20997 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
"unding Proed Identification PERMITNO.
0997 tlu0din Address: - �/��
6
CITY OF CUPERTIN0.6UILDING DIVISION-
en or. ante 6ZG 4SOR/,e 4;,:�ftq APPLICATION 1 PERMIT
BUILDING-MFJCTRICALPUTMBINGMF LAICAL CATEGORY CONTROL X
Architect/Faglaen Lk.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address:
l
LICENSED
CONTRACTOR'S DECLARATION
, my
PERMITISSUANCE ❑ El
❑
therebythat aRceaedunder sofChap[er9(rommen APPLIANCSRESIDENTIAL JOB DSPTON
IngwRhSection7D00)o(Div heauslnessandProlneloaCodeand
icenseleIn(u to d effect.
_
PANk]S
Dan�ls C ntucto 201-1000 AMPS
ARCHITECPS DECLARATION
9CO IundeutandmypkaehaRbeuwdupubherecoNe. OVERT AMPS 5Q.FT.FLOOR AREA S/°.Q.FT.,
(/ Licensed Frustrations] SIGNSEL
6 FLgy OWNER-BUILDER DECLARATION SPECIALCIRC T MLSC
1.., Iherebyaffirmthal lamnempt fromlhe Comranor's Liceae lawforthe
7p following reason.(Section 70715,Business and Professions Code:Any city or '^` r
Oy TEM OR POLE INST.
Py county which requires a permit to roatmet,site,Improve,demolish,or repair
any structure prior to its Wuance,also requires the applicant for such permit to POWERD CES
file a signed statement that he Is licensed pursuntto the pen son"of the
�Dµ Contran°rb License Law Chapter 9(commencing with Section 7lXD)o(Dlvl- Y tie VALUATION
Oa sion 3 ofthe Business and Profession Code)or that helsexemptthere(rom and POQLFlE C y
6 X the basis for the alleged exemption. Any violation of Section 70115 by any HFSFIXTUREBIt` l"'Y X�'
applleant for a permit subjcda the applicant to a civil penalty of not more than
five hundred dollars(S500). W R AL ELECTR ` SQ.FI. -
E]1,as owner of the property,or my employees with wages as their sok SMRrr.S TYPE CONSTRUCTION
compensation,willdothe work,and thestrunure It not Intended or offered for 11 uq
psok(See 7004,Business and Pro(mebm Code:The Contnctoe LlceaeLaw `
don not apply to an owner of property who builds or imp=thereon,and `I OCC.GROUP RFS.UNITS
whodme .s hworkhMulforthroughhaownemployen,providedthatwch
Improvements an,not Intended oroffered forsale.If,howevepthebuilding or TOTAL:
I :mprovementusoidw:thin oneyearofcwnpletb theowner-bullderwill have
fla*rdeno(pmvingthalhedid not build orimprove for purpose ofuk.). QTY. PLUM TNG URMIT FEE
LJ L as owner of the property,am exclusively contracting with licensed FLOOD TONE APN
PERMIT NUANCE
contractors to constructthe project(Sec.7066,Business and Professions Code:
The Contractor's License Law does net apply to an owner of property who ALTER-DRAIN k VENT-
Wilds or Improves thereon,and who contracts for such pkojens with a WATER(EA) -
cc5actor(s)licensed pursuant to the Contractor's License Law. FEE SUMMARY
I am exempt under Sec B k P C for this reason BACKFLOW PROTECT.DEVICE
DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y N
. Owner Date RECEIPT X
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOLTAX Y N
I hereby affirm that I have a anl(Icate of cnsent to self-Insure,ora RECEIPT X
cISA/rtf�Id/flwteofWorken'Compcmationlu mnmmaartifiedmpythem°f(Sec. GAS EA.SYRIM-1 INCA OUTLETS •PARK FILE Y N
3800,lab C.)��y/ 7 O� RECEIPT%
Al
Pollq•X L�7�
Ca � GAS EA.SYSTEMAVER 4(EA)
BUILDING DIVISION FEES
Cert:le copy ls hed with the city GREASEANDUSMI,WASTE INTERCEPTOR PLANCHECK FEE
Ce Ified copy ls(sled with the city inspection division.
CERTIFICATEOFEXEMPTION FROMWORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWEWSANITARY-SIURM EA.200FT. Date Reeel t#
(hisaedkn need cad becompleted:f the permit ls foroa hundred dollars
($100)ortmj WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
lartifythatintheperfomunce ofthework f which this permit b timed,
I shall nm emylpn an person In any er as to roi a ' o the WA•I,CR 5Y51,CM/.I.REA.I.INC
Workeri Co t las o - PAID
O Z Appllant / M - NEW RESIDENTIAL ELMS. SQ.FT. Date Re:ei t#
Z O NOTId become
s I to
after maW h ertnicateof Exempt the
should become subject to the Workers'Compensation provlsloa of the GWr TOTAL:
N Code,you must forthwith comply with such provisions or this permit hall be N 11 CC
CC W 7 dMmcd revoked. BUILDI
r LU c CONSTRUCTION LENDING AGENCY SEISMIC FEE l
I hereby a(firmthat there Is construction lend Ing agency for the perform- ELECTRIC FEE
SO
M Z onceof the work for which this permit b,lasued(Sm 3097,Civ.C.) TOTAL:
00 Lender'.Name PLUMBING FEE
H Lender's'Address QTY. MECHANICAL PERMIT FEE
LL MECHANICAL FEE
OW I cenlfythatl havereadthis applicat:°nand statethactheabowinfomutlon
d is correct,I agree to comply with all city and county ordinances and nate laws PERMIT ISSUANCE FEES PAID:
} N relating to building construction,and hereby authorize representatives of this
cat to entero n the above-mentioned for W loci s ALTER OR ADD TO MECH.
Z y upon kee In rootless the p"rpO9e Date Recei t#
(Ne)agree to ave,indemnify and tin harMen the City o(Cupertlne
V ago IabNt jrdgmenta,mrtsand ex i:gwhich yin anywayacerue AIR HANDLING UNIT CTO 10,000 CFM) SUBTOTAL:
a old Ci itn-covn(elejiu-e(-/o/e//vo�/the satin °(this permit. r
A0-41-90 AIR HANDLING UNIT(OVER l0,000CFM) CONSTRUCTION TAX
Sigatom.f AppRcent/Contractor Date EXHAUST HOOD M/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will theapplicanl or f tum building ocutpant store or handle hazardous HEATING UNIT(TO 700,000 BM Date Recei t#
material as defined by the upertino Municipal Code,Chapter 9.12,and the
Halthand SafetyC ctio,25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
YeaNo'
W:Illheapplic uo future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSpI{LI;I�DATE
hich emit hazardous air contaminants as defined by the Bay Area Air Q[/"N+@�J
Quality Management D t 7 BOILER-COMP OHP OR 100,000 BTLU
4 Yee
Q
�+
• havercadthehaza ousmalenaisrequirementsunder Chapter 6.95of BOILER-COMP(OVM100,000BTU) Q T 41990
the Cailfomla Health Safety Code,Sections 25505,75533 and 25534.1
understandthatlfthe uildlog doesnot currently have a tenant,that it E my NEW RESIDENTIAL MECH. SQFT
respoa Ilitytondilytheoccupantofthe Iremenlawhlch muslW rret t T}M4/p
prior n daCertifi ( pa
eror auC ��Datte ISSl1ED BY:V lJ
TOTAL:
1
OFFICE COPY