24811 (2) APPLICANT TO FILL IN INFORMATION WITHIN R"n LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINOPLUMB
B ...DI G-ELEL RICAI. PERMITNO.
APPLICATION/PERMIT PING RODE T ICEANIFIC 2 /' 811
BUILDING DIVISION BUILDING PROJECI'IUf:\'TIFICA'I'I(IM1' L /L{�o
BUILDING ADDRESS: �/1 SANITARY NO. APPLICATIONS HMHTAL DATE
-( # UNTr# LOT#
- OMLS NAME: f PIIONIi: CON CI'gR'$NAME� ���� 36NG.
/ / 9 F✓�)'�l/`L-,�D ,rs, I� ,1/ NIC CON'IHOI.
0 �NCHITECI'/ENGINEER: �7 MIC NO: ADZIgZ rnaw,/� C/f El
C(`xemnA
CONTACT: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
[LF. PLU ME
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RHSIDHN'1'IAL JOB DESCRIPI10N
cyz Ihereby affirm then i ant licenced under provisions al Chapter 9(commencing with
iU00 Section]fgltp of Division 3or Nr Business and Profession,Cole,snit in,license is in PANELS
ff cu full force and Ifect / // ■y�/� .kms`
FZW License Lic.# 3G S�iEo� UPT02MAMPS • m 1
m<a Date_ Comment, 201-IMAM PS
FyG ARCHITECT'S DECLARATION OVER 1000 AM ? cit —\ i's, ri J SQ.I'T.FLOOR AREA E/SQ.FT.
Z O w_— I understand my plans shall ro used as public records. n �
OmC W SIGNS ELECIRI AL (, ?` II
Yj Licensed Professional
y�=< OWNER-BUILDER DECLARATION SPECIAL CIRCUT ISG.
K0EU I hereby affirm that I nm exempt from the Contractor's License Law for the �•
IL or 0rF'ja follownrEi mcom.(Section7031.5,Im,loess and Proressimd Code:Any city or county TEMP.METER OR POATE
- o 5 which requires a famtii to construct,cher,improve,demolish,or repair any structure
Y2 print o its issuance,also requires IM1e applicant for such permilto file a signed statement POWER DEVICES
C< that he is licensed pursuant to the Provisions of the Contmctor's License Law(Chapter
W—00 SWIMMING POOL ELECTRIC
ae%,oR' 9(cmmmencing with Scairn]0U)nf DivismnJof IM1e Business and Professions Code? VALUATION /'
-
W_w or that he is exempt thertfmm and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-FIXTURES �•
F Z Q Section 7031.5 by any aptilieart for a permit subjects the upplicnm m a civil peau by of �W
ESp not more than five hundred dollen(E500). NEW RESIDENTIALELECTR SQ.FT. STORIES TYPE CONSTRUCTION
wto ❑ I.as ownerofthe property,or my employees with wages es their sole compensation,
y3_ will Jo the work,and thextmene is not intended reoffered forsele(See 7044.Business
and Professions Cash:The Cnntmaors License Law dues not apply In an owner of
pmpery whobuildsorimpmvcs thercnn,and whodues rose wok himsclfur through his
own employees,provided that such lmprovemmusanot inlendedorrffereA foreale.If, OCC.CROUP HIS.UNITS
hwever, rc the building or improvement E xold within one year of vompletim,the owner- .roT
builder will have the burden of proving that he did not build or improve for puryou of
sale.). PLUMBING PERMIT FEE l
Q'I'Y,
[3Las uwnerof the propcnY•amenclusively contrxting wilt liansdconuaztorstoFLOOD ZONE APN
nmwe the Mi.(Sec.70x4.Business and Professions Code)The Conuaclmx
License Law dues not apply to wownerofpmpcnywho builds orimprovcs tM1crcon.vtd PERMIT ISSUANCE
whoamtmcts for such projceswitha<nnvaaor(s)liccnsdpor roam Ne Cono-etor's ALTER-DRAIN&VENT-WAl'ER LEA) FEE SUMMARY
Licenl ase Law.
❑ m exempt under Sec. ,B&PC for this reasonHACK FLOW PROTIiCI'.DEVICE SANE
FIA:,
SANI'T'ARY Y N
Owner Duro RECEIPT#
\j.'",
DRAINS-FLOOR,ROOF,AREA,COND.
