22790 (2) APPLICANT TO FILL IWINFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building?mea Identification - PERMITNO.
Bullding Address: - f'�n n O
O d r1/L�i B G G J
corers ante: one:
- 1&8.3 CITY OF CUPERTTN0.BUILDING DIVISION
• c°nredarsN me: LIe.Na: APPLICATION /PERMIT
I alJ T/ BUILDING¢ECTRICALPLUMBINO-MECHAMCAL CATEGORY CONTROL N
Archftece/Engineer. Lic.No:
ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE ® ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am Bernard under provisions of Chapter9(commenIOVERIODOAMPS
APPLIANCESRESIDENTIAL OB DESCRfIrDON
IngwlthSedion7000)of DiAWon3oflhe Buknessand ProfesalonsCodd,and my
PANE[5
license fs In full( and a fect. 3 _ ♦el
Llcenso Class_ .N �'��+\�
Date Qj��-v�.]a_CHITE T' LARA 201-IODOAMPS V '
p�p�uu
00 I understand my plaru shall be uedd u public records. SQ.FT.FLOOR AREA 5/SQ.FT.
Fi E Licensed ProfessionalSIGNSELECTRICAL tz
<6 OWNER-BUILDER DECLARATION
G SPEC ALC!CULT/MLSC
71.., Ihemby afBrtnthatlam exempt from the Contractor's Llttnm Law fm the
pp following reason.(section 7m I5,Business and Professions Code:My city or
O Z H TEMP.METER OR POLE INST.
ceuntywhlch requbesapemdttoconstmct,alter(mprove,demoWh,or repair
any structure prbrlo Its lswance,also requlrestheappBcantfmauch perMuo POWER DEV ICES
file a signed statement that he b licensed pursuant to the provisions of the
Oµ C mrsorr'e License Law(Chapter 9(commencingwith Section 7000)ofMet.
�OS elon3ofthe Buknessand Pro(esslomCode)orthal hebexempt thercfromand SWATMING POOL ELECTRIC VALUA'Ilr'
< the basis for the alleged exemption, Any violation of Section 7031.5 by any OUTLETSSWITCHESFIXTURES "Z3 Doe-
five W
applicant fora permit subjects the applicant loa civil penalty of net narethan
R hundred dollars($500). NEW RESIDENTIAL ELECIR
I,as owner of the roe oremployeeswith wa es as their solecompen �'FT' STORIES TYPE CONSTRUCTION
property,ky, he g
�7 Q .1.(Se 7014,Busimwill do the col Pmfesrk,and the structure h�not,tnict e or Les.offered for
i ❑ sale(Secappy Bualnan owand Profnerty Cade:The Cimprovea License Law
[O jQ whorldoes apchy rkbi ntofpmpertywhobulldeorlmpmvesth ihatwch,and OCC.GROUP RFS.UNTS
0. whodmseuch are not msended oraghhisowne.If,ho es,providNilding or
improvement issold Intended yearofcomplaereii ale.lf,howerbuildbuRdi have TOTAL:
Improvement issold wllhln one yearo(compldbM the ownervbullder will have
tl�,(Nrden of proving that he did nm build or Improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD TONE APN
as owner of the property,am exclusively contracting with Bernard PERMIT ISSUANCE
contractors to construct the project(Sec.70K Business and Professions Code:
The Cont actors Clamed Law deed not apply to an owner of property who ALTER-DRAIN&VEM-WATER(EA)
or Improves thereon,and who contracts for such piejects with a FEE SUMMARY
o%4.dar(a)licensed pursuant to the Co"tradm'e License Law. BACK FLOW PROTECT.DEVICE
1_f I am exempt under Sec B k P C for this reasonOUTSIDEFFFS
' r SANITARY Y N
Owner Date DRAINS RRGCIIsA .G(�PID. . p P ! RECEIPT#
WORKMAN COMPENSATION DECLARATION FD(TURES7 COOL TAX Y N
