20512 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Pro en Identification
Building Address: PERMIT NO.
Z -1cd>ua►J iie, t) Wcw-o + 20512
r ams: A , 'T me:
Q yam$ •t"7'Q YZ'551 ZCITYOFCUPERTIN(}BUILDING DIVISION
facie am: Lie.No: APPLICATION / PERMIT
BUTLDING-ELECTRICAL MP BINGMECHAMCAL CATEGORY CO 11-a
rchiten- /En n r Lk.No:
s � Sia,G991 QTY ELECTRIC PERMIT FEE BUILD GPERMIT INFO
Add— I(QM W. ri�L•CAVAL',CJ �'^I"a V I'ERMITIAUANCE - 11LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter9(rommene APPLIANCES-RESIDENTIAL JOB DFSCKB'FION
ingwith Se oA7000)of Divi.i.3.fthe Bualnenand PmfmkonsC„odcandmy
License Is in full force and effect. PANELS O�
Dale ContractorV_✓a
ARCHITECTS DECLARATION 701-t ODD AMPS
a0O I understand my plans shelf be used as public rerorciL OVERIOWAMPS SQ.FT.FLOOR AREA S/SQ-
zu Licensed Pro(mional SIGNS ELECTRICAL
< OWNER-BUILDER DECLARATION SPECLILCIRCUIT/MISC e-1
OO-� owingra(BrmthcUam n¢mptfromthed Professions
License Law for the,
Z followingreason.
requirmap 7031.5,Business and r,mprove,s Code:Mydtyor TEMP.METER OR POLE INST.
py ceuntywhire rcqulma becance,alsore wire,the APPUMAt
such prmpair mitto
1 Q any structureprioroits hat heir ltwrcqu pursuant to the ronion,of cite POWER DEVICES
K U ❑k a Ngned statement that be Is Licensed pursuant to the proWbm o! the
3 Contractors Licewe law(Chapter 9(commencing with Section 7000)of DIA-
tlon3ofthe BudnmandPambmCade)arMat he Isexempttherefromand SWIMMI -LELE C VALUATION
Sm the basis for the alleged exemption. My violation of Section 70115 by any eJ'4a / �� l] .C""•
applicant fora perat subjects the applicant to a civil penalty of net room ban OUTLETS. ES -GAJ
O five hundred dollars($SOO). a
[,as owner of the properly,or my employers with wages as their sok NEW RESIDENTIAL ELFOIR SQ Fr 57ORIFS TYPE CONSTRICTION
compensation,wllldothe work ancithestructure ism intended or off for P'
O sale(Sec.7064,Business and Professions Code:The Contractors U. 1Law ''•'
3$ does not apply to an owner of property who builds or lmprovnthero land - �;�� I .
who does such work hinesalforthmugh his own employees,Provided the ch OCC.GROUP ftFS UMTS
Improvements are not Intended oroffered formic.If,however,thebulldl orx� n IST TAL: 06
Mprovement Issald wlthlnooryearolcompldbn,theowner-WllderwRl ve
t1i,isurden of proving that he did not build or improvefce purpou of2ve aQ. , OPI&MAING PERMIT FEE FLOOD ZONE APN
Ll L as owner of the property,am exclusively contracting with less�d P ANCE 1//
contactors m nmttruct the projen(See 7044,Buslnm and I'ro(mioro C 1
The Contractor's License Gw don not apply to an owner of PrvpSy - RAIN&VENT'WATER(EA)
Wilds or improves thereon, and who rontrana for such TeWfeda:with e . �.actor(s)lic151ensed pursuant to the ContraFEE SUMMARY
dors Llcenn Law. BACK FLOW PROTCC EVICE
am exempt under Sec. B&P C for this reason
DRAINS P,AREA,GOND. SANITARY Y N
Owner Date RDCEFr M
WOBIOttAN COMPENSATION DECLARATION SCHOOL TAX Y N
❑1 hereby afOrm that I have a artlBare of consent to uR-Invm,ora ��p i
certlBote ofWorlen'Com wtlon lrurnranceara certifkd mpythert f(Bec. GAS EA gy .1 INC40II7LEf5 PARK PER Y N
