22656 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMITNO.
ding Add.: 22656
2l We t AAIL4 �
me:
Cr Z S7- �o (� CITY OF CUPERTIN68UILDING DIVISION
C nr �"�' !`"1=.Na APPLICATION I PERMIT
O
a J CO'vS�• ( IoY BlI1LOINGELECTRICALPLUMBINGMECHANICAL CATEGORY CONTROL Y
ItM/Engineer. Lk. -
No:
2'BUICDING PERMIT,INFO;;,4' .•4
ELECTEtL6PERh11T .' FEEILUM
''1 - -
Addnu 0/ PER.WTISUANCE ❑ ❑
LIC N'SED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under prwblonsof Chapter9(comm®c- APPLIANCESRESIDENTIAL JOB DESC 'f ION
ingwith Section 7000).(Division 3of1he Bued... Professions Code,and ^'
Ilomeisin(ug dMfer. /e//� Q" PANG-'e Sea,(jer L /`/v✓M,
Linnx Class LIcY O
Date Conerecter 701 UP TO2DO.AM
AACHPS
ITECPS DECLARATION OVER1000AMPS SQ.Fr.FLOOR AREA $/SQ.Fr.
ot0 0 I understand my plans slug W used as public..,.
to E Licensed Professional SIGNS ELECTRICAL
<4u OWNER-BUILDER DECLARATION G SI ECTALC RCNT/M SC
7f, IhercbyafOrm Wham exempt from the Contractor's License Law for the
Opp following reason.(Sectio.7031.5,Business and Pmfmlons Code:My city or TEMP M=ORPOLE INST.
Cc.untywhichrequimapemdltommtruct,alter,Wpmve,demogsh,ormpair
any structure priorto its issuance,also requlm the applicantfor such permit to
POWER DEVICES
file a signed statement that he at licensed pursuant to the provisions of the
83 Commoors License Law(Chapter 9(commencing with Section 7000)of Dwi- SWIMMING POOL ELECTRIC VALUATION
sion3o(the Businev and ProfenlamCode).rthat hebexampt therefromand
the Web for the alleged exemption. My violation of Section 70315 by any Ol1TLETSSWITCHESpI%711Rp5
applicant for a permit subjects the applicant to dull penalty of not rrorc than
R B6undred dollars W00). NEWRESIDENTIALE,ECTR SQXT. STORIES TYPE CONSTRUCTION
�n I,as owner of the property,or my employees with wages as their sob
compensrtica,will do the work and the structure is rot intended or offered for
r O sale(ice 7064 Business and Prdeasions Code:The Contractors Llcame Law
�$ don not apply toan owner of property who builds orimprovesthermicand OCC.GROUP RES ANTIS
c whodoessuchwork himeeBorthrorgh Meow.employe.,provided that uch
improvements arc not Intended reoffered forsale.If,howerver,the bullaingor TOTAL:
improvement bsold wkhinomyearofeonp)e1WRthe w er.bullderwN have _ _
t4c.Ilurden of proving that he did not build or improve for purpose ofsale.). QjY,,;. + _PLUMBING PERMIT'. - „FEET FLOOD ZONE APN
u 1 as owner of the property,am exclusively..g won umn. ppn,MTT)SSUANCE
"mr, rstom MructW project(Sm 7061,Business and Professions Code: .00
The Comrsdoe.Limue Law does not apply to an owner of property who 4ALTER-DRAIN&VEM-WATER(EA)builds or Improves thereon, and who common for such Plows with a W.-:;Q).• -`-,
egn1ractor(s)ucamed pursuant to the Contrsdors License Law. BACK FLOW PROTECT.DEVICE
ec FEE;SUh1MARY_y„}'�,-{c
J 1 am exempt under SB 4 P C for this reason
_ Owner - DataDRAINS FLOOR ROOF,AREA,COND. SANITARY aerFFJ).'N
WORKMAN COMPENSATION DECLARATION PER TRAP SCHOOL TAX Y_ N_ 7
❑I herbFDnIJRES
y affirm that I It.a oMflote of consent to seg-Inurs,or a RECEIPT a