❑I he
affirm that I have a certificate of consent to dell-insure,or
,I RECFR'I'N
amlflcale o(Worken'Compenutionlnsurana ora cekl(kvT copy thereof(Sec. GAS EA.SYSfLPAL INC.4OUTLETS I � '' ARK FFR Y N
3g00,1Jb C.) i RF-CEPTB
Policy N GAS EA.SYSTFM-OVER N IEA,
Com any I . BUILDING DIVISION FEES
�CeklEed copy Is hereby furnished. GREAS (tNDu L PLARICHECK FEE
�artlfmd copy is filed with the city Inspection division. _
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE sEWF.R-SANRARY-STORM LA.200FT. Date Reccip[#
(This section need net be completed if the pernat is for mu hundred dollars
(EI00)alees.) WATERI�AIFR W/VENT/¢FLTR ENERGYFEE Y N
I mklfythat N the performana°f the work forwhich this permit is issued,
I shall not employ any person In any manner so as to become subject to the WAT74t SYSTEM/TItGTINC
Workers'Compensation Laws of Callfarnie.Data PAID
-
Z Z Applicant NEW READENTIALPLMB. SQ.FL Date Recei t#
O NOTICE TO APPLICANT.If,after nuking this Certificate of Exemption,you
should become subjectto the Workem'Compematlon provisions a the Labor TOTAL:
N Code,you moat forthwith comply with such provisions or this permit shall be .BUILDING
W > domed revoked.
a c CONSTRUCTION LENDING AGENCY SEISMIC FEE
!hereby affirm that there is a mwtrualo"lending agency for the pekorm TOTAL: ELECTRIC FEE
0 ance ofthe work for which this permit 6 Issued(Sec.3097,Civ.C.)
Lenders Nark PLUMBING FEE
LL ~ Landes Address QTY. MECHANICAL PERMIT FEE
OW Icertlfylhatlhave ad bappBcatlon and, that the above information MECHANICAL FEE
R isommet.Icgree to complywith all cityand county ordinances and date laws PFRMITLSSUANCE FEES PAID:
} N relating to Wl&, =
n,and hereby authorize representatives olthls
H Z city to enterontioned property for Impaction purposes. ALTER OR ADD TO MECH. Date ReCCipt#
(We a lfy and p rron'—fid City of Cupertinoke ands ran whichmayinanywayaccrue AIRHANDLING UNIT(TO 10,000CFM) SUBTOTAL:
e/CI� ntmgn tMspermit. CONSTRUCTION TAX
AIR HANDLING UNIT
(OVER 1B,DBocFM)
sl leant/ rad°r Date EXHAUST HOOD M/DUC'q CONSTRUCTION TAX PAID:
HAZA US MATERIALS DISCLOSURE
Will the applicant or future building oa'upalkstore or handle harardous HEATING UNIT(TO 100,000 BTU) Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
I health ami Safety Code Section 255320)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
D Yn No
Will the applicant of uture building occupant use equipment or devices VENTILATION FAN(SINGLE MID) ISSUANCE DATE
which emit hararduus air contaminants as defined by the Bay Area At,
Quality Mawgement[).kind? BDILER-COMP OHI'OR 100,000 BTU) ALM'
4I I Yea No BOILER-COMP(OVER 100,000 BTU!
havoreadthehero o�mkde,Setions2rrenbunder 5533aChapter.1 of (;C(]
theerstand that
iftfornia hklld Code,Sections25505,25533hvea tend255at.1 sISP etN(N,
usp.rundyi.til - ulldingdoes nmcoref.khavea hkh that b l9my.et NEW RESIDENTIAL MECH. SQ.FT.
prior bility Ion ity the oavpantof erequUementswhkh must be met city ofop pm,
prior uanca fl�of0 panty. Z
mer or au%orizA a eqt Date 11
TOTAL: ISSUED B1Y:�,_{�{I •
OFFICE COPY