24184 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Idemlflatlm I,, .BT
ecN 418 Building neem.,:
(q O
rc me A
2tq CITYOFCUPERTINO-BUILDING DIVISION
Co roA(zA APPLICATION /PERMIT BUrMNGELEC RICA MLIWINGMECI IANICAL CATEGORY CONTROL
A t / e. O No:
Q ELECTRICPERMIT FEE BUILDING PERMIT INFO
Add. ' PFRNITISSUANCE
ENSED CO. A OR DELLA T10
IhembyaffbmthetlamlkmseduMerplovWs of Chapmr9(mmmmc APPLIANCESRESJDENTIAL pg
Ingwlth Sc on70W)of Dl 9.3ofthe neaeandPmfeadaru Code,and aa�..)
Have isln and dl—PANELS 1 r r
Llan Lk
Date Contractor
ARCHITECTS DECLARATION AMPS
0'LO Iu cnatand my ph . yb�umi aypuppc remrdA OVER 1000 AMPS Ej�111E1-OOl"N S/SQ.FT.
Lkevxd Professional 67fGe—ate SIGNS ELFILIRICAL C ,Vl g^�V/
6 OWNER-BUILDER DECLARATION SPECIALCRCIIIT/MISC
,. 1 heneby.ffinn that I am exempt from the Contrador'.Lieense Law for the T E
p 9 t- following reason.(Section 7m15,Business and PmfessbM Code:My dty or TEMP.MEFFR ORPOLE INSI. /y�L
KY =ntywhkhrequimape tomMtnud,aller,lmprw denm h,ormpalr
DEVICES
prbrto lb bwarcgalwrtqukntheappl]ant(orwch perMtto IA7WEft CES
Mu file s signed.btement than he Ls Ikens<d pursuant to the pro leoj d the
ctke
Contractors Lrue Law(Chapter 9(mmd
menng writ Section 700M of Did- VALUATION M
F. soon 3 of the Busioess and Prefedoro Code)or that he b exempt therefromand SWEdhENG POOL ELECTRICLe
Y.' the ba.b/or the alkged eaomptbn. Any vidatbv of Sectbn 76315 by any
<5 apph dreraas.IWS00). he applicant toe,dWl penaltydna more then f>n•EISSlVI'IC"I IFSFlXfURES
< t 1,u awrcr of the property,or mry employees writ wage u tkb wk NEW RESIDENTIAL E1.ECIR SQ}T. STORIES =CONSTRUCTION
mmpcwatlm,will dock work and thestm=m b ret Wended or offered for
❑ ak(Sec7014,Buslnras and Profo.bMCode TheContractors Wavelaw
$ don not apply to an owner of property who build.or improves thereon,and
F- who doessuch work himself or through his own employees,provided that wch OCC.GROUP RES UNTTS
Improvementsart wt lotended oroffered fwssle.If,however,thebulldfrg m
Improvement bold within omyearofcompletbgtheowner-W ildsrwill have
t Iden of pvinat did int Wild Werod
d or Impve forpurpvsesale.). QTy. PLUMBING PERMIT FEE FLOOD ZONE APnr
Urogthm
4 as wvnor of the property,sin euhralvely ntraellng writ llaneed
mntradon to construct the vmjed(Sec es 70K Businand Profend
lons Cade:
I'FRMIT ISSUANCE
The Contnadors Lice.Law dm not apply to an owner of property who pl'ITR DRAIN&VENT WATER MA)
or imp.thereon,and who mntrads for such pm tvjewith a
cq�ac�m(s)Ikanxed pursuant to the Contractor's Liable Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
[:]I am exempt under Sec B k P C for this rt
Lon•
OUTSIDE FEES
Owner Dace DRAINS FLA3OR ROOF,AREA,GOND. SANITARY Y— N—WORgNAN COMPENSATION DECLARATION RECEIPT
[:]I hereby aHbm that I have•certificate of mmmtt to self-insure,or s FIXNRES PER TRAP t� SQ IODL TAX Y_ N—
anlfiated Worker Canpewtim TMurwaoramr fkd mpythereof(Sec- RECEIPT
35(14 Lab C) GAS EA.SYSIFAt-1 INC4 OLTLETS PARK FEE Y— N_
Pul
Co��m����aaaany GAS EA.SYSTTN`-OVER 4(EA) BUILDING DI V ISION FEES
I I Cert fbd copy b hereby with
liehN.