certifiam.fWmiteri Comperwtion lmuranse .certified copy thereof(Sec. GAS EA.SYSTEM.1 INC.]OUTLETS PARK FEE Y N
3800.IAb CJ 2 � �, RECEITT0
Prliry a GAS.EA.SYSTEM-OVER/(EA)
Com env ,� BUILDING DIVISION FEES
�Cemil, pyl-lumbylumilhad.� GREASE/INDUSIAL WASTE INTERCEPTOR PLANCHECK FEE
rilflnd copy at filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GRF.ASETRAP PAID
COMPENSATION INSURANCESETyEA-SAMI'MXSTORM FA.gppT /500 Date Recel t#
(TTI.sectWn need no W completed RtW permit blm.m hundred do0an
Q103)onlea.) WATER HEATER w/VENT/ELECTR ENERGY FEE Y_ N_
1 unify that W the performance of thewmk for which this permit 1s issued,
I.W g not employ any person in any runner.as to become subject to the WATER SYSTEM/TREATING
Worker{Compensatbnlawsof Callfom..Date PAID
0 Z Applicant NEW RESIDENTIAL PLMB. SQST. Date Re i t#
Z O NOTICE TO APPLICANT:If,after making that CerWkale of Exemption,you
should become subject m the Workers'Compensation pnoxisk aof the Labor TOTAL:
C N Code,you rust for hwRh comply with such provislom or this permit"I be_ BUILDING ME
deemed reked.
' W � ,oCONSTRUCTION LENDING AGENCY SEISMIC FEE
CL e Iherebya(firtnthat there at a coimmctlon lerWWgageruy for the perform• TOTAL ELECTRIC FEE
Z ...of the woekfor whkh thin permit b Issued 304/,Civ.C.) Q�
O O Iendds Name 0 PLUMBING FEE 30.00
LL t- Ie.aersnaarea CITY. •S,'-:.cMECHANICAL;PERMIT�?'?":'-`..,FEE, MECHANICAL FEE
U Iortifythatl have read thatappliotionand statethrttbeabove Wfemudon
0 W econet.Icgm to complywilh ail cityand countyominances and state laws PERMIT ISSUANCE FEES PAID:
} a relating to building construction,and hereby authoiae represenuives of this
d to enterupon the above-mentioned foW 1 ALTERORADDIOMECH.
~ ? city
agree ave,Wdemnlfy an d loce�F h property
the City of C.P rtWo Date _Reeei t#
V against lbbWtles,Ndgmens,mreand..par.which may in any wayaouue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
aid city I ..sequerm oftha gremi.g d thi.pemdt' CONSTRUCTION TAX
G � � AIR HANDLINGUNIT(OVER IO,000CIM)
um.f Applicant C. Date EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT 100,000 OTT!)
Will the applicant or furore building occupant store or handle hazardous Date Revel t#
materatl as defined by the Cu Perm..MuMdpal Code,Chapter 9.17,and the
Health and SafetyCode Sectlon 2S5R(a)7 HEATING UNIT(OVER IM,=BTU) TOTAL: O.OO
❑
Y.Willthe ippLica.t No
tore bcilding raupantux equipment ordevicea VENTILATION FAN(SINGLE REBID) ISSUANCE DATE
which emit hazardous ab contaminants as defined by the Bay Arca Ak
Quality Marugement Disirkt7 BOM ER-COMP OHPOR 100,000 BTU) .
Yea No
1h.w, dthe haa.Q.materials requirerrenbunderChapter495of BOILER-CA. (OVER100,000BN)
the California Health 6 Safety Code,Sections 25505,75533 and 75534.1
undnrswnd thatit the building da.nal urremly haveatenanL shat llbmy NEWRESIDENIIALMECH. SQFf.
responsibility to notify the occupant of the requirements which=at be met ��
prior to issuance d a Certificate.(Ocupanry. n t�Q
Owner or authorised agent Date TOTAL: ISSUED tar--JJ
OFFICE COPY