20873 (2)APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification
Building Address:
PE1th97NO.
_
Z•z385-A JZANGNo' VENrV 5'
20873
nere ante: e��A
LARizY G •
CITY OF CUPERT[N0.6UILDING DIVISION
APPLICATION / PERMIT - -
+—T__pt%
�((
Cono-actora Name: Lk. No:
C
BUILDINGELECTWCAL-PLUMBING MECHANICAL
CATEGORY CONTROL If
Architect/Engineer. Lk. No:
QTY ELECTRIC PERMIT FE��E
BUILDING PERMIT INFO
Add. -
PERhBTISSUANCE a2 C3La
❑ ❑
LICENSED CONTRACTOR'S DECLARATION
_
IhthSmton7 )ofDiat lic on3ofthe usineslslon,ofC onsCode,mmeno-
(the BuslneaaandPro(eselonsCode,and my
Inlicense1Section to.
Limnu Clam Lk. M
Date is in full form and effect.
Date Contractor
APPLIANCES -RESIDENTIAL
] DFSCREPTION
I
Ire` LX
Y
PANES
, t ''y�
I �� -/"'
7O7-1 ODO AMI'^"^`
ARCHITECPS DECLARATION
I understand my plans shall be used as public remits.
OVER 100E AMPS n- I`w
SQ. FT. FLOOR AREA
S/SQ.FT.
SIGNS ELECEWCALQ,_ / `X
R
Licensed Profemlonal
OWNER -BUILDER DECLARATION
I hereby affirm that l am exempt from the Contractor's License law for the
followingma n.(Se im7O31S,Businmand Professions Code: Myciry or
ceunrywhkh rcquireaa permit tarovtruR, aitep Improve, dennlbh,orrepalr
anystructure pdorto its katuance,aborequiresthe applluntfor such permit to
file a signed statement that he is licensed pursuant to the proisic of the
v
Contractor'sLicense Law (Chapter 9(commencing with Section 7000) of Owl-
Sion 3ofthe Business and Professions Code) Code) or that he is exempt therefromand
the basis for the alleged exemption. Any violation of Section 7ai L5 by any
for a permit subjectsthe applicant to a civil penalty of not morethan
4 �
SPECIALCIRClAT/MLSC1�-
1.
NFh'Iv y
TEMP.ME7E2OR 1!OLE INST. p�n
N
^ 1le I
POWER DEVICES I w V
�Wp{AgNG IDOL ELECTW�
-
O ETSSWITCHES—FIXTUR,ES \ V
VALUATION
Co—
o '
`
hEAEgD ALELECTR� FP, p
it
five "hinollars (8500).
as owner of the property, or my employees with wages as their sole
STOW 6
TYPECONSTRUCTION
�(1
c pe ation,will dothe work and the structure Isnot intended or offered for
Ie (Sec. 7044, Business and Professions Code; The Contractors Llmme law
O_OCC.GROUP
TOTAL; %,Improvement
does not apply to an owner of property who builds or improves thereon, and
whodocsuch work himulforlhrough his own employees, provided that such
Improvements arc not intended oroffered forsale. If, howevep thebullding or
bwidwlthlnovyearofcompletb theowner-bullderwlll have
RES.UNITS
tlurden of provingthat he did not build or bnpvve for purpose of sale.).
u I, as owner of the property, am exclusively contracting with licensed
contractor to construct the project (Sm 7044, Business and Professions Code:
QTY; PLUMBING PERMIT FEE
.
PERMIT ISSUANCEj
I
ELOOD ZANE
APIs
The Contractor's License Law does not apply to an owner of property who
bulids or improves thereon, and who contracts for such pkojects with a
"g5actor(s)I1,enxd pursuant to the Contractor's Limnu Law.
I am exempt under Sec. B & P C for this reason
-
ALTER -DRAIN &VENT WATER (EA)
BACK FLOW PROTECT. DEVICE
FEE SUMMARY
FEES
DRAINS FLOOR ROOF, AREA, COND,
FUTIURES. PER TRAP
SANITARY Y NOUTSID�
RECEIPT N
Owner Date
WORKMAN COMPENSATION DECLARATION
Of hereby affornorkers that 1 have ate of consent to selop finsure,thereof
SCHOOLTAX Y N
ora
o Insurance
3800(lcate bC.) rkera CompevaHonlvurancemacertified copytherm((Sec.
