name
land difythall have ress
Ime. Iagrectocosadeh6applicityand c irayoattheaasand gate laws
6coingt building complywW all hem's couhomdlnanms and sesoftws
ori or nrcprcxnpurpos of this
rcy toetobullding conswctloe,and hereby property
property tless the Cit purposes.
citye agree
(We)agree to save, Indemnify andkeepes whihthe in ay ay ammo
to the sav,Wvemnify an
against liabilities, jadgmenus, coxsand expenses which may in any way accrue
TOTAL.
ELECTRIC FEE
PLUMBING FEE
Q TY, MECHANICAL PERMIT FEE
MECHA CAL FBE
1
PERMIT ISSUANCE `
\ ^�
Date Receipt#
ALTER OR ADDTO MECH.
AIR HANDLING UNIT(TO 10,000 CFM)
SUBTOTAL:
agairet said City In consequence of the grunting of lhls permit.
-
AIR 1iANI)L1NcUNIT (OVER to,aoocr•M)
CONSTRUCTION TAX
Signature of Applicant/Contractor Date
EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (TO 100,000 BTU)
Will the a pplicant or future building occupant store or handle haeardous
Date Recel t#
material as defined by the Cupertino Municipal Code, Chapter 91Z and the
lira th and Safety Code Section 25532(.)7
Yca �]No
111 the applicant m future building occupant use or devices
HEATING UNIT (OVER 100,D00 BTU)
TOTAL'
VENTILATION FAN (SINGLE RESID)
ISSUANCE DATE
theequipmentBay Ar
QuaaFtManaementsairrict? contaminants by the Bay Arca A4
Quality Management DuMct7
Y:sP� No
BOILER -COMP PFI'DR 100,0110 BTU)
BOILER-COMP(OVER 100,000 BTU)
read the h 2us materials requirements under Chapter 6.95 of
the California Health & Safety Code, Sections 2550.5, 25533 and 25534. I
understand that if the building does not currently have a tenant, that it 6 my
#W
P A 9 D
NEWRFSIDENTIALMECH. SQ
rnpoms 1 y)torynotqify the occupant of the requirements which must W met
prlg�ai c W Ceti% n�(. sYA —
/dd
��� r 199
ISSUEDBY:
ter.,....ttthh/g�r�l agent Data
TO A :
VII 1 f taU1'-CETT IIYV
OFFICE COPY