24083 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NQ 4 0 8 3
Building Addreax:
G. ane: VVone:
^�� CITY OF CU�aERTI UILDING DIVISION �!
` ContaRo eName: c Lk.No: APPLI ION /P MIT
BUILDING-fl, CALPL BING- HAMC L CATEGORY
r A hired/Engineer. Lk.No:
QTY LECI' I MFT FEE BUILDING PERMIT INFO
Address:
iISSUAN
LICENSED CONTRACTOR'S DECLARATION
I herebyaffirmthat l amlicensed under provWonsof Chapier9(m ANC ]OB DESCRE'TfON
Inense 1.1.fon force and died. ([hegudwsand Profntl Cud d P 'r /�^
Liens is la SIB fora and died. r)
License Class Lmm
Date Conranar
ARCHITECTS DECLARATION 301 AM
pQ+Q OC I understand my plana shall be used as public records. OV 1000 PS ��FLOOR AREA �5��
E f/ Licensed Professional SIGNS TRICAL
«<<tlLg° OWNER-BUILDER DECLARATION LCEiCNT/MISC 6$
Iherebyafflrrothat I am exempt fromthe Contractors Lim..law fm the �, ,
cmntyfollowing nuescar.hichreuimaae7 tt,Business mtmdand Professions
e=ie hey city or TEMP.MEITRORPOLEINST. �O 9 QM
K� cwntywhich requlmaperMttocomtrud,iller Improve,demalah,or repair - L{/
any struduro priorroit awance,alw rcqulrestheappgcant(w such perMtto [OWER DEVICES
file a signed statement that he a licensed pursuant to the provisions of the V �+
Oµf. Contractor's License Law(Chapter 9(commencing with Section 7000)of INA.
1-,3.. elon3ofthe Buetessand Profeuloru Cade)orthathebezempttherefromand SWIMMING IDOL ELECTRIC �r.V VALUATION'
o....••5]]]]]] the basis for the alleged exemption. Any violation of Section 7MIS by any ` E.ISSW[TcHESFzxrUREs Ma 1 /S r� I O
applicant fora permit subjectstheappllcamtoa civil pevity of not mare than V 1 `^l v
$� five hundred dollars(A M. NEW RESIDENTIAL ELECTR SQ.Fr. STORIES TYPE CONSTRUCTION
�n ❑I,as owner of the property,or my employees with wages as their sok
compensation,will do the work,and the structure is not intended or offend for
M .1.15cc.70K Bucinees ane Professions Code:The Conlradoes Lt..Law
p'j $ does not apply to an owner of property who builds or Improves thereon,and OCC.GROUP RES.UNITS
whodoessuchworkhlmeelforlhrough Msownemployees,provided that such
Improvement are not Intended oroffered fwule.If,however thebuilding or
Improvement b sold within oneyearofcompletion,the owner-builder will have
tlj!TLrden of proving that he did not build or improve for purpose of side.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
as owner of the property,am exclusively contracting with licensed
contractors to co.tract the project(See,7046,Business and N fesslove Code: PERMIT ISSUANCE r
The ConraL I
do .Lictme Law does not apply to sn owner of property who ALTER-DRAIN&VEM-WATER(EA)
builds or Improves thereon, and who contracts for such pw,kets with a
cgd
Bjraor(s)licensed pursuant to the Contndor's License Law.
LII am exempt under Sec. B&P C for this reason BACK FLOW PROTECT.DEVICE FEE SUMMARY
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N—
r Date RECEIPT I
WOR IQAAN COMPENSATION DECLARATION FIX'IIJRFS PER TRAP SQi00L TAX Y_ N
QI hereby Ofbm that I have•cedlficate of consent to aelf-Insure,or• RECEIPTN
certlBatea(Worken'ComperuaHan 1psurana ova certlfkd copythereo((Ee<. AS PA SYSTEM-1 INCAOUTLETS PARK FEE Y N
3X00,Lab C.)Al"01Ja^/f/ a RECEIPTN
I'dkyN '1 GAS EA.SYSTEM-0OVER BUILDING DIVISIO EES
Ca any / !!1/I! J
Ccrtlned copy is herebydwithfurnished.tcity -pec -—�-- GREASE/INDUSDU,WASTE INTERCEPTOR PLANCHEC
rteled copy t here with the dry inspection divisors.
as
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP P `�n
COMPENSATION INSURANCE SEWER-SANITARY-S'NRM EA.700FL Date RCC
(rhissedlon need notb completed lithe permit a forams hundred dollars
tiIIIIA
(SI00)or less) WATER EIFATER w/VENT/ELEGTR ENERGYFE Y_
I certuythat a the perfomanceuf the work forwhfch this permit Is aed,
I shall not employ any person in any manner so as to become subject to the WATER SYSTEM/TREAnNG
Worker'Compensation Laws of Calffoma. Date PAID
Z Z Applicant NEW RESIDENTIAL P1.1,111. SO.Ff. Date
Z NOTICETO APPLICANT:If,after makingtha CertffiateofExemption,you
Hshould becomesubjecl to the Workeri Compensation provisions of the Labor TOTAL:
N Code,you at forthwith comply withsuch provisions ortht pemnt.hall be BUILDING
W y deemed revoked.
o c CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that theret a wrotructlon lending agency for the perform- ELECTRIC FEE
Z anceafthework forwhkhtha permit is eased(Sec.3097,C1v.C.)
02 I.ender.Name PLUMBING FEE Q
LL F I.ender'.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW Iceeltylhat]have readtht appBatlonand rtatethatthe above TormatIon - -
IL tconect.Iagrceto comply with all city and county ondlnancesand stat.It.. PERMITISSUANCE �� FEES PAID:
>- In rewingtobuilding construction,and hereby authorau represenativeioftha
F Z city to enter upon ab.v mmtkmxcI property for inspection purposes. ' ALTER OR ADD TO MECH. OR
Daft ReCel til
Z (We)agree to ve,Indemnify a d keep harmless the City of Cupertam
agabt,t BabiBt dgmente,mnun ezpen.Ze..,hmayinanyway.case AIR HANDLING UNIT(TO 10,ODOCFM) SUBTOTAL'
against Bald Inc rice oft granting of this permit. AIRHANDUNG UNIT(OVER IO,OWCFM) CONSTRUCTION TAX
gw ren AppB ra r Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HA U M ERIALS DISCLOSURE
Will the applicant or futurebu ng onvpant stare or handle hanrdoue IiFAnNG UMT(TO 100,000 BTU) �. Date Recei to
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the
Iieallh and Safety Code Section 75531(a)7 HEATING UNIT(OVER 100,000 BTU)
❑YeeNo
Willtheappllant cur turcbullding ocavpant use equipment ordevices VFMLAIIONFAN(SINGLE RESID) ISSUANCE DATE
which eM[ha s air conlaMnants as defined by 1M Bay Area Ak
Quality Management Dttdct7 BOILER{OMPOM'DR IOO,IXp BTII)
❑YeaBOILER-COZ(OVIA 100,000 BTN
❑No W
(have read the baaardousmatedaa requlrementunderChapter6.95 of a�
the California Health&Safety Code,Sections2S505,25533 and 25534.1 SeA
u not that if the building does not currently have a tenant,that it a my NEW RESIDENTIAL MECH. EQ.FT ff 8
responsibilitytonotify the occupant of the requirements which must be met /x
prior to Issuance of a Certificate of Occupancy. y/7
y uh LV 'DTII
Owner or authodud agent Date 7SSIlED BY:
OFFICE COPY