3800, Lab C.7
RECEPT M
CAS EA. SYSTEM -1 WC4OUTLET5
PARK FEE Y N_
Policy Y
M
GAS EA. SYSITM-OVER 4 (EA)
Com any
DING DI
BUILDING DIVISION FEES
�Cedlfied copy i, filed
�Certitled copy V filed with the city Inspection division.
the city
GREASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECKFEE
GREASE TRAP
CERTIFICATE OF UEMPEION FROM WOR KER S'
COMPENSATION INSURANCE
IThi e section need not be completed I(the permit V (Drone hundred dollars
PAID
Date RCCelpt#
SEWER -SANITARY -STORM FA. 700pr.
($100)orlem.)
I certily that In the performanceotthe work forwhich tMe permit is issued,
I shall not employ any person In any manner so as to become subject to the
Workers' Compensation Laws of California. Date
WATER HFATIR W/VENT/EI-[CTR
ENERGY FEE Y N
PAID
WATER SYSITM/TREATING
Applicant
NOTICE TO MPLIGtote aftermakingthioation pro is Exemption, you
should become forth tto the Worker' Compevalfonprovblovofthe Lab or
Coda you must forthwith comply with such provblov or this permit shall be
rimmed revoked.
Date Recei t#
NEW RFSIDENTIAL PLMB.SQFI,
TOTAL:
BUILDING FEE
TOTAL
SEISMIC FEE
EI-ECTRIC FEE
4
CONSTRUCTION LENDING AGENCY
Iherebyafflrm thatthereba construction lending agency for the perform
once of the work for which thio pemdt V laded (Sec. 3097, Civ. C.)
I<rder's Name
Lrocicr,Addmm
I certifythatl have readthls application and rtatethatthe above Information
QTY. . MECHANICAL PERMIT FEE
PLUMBING FEE
MECHANICAL FEE
FEES PAID:
Iscormct.I agree to comply withWHly and county ordinances and statelaws
PERMIT ISSUANCE
relating to building comtrutllon, and hemby authorize representatives.(thin
citytoenterupontheabuve-mentioned property, for inspection purposes.
(We) agree to save, Ind emrdty an d keep harmless the City of Cu ped Ino
against lla llitles, Ndgmente, coats and expenses which may In any way accrue
gal t WCB run en3e of anting of this permit
fS - ti.�TO
-
ALTERORAODTOMECH,
AIR HANDLING UNIT (TO I(EOf1O CFM)
Date ReCei t#
SUBTOTAL:
AIR HANDLING DNTr(OVEt morili EM)
CONSTRUCTION TAX
si rcer Ap can</ ontmctor Date
FXFIAUSTIIOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT OG, 100,000 BTU)
Will theappllant or future buildingoccnpant,lore orhandle hazardous
material as cieflmd by the Cupertino MuNcipal Code Chapter 9.17, and the
Date RCCCI f#
HEATING UNIT (OVER 100,000 BTI)
TOTAL:
dsC-V
Ilealth and Sof etyC Ion 25537(a)7
❑ Yee o
YFNTILA77DN FAN (SINGLE RESID)
ISSUANCE DATE
P��
Will the zppllranl or tobuilding ocmpant use equipment or devices
which emit hazardous rmntaninantsaade0ned bythe Bay Area Air
OualBy Managemen Dat 7
BOILER -COMP DEEP OR 100,IXU BTU)
7 haves o
e madthehaza u,materlalsrequlremenwunder Chapter6.95of
the Caefornlallcalth& fety Code, Sections 8505,25533 and 75534. I
understand that ifthe ilding does not currently haveatenanq that itlamy
rapovibility, to notify the occupant of the requirements which must be met
/1•I IC sf 1990
f VU
BOILER-COMP(OVER100,DDO BTU)
NEWRESIDFNTTALMECH. SQ.Fr.
prior nuance of 1. Cedllimte o(Occupanry.
z �i/j arc _
of C IlpPrilno���
^����(] Yw.Ay,.rU
ISSIIEDBY: Q(2Fof I"I
rauthol gent Data
TOTAL:
OFFICE COPY