- � WORKMAN COMPENSATION DECLARATION PARKSCHO .TAX Y N
❑ affirm mantrem.eamfiofecansunt edc,dremmlbinsure,or acenifiemaof FIXTURES-PER TRAP RECEIPI'p
/laAe 1 compcYsationl c�tee rrnunifd copy themof(Eec.lggl.Isb C.)which GAS-EA.SYSTEM-I INC.40UTLETS PARK FtiIi Y N
f RECEIPI'p
Policy Ji �����/O BUILDING DIVISION FEES
C,oytpony �]U GAS-EA.SYSTEM OVER 4 PA) PLANCHECK FEE
,$�cnified copy is hereby famished.
❑
Certified copy is riled with the city inspection division. GRFASE/INDUS'IRI.WASTE INTERCEPTOR GRADING IEE
CF,RTIFICATEOF EXEMPTION FROM WORK17RSI GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
This section red not beatmpleted iffle pemtil is for one hundred doU.(E100) SEWER-SANITARY-STORM FA.2011FT. ENERGY IEE
orlexil
I cenify that in the performance of the work for which this permit is issued.l shall WATER HEATER WNEN'17ELECTR
not employ any person in any manner so as to become subject to the Workers PAID
Compcmatior"u,isf Caliromia. Dam WATER SYSTEMIrREAAJNG Date Receipt#
O z Applicant
z O NOTICE TO APPLICANT:If,after making Nis Certificate of lisemplion,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
(•" become subject to the Worker x Compenmtion peviumm,of the Labor Cade,you must
forthwith comply with such powkicn,or this permit ehnll he deemed revoked. BUILDING FEE
0. QCONS'1'RUCTION LENDING AGENCY SGISMIC PEE ,
a z I hereby affirm that hem is a conmmetion lending agency for the performance of TO ELECTRIC ITE
V O the work for which this permit is issued(Sec.3097,Civ.CJ
Lender's Name PLUMBING FEE
u'• F Lender's Addm,a QTY. MECHANICAL PERMIT FEE /•
U 1 cenify that I have rend this application and state that the grove information is MECHANICAL FEE
Fcorrect. I agree to comply with all city and county ordinances and soft,lawsrclannig1. TPERMIT ISSUANCEI IT D
y buiWingconswttion,and hcrehy tmthnrme rtprcsentatives ofthis city teener upon the CONSTRUCTION TAX
U ahrve- min J propcny rn n purposes. ALTER OR ADD TO MECII.
e7 ugr m suvit keep hmml the Ci or Cupertinolie liticsjud fano nl: 'which any emeagainst said City AIR I IANDLING UNIT(I'010,00 CFM)
n. Yuen of a mis'
u qIR HANDLING UNIT(OVER I0t(k0)CFM)
3 -/-
eofApplicnnVContmctm Date EXHAUST HOOD(WIDUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING HNIT(To 100,0010 BTU) Date Receipt#
Will the spplicant a,future building occupant store or handle twor us materiel HEATING UNIT(OVER 100,000 BTU) TO1.:
as defined by the Cupeninn Municipal Code.Chapter 9.12,and the Health and Safety '
Code,Section 25532m)1
11 Yes XNo VENTILATION FAN(SINGLE BESIDE
BOILER-COMP(3HP OR 100,010 BTU) ISSUANCE DATE
hararJom air contaminants m defined by One Bay Area Air Quality Management BOILER-COMP(OVER 100.0110 BTU) A B
Oleate? n
❑Yes Nn NLW RESIDENTIAL MECII. SQ.FT. 4ryR
/� 1
1 have read the haaardoue mmcmd.,requirements under Chapter 6.95 of the /A
California Health&Safety Cole.Sections 25505,25533 and 25534. 1 understand that Ci/)'Vh 9
tribe building dues net currently have a tenant,that it is my responsibility to notify the
capam nr ter relairementa welrn mLL41 ro mel pdm n.tcaannae era Cenifirwe ar � Cfvli v 1
acapan<y.
Owner or a ithmiud agent Date / ISSUED BY:
OFFICE
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