38W,ylabG u//' o D/ -p/
Polk tl RECEIPT X
Corn anvi GAS EA,SYSTEM-OVER 4(FA) BUILDING DIVISION FEES
out
copy Is herebylle, CREASE/WDUSIRL WASTE INTERCEPTOR PLANCHECK FEE �f
Certified copy Is flied with the my Inspection division. a
CERTIFICATE OF EXEMPTION FROM WORKERS' CREASE TRAP NSATIPAID
COMPEON INSURANCE SEWER-SANITARY-STORM E.A.700FT Date Recei [N
(fNasection need notbeNSATI if thepermit b(oronehundred dollen
($103)celm.) WATER HEATER W/VENT./ELECTR �� ENERGYFEE Y N
J amlythat in the performance of the work forwhia this permit is Issued, —
I shall not employ any person In any counter an as to become subject to the WATER SYSTEM/TREATJNG
Workers'Compensation lwwa of California. Date PAID
z Z Applicant NEW RESTDPNITAL PLMB. Daft Recei [N
Z O NOTICE TO APPLICANT:If,after makingthisCerli!late of Exemption,you SQ�
Fshould become sub fen hto the Worker Compensation provisions of the Labor TOTAL:
N Code,you muaifMwlth comply with such peovishms mthis permit shall be
W > deemed revoked. MLDING FEE
a o CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there is a combrottion lending agency forthe perform, p ELECTRIC FEE
Z ata of the work for which this permit is issued(Sec.3097,Clv.C)
TOTAL:
U O Landers Name PLUMBING FEE Bou
IL H LendeesAddreas QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Icertifythatl have rend thlseppllatianaM etatethattheabove Nformatlon
Iscorrect.Idgreeto comply with all cityand county ordlnancesand statelaws PEKMITISSUANCE FEES PAID:
. 0) relating tobullding mvtrudlon,and herebyauthorizm representatives ofthIs
F N city to enter upon the abovementloned property for Wprelon Purposes. ALTERORAODIOMECH.
Z (We)agree to save,Indemaify an d lump harmlessthe City of Cuprolno Date Recei [#
V against liabilities, mens,seta and expenses which mAI
aytnanywaya R HANDLING UNIT CFO 10,000 CFM) SUBTOTAL: r
against old ty neeque ceof the fMt Ing of this permit
�Q AIRIfANDLINGUIsTr(OVERieficeCIM) CONSTRUCTION TAX
slgoature uu /c tenor Dai[
at EXT{AI15THOOD(w/Duca CONSTRUCTION TAX PAID:
H ZA OUS MATERIALS DISCLOSURE
Will hes Ile torfuNrcbuildingompanbmreorhandlehazardous HEATING UMT(T0100,000ETU) Date Recei Ta
material as define by the Cupertino Municipal Code,Chapter 9,17,and the
Health and Safety Cod a Section MiMa)7 HEATING UNIT(OVER 100,(810 BTU) TOTAL: d
n Yea No
Will the applicant or tore building occupant use equipment or d evicen VENTILATION FAN(SINGLE RESID) Ism_ SATE
which emit haarom
rcious air ntakunts as defined by the Bay Area Air
Quality Managerrem District? BOILER-COMP C311POR 100,000 BTU) JULYen nNo L U `al 1VW
4have eath&SafetyCode,Sereons255nbUnder nd2553Chapter 6.95of. BOILER-COMPOVDilOO,000BTU)
the Californiala Health&Safety Code,Sections 5505,25533 and 75536.I
u ederstand that if the buildingdoes not currently have a tenant,that It is my NEW RESIDENTIAL MECH. SQ.FT, Qatj of C_UU•LI6�nQ
responsibility to notify the occupant of the mquimments which must be met
prior to issuance of a CertlRate ofOsupancy, -
Owneror authorlecd agent Data ISSUED �Y
TOTAL:
OFFICE COPY