24376 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Paned IdentificationPERMYTN
Building Address: 10 24376
one:
CITY OF CUPERT[NO BUILDING DIVISION
car Toy I C_,`
contactor'• No:
APPLICATION / PERMIT
�RUILDINC-ELECTRICALPLUMBINGMECHAMCAL CATEGORY CONTROL.N
Arc imet/Engin r. Lk.No:
QTY ELECTRIC PERMIT PEE
BUILDING PERMIT INFO -
Add. PFRIATISSUANCE ❑ f�-1
LICENSED CONTRACTOR'S DECLARATION �f
I hereby
fimthatl provisions Chat fear 9 c
AlPLlANCFSRESIDEMIAL JOB Dl1�SRhBTI1ON
nbSection7 )ot Aivldoa3 ofthe Businessand ProfessonsCode,and my
license 1e In(uI1 � 3act. PONDS
Lkrmv ssJVWk.=�n
at / Cmdp
,
UPT0200AM
ARCHITE DE AT N
qWqW w�w ZO I understand m7 plane,hall be usedss public records OVER IODO AMPS SQ.FT.FLOOR AREA $/SQ.Fr.
Licensed Professional SIGNSELECTRICAL NLA IpN��
<Q OWNER-BUILDER DECLARATION E� D ' N
Ir'i FeiS SI'FLIALCIRCUIT/MISC
Thereby afRrm ltitlam exempt from the Contractors License Law for the i
llbVI �pI �
T
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following reason.eledine 7031.5,Business and professions Code:Any city or I V C R
p t., TFMP.METDtOR[sOLE INST. 1
county
ystmuwhich re Troup alttoco mquimsth,improve,abntforsudemolish,orrepto
g any swnud statement
thauance,aUoregW pursuant to the revisions of the ppWpJR DEVICES
6� � file a signed statement that he V Ikensed pursuant to the provisions of the
�a Contractor's License Law(Chapter 9(commencing with Section 7000)ofDivi. SWIMMING POOL ELECTRIC VALU O��
O slon3ofthe Bu,in nand Professiom CWe)orthalhebexemplthemfromand
Yi S the basis for the alleged exemption. Any violation of Section 7031.5 by any O `LETS-SWITCHESFTXIURE9
6i
applicant for.permit subjects the applicant an t to a civil penalty of not more than
e. � five hundred dollars(S503). NEW RESIDENTIAL ELECTR SQ.FI'. STORIES TYPE CONSTRUCTION
..�n ❑I,as owner of the property,or my employees with wages as their sole
G�6 compensation,will do the work and the structure is not intended or offered for
O sale(Sec.7044,Business and Professions Code:The Cmntranors Llcnnx Law
Q does not apply to an owner of property who Wilds or improve thereon,and OCC.GROUP RES.UNITS
who dmesuch work himself orthrwgh Ms own employees,provided that such
lmprovementa are nm Intended oroffered for,ale.If,hmwevepthebuilding or TOTAL:
lmpmvementLwidwhhlnomyearofcompldt n,themwner-buRderwillhave
are
f proving that he did not build or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
L�L as owner of the property,am exclusively contracting with licensed PIXMIT ISSUANCE
contractors to construct the project(Sec.70,14,Business and Professions Code:
The Contractors License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
builds or Improves thereon, and who coarses for such p,jects with a FEE SUMMARY
ffI ctor(s)hansedpunuanttothe Contractor'sLkeme Law. BACKFLOW PROTECT.DEVICE
l are exempt under Sec. B &P C for this reasonOUTSIDE FEES
Owner Data DRAINS FLOOR ROOF,AREA,CON I. SANITARY RECFR'TN
WORKMAN COMPENSATION ON DECLARATION FD('1'URFS PER TRAP SCHOOL TAX Y_ N—
QI hereby affirm a certl0am that I have• te of consent self-Insure,ora RECOPY N
certificate of Workerd CompenuRonlmurance or a artif4.d copy thereof(See. GAS EA.SYSTEM-1 INCA OUTLETS PARKFEE Y N
MOO,Lab C.) —
policy Y RECEI'T N
Co any GAS-EA,5YSTEM-OVER4(EA) B UIL DING DI VI SION FO ES
ffCaYified copy le hereby furnished. CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
amfied copy is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWFRSAMTARY-STORM EA.200E 1'. Date Recel t#
IThissection need not be completed If the permit Is formic hundred dollars
(4100)orlcies.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y_ N_
1 metify That in the perfmrmanre of the work forwhich this permit is issued,
I shall not employ any person In any manner so as to become subject to the WATER SYSiTM/17REA.ENG
Workerd Compeneation Laws of California.Date I PAID
-
0 Z Applicant NEW RESIDENTIAL PLMB. SQ.FT. Date ReCeI t#
Z0 NOnCETOAPPLICANT:ILafternuWngthb CertRicaleof Exemptbu
n,yo
HN should become subject to the Worker,'Compervatbn provkiomofthe Labor TOTAL:
Code,you most forthwith comply with such provkslors orthb permit shall be BUILDING FEE
decreed revoked.
(L mCONSTRUCTION LENDING AGENCY SEISMIC PEE
d I herebyaftlrenthat there is a construction lendingagency forthe perform - TOTAL: ELECTRIC
Zana afthe workfmrwhlchlhis permit is heated(Sec.3097,CIv.C.)
0 0 lender.Name PLUMBING FEE
LL H Lender.Address QTY. MECHANICAL PERMIT FEE MECHANICAL PEE
OW Imrtifythatl have read thisapplationand state thattheabove information
1 isconed.I agmato comply with all cityand countymclinancesand sunclaws PERMIT ISSUANCE FEES PAID:
>_ 0. to building construction,and hereby authentic exprexntalives of this
F' Z city to enter upon the idovo-membned property for lmpenim purposes. ALTFRORADDTOMECH. Date R eipt#
(We)agree to save,idemnHy an d keep harmless the City of Cu pertinm AIR HANDLING UNIT 10,000 CFM)
against liabilities,01 %meta and expenses which may In any way accrue BTOTAL:
against ity 1 g of this Pa.I. C S R ION TAX
AIR HA NDUNG UNIT(OVER 10,000 CFM)
at of Appliantlomracmr Date EXHAUST HOOD(W/DUCT) CONS UCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Willtheapplicant orfuturebulldinguerupantstoreorhandle haoardous HEATING UNIT 00100,000 BTU) Date RCCeI t#
material as defined by the Cupertino Municipal Code,Chapter 9.1 2,and the
Health and Safety Cade Section 25532(a)2 HEATING UNIT(OVER IDQOW BTU) TOTAL:
❑Y. No
Will the applicant or uturn building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hamedom air contaminants as defined by the Bay Area Air
Quality Management District?
pI-0spR 100,000 BTU)
Yrs M No
have read the h.Rlou,m ateriah,requirements under Chapter&95 of BOILER-COMP(OVER I W,000 BTU) Q
the California Health&Safely Code,Settlors 25505,25533 and 25534.I
understand that it the building does nM currently have a tenant,that it Is my NEIN RESI DENTIAL MECH. SQ.FT.
r6ponsibility to notify the..pant of the mqu lrements which at be met OCTDaSsaQ
prior to Issuance of a CertlBa21 1te of Occupancy. F9 1{99192
Owner or authorized agent Date rornl: ISSUED BY.CITY U1' I✓UrCFI 111 YU
OFFICE COPY
a