20528 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project identification PERMIT NO.
iulding Ama,:
89 20528 OC
rcr. SUHMFFEAL DATE
• j rne CITY OF CUPERTTNO-BUILDING DIVISION _?7 �/�
cono-ador Name: as� Lie.N.: APPLICATION /PERMIT
1--or BUILDING-ELECMCA4ML BINGMECHAMCAL CATEGORY CONTROL N
Amhite /Engines Lk.No:
QTY ELECTRICPERMIN FEE BUILDING PERMIT INFO
Add 2 PERMIT ISSUANCE ll ii' ❑ 1:1 ❑
LICTRACTOR'S 4LARATION L�
T hereby efllrm that lam lkensed under provblons of Chaptcr9(cammenc APMANCESRESIDENITAL JOB DPSCRIPHON
M'ngwith Sedkn 7000M Divinctr3 ofthe Buslnessand Professlon.Code,and eny
anx In In full file and sic.# �� PANELS
LlcenxC /_J,(�LICN
Date_ _a la_Contra NI I"AMS .J
• !" ARCHITECTS DECLARATION OVERIWO AMTS SQ.Ff.FLOOR 5/SQ.ET.
Z I erss tand my plans shall be used as public records.
CN(� Licensed ProfessionalioProfessionalSIGNS ELECTRICAL
<Z. OWNER-BUILDER DECLARATION
G F S FOULC RCD.T/MLSC
fherebyalffirenE' er owingrsson. ttutlamexemptfromthed Profess.Llrenx Law fee the
O O F Q following reawn.(Smlon 70315,Businem and Pm(emlov Code:Any dry or gyp,MECER OR E IN
til county which requires a permit to mmtrud,alter,improve,demolish,or repair
F gCai any structure prior to its issuance,a bo requires the a ppllcant for such permit to POWER DEVICES
0 V file a signed statement that he b licensed pursuant to the provisions of the
3:u,� Contractor's License Law(Chapter9(mmmendng with Section 7000)of Divi- SWIMMING POOL ELE�kV VALUATION
O slon3ofthe Busineuand Profexiom Code)orthathebemm themfromand
the fasts for the alleged exemption. Any violation of Section 70315 by any OUILETSSWFICHESH FS
py0� applicant fora permit subjedsthe applicant o a dvll penalty of net morethan
LLYY Q five hundred dollars(6500). NEW RESIDENTIAL EL
g?
E)1,as owner of the property,or my employees with wages as their sok `�'Fr. STD ES TYPE CONSTRUCTION
eenrinconation,will do the work and the structure is not Intended or offend for
❑ xlc(Sec.7614,11u3
t, and Professions Code:The Contractors Llccnse Gov
�$Q does not apply to an owner of property who Wilds or improves thereogand OCC.GROUP RES.UNITS
a who doessuch work himself or through hisownemployces,provided that such
Improvements are not Intended oroffered forsale.If,however,thebullding or TOT
Improvement Issold Mthinoneyearofcompletiomtheowner-buBderwBl have
t"eden of proving that he did not build or improve for purpose of sale.). QTY. PLUMBI GPERMIT •'E FLOOD ZONE APN
[_I L as owner of the property,am exclusively=trading with licensed PERMIT ISSUANC
contractors to construd the project(Sec.7044,Business and Professions Code:
She Contractor's License Law does net apply to an owner of property who
Wilds or Improves thereon,and who contracts fou such p,jem with a ALTER-DRAIN&VENT-WATER(EA)
dor(s)licensed pursuant to the Contractor's License Law. BACK FlAWPROTFOT.DEVICE FEE SUMMARY
LJ I am exempt under Sec. B&P C for this reason
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_
Owner Date RECEBTN
WORK MAN COMPENSATION DECLARATION FLYNRES PER TRAP SCI OOLTAX Y_ N_
❑I hereby affirm that I have a artl0cate of consent to self-Inmre,or a RBC=N
adiftateof Workers Compensaioninsuranarnacenlfled copythecof(See. CAEA.SYSTEM-1 INC EEOUTLF1'S PARK FEE Y N
3800,Lab CI — p
Pollrytl cad Z2t�f7—meq R
GAS EA.SYSTEM-0VER4(EA) BUILDING DI VISION FE CSCom v
Certified copy ato tl PLANCHECK FEE
PEJ2tnrcJied copy Is with the city Inspection division. CREASE/INDUSTRL WASTE INTERCEPTOR
CERTIFICATE OF EXEMPT ION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200FI. Date Recd t#
(This section need net be completed if the permit b fee one hundred dollars
($10))orhoes.) WATER HEATER W/VENT/ELFOTR ENERGY FBG Y_ N_
I unity that In the performance of the work for which this permit Is Issued,
1 shall not employ any person In any manner so as to become subject to the WATER SYSTB4/TRFAnNG
Workers Compeoutton Laws of California. Date PAID
Z Z NOnCETO APPLICANTaf,after making this Certificate of Exemption,you cant NEW READENTIAL PLMB. SQ.FT. Date Reeel 1#
O should become subject to the Workers Compensation provbiom of the Labor TOTAL:
fp Code,you must forthwith comply withauch provisions orthisperndt shall be BUILDING - E -�
domed revoked.
W — CONSTRUCTION LENDING AGENCY � SEISMIC FEE r
CL rz I hereby affirm that there is a construction lending agency for the perform- TOTAL: ELECTRIC FEE
D Z ance of the work for which thin permit LS Issued(Sec.3097,CIv.C.)
U O Lender.Name PLUMBING FEE
LL F Lenders Add mss QTY. MECHANICAL PERMIT FGE
Ow IanifythatI have read thin application and wmethattheabove lnf.mutt MECHANICAL FEE
CL Is correct.I a gree to comply with all dty and aunty ordinances and state s PFRMH ISSUANCE FEES PAID.
eclatingto building mnstrvdlon,and hereby authorize resentatly of this
N city to enter up. the above-men0oned propertykei pedto. .� ALTERORADDTOMECH.
_ Z Dale Receipt#
(We)a o save,Indemnify an d keep Ear a the City Gu Ino
L) agaft411.b �,judgments,dad. expen Ich mayI ray .esus AIA HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
againronsequene,o:the grant' oflh.pe B. CONSTRUCTION TAX
_ AIR HANDLINGIMIT(OVER 10,f100CIM)signaradrn ate IXFIAUST HOOD(W/DIIC'q CONSTRUCTION TAX PAID:
HAZARDOUS MATERIAL ISCLOSUR
Will the applicant or future building oc ant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date ReceI t#
mrtcrlal as defined bythe C.geAino Muni pal Cud,Ch.p1c,9.IZ.rdtho
Health and Safdy Code,Scp1.o 29532(.)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑ Yes No
Wllltheapplicant orfuturebuildingoccupant use equipment or devices VENTILATION FAN(SINGLE RFSID) ' ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
Aly Mawgement D'td BORER-COMP DHP OR t Wp(10 BTU)
Y . JUL 2'7 1990
ahavere thebazar ousenalerlabrequlrementsund hapter6.95of BOILER-COMP(OVER 100,000 BTU)
the Glifor aHealth&Safety Code,Sectio 505,25 and 25534. 1
understa thatitthe building does not crafty hav atenanl at it NEW RESIDENTIAL MEC}I. SQ.FT. r•
r¢ ons flity tondlfy theoccupan of a ire ntswh' must be met /la) Q:
Pm u atcof n
au orlud agent t
TOTALTSSUEDBY:Ql���
: /
OFFICE COPY