L�JScenlnea mpybfuea wdtntk dry lMpedbn diwlm. eRE,kse/INDusrRL wnsIE INTERCEPTOR PLANCHECK FEE
CERTIFICATE OF EKEMPTION FROM WORKERS GREASE TRAP PAID
COMPENSATION INSURANCE SEWEILSANITARYSTORM EA.Z0GT. Date Recel t#
(0 oraectbn need out k complded lfthe permit b fororc hundred dollar
(5100)alea.) WATER HEATERw/VENT/ETrrLR ENERGY FEE Y N
lanlfy thrtbthe p<rfomunes dthe wakfor wMch Wapemet is issued, —
I.hall not employ any person In any manner n u to become subject to the WATER SYS EhI TREATING
Workers'CompenuBonLaw,of Gufornb. Date PAID
O' Z NOTICEAppileari
NEW RESIDFNIAL PLMR. SQFT. Date Recel tk
Z O NOTICE TORI bje APPLICANT: maCon,4bCenl(lp o(Fi ofttbn,ym
ehaldbemmr wbFd to the Workers'Campv m orthbpoftheLWr TOTAL:
~ N deemed
hwrh comply with such provbbM orthb permN ehallk �s
� > deenrd revoked.
CL —p CONSTRUCTION LENDING AGENCY S
EISMIC FEE
Iherebyaffn,n at thelebamMtmmmLending agencyfor the perfrm,
M Z arm of Ne workfor whkh thb permlt b bwed(See,3097,CW.C) �. FEE
U O 1<rder's Name NG FEE �+
LL 1– Lenders Add. QTY. MECHANICAL PERMIT FEE MECHANICAL FEE �
O w Ismm
I mnilythat l have read thbappItatbn and statethatthe above Information FEES PAID:.
rrect:laSere to comply withal]dtyand owNWR
ntyonces and state laws PERMISSUANCE
} N relating to Wilding mMlmcilon,aM hereby authorize representatives ofthb
= efty to enter upon the abo ementbrcd property for bupeetion pu�p• ALTERORADDTOMECI7.
V _ (We)agree to save,indemnify an d keep harm]m the City of Cupenro Date ReeCI tM l
aa1Mt bill"" b, nd�ma in. avue AIRIiANDUNGUNTr(TO10,000CM SUBTOTAL:
aga� I n In dthbpem
AIR HAN13urTc uNrr roVFR 1400oCFM) CONSTRUCTION TAX
Slgoatu'4dfApp am/ mtoactoe " Darie '— EXHAUST HOOD(W/DLCO CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Wllltheapppllaat NWm Wedingamnpantstomorha leh.minim. HEATING UNIT(TO 100,000 RTL) Date Recei t#materbl as de=by the Cuponim MuNdpal Code,Chapter 9.17,and the
IlWhhandS9xoyCodeScdlm755n(e,)7 HEATING UNIT(OVER IM"BTU) T T
❑ Yes No
Wiilthesppllod or sure WOdNg occupant use equipment or devim VEMILATION FAN(SINGLE RESID) a ISSUANCE DATE
whkh emit harardms air contsmW Ms as defined by the Bay Area Ab
.
Quality Management District? BOILER-ODMP PHP OR 100,000 BTU)
Y. ❑No
Thavertadtheh mms"terbbrequiremenbunderChapterG95of BOILMODMP(OVER 100,00()BTU)
the Ca llfomla I leaith k Safety Code,Sections 25505,T.v533 and 75534.1
urdmtoM that 11 the Wilding does not tvrn,ody have a tenant,that It b my NEWRESIDENMALMECH. SQd7.
re.povmlllty to netfy the occupyM d the requirements wh ieh must be met
usu..d a C
Prior to Lsu. efla
nite of Omrpancy.
Ow net or authorized agent Date SEP - 4 igg�
ISSUEDBY:
OFFICE COPY loll r ut- "UrCrI I uTv