24010 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification
BuOdleg Addres.: PERMIT NO.
�it3 wta-wtim �� 240.10
wnera one:
MRI' m es. CITY OF CUPERTINO-BUILDING DIVISION '7 _
"eed1°/r.Na'"e1 LAO a=•No APPLICATION /PERMIT
F'UG T.i1O E 0c, 3 G6y BUILDINGELECTRICALPLUMBINGMFLFIAMCAL CATEGORY CONTROL#
Archimd/Engineer; Llc.No:
•� BUILDING PERMITINFO
QTY ELECTRICPERMIT FEE MEL
Address: bpif,_ Km D&LL "F, at/('A�rl BELL, PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION
Iherebyelfirmthat l an Harassed under pambioneo(Chapter 9(commm APPLIANCFS-RESIDENITAL JOB DESCRIFIION
Ingweth Section 700D)of Division 3 ofthe Buslneseand Pro/essioneCode,and my
license la In full fo a effect. ��lqA Z PANELS
License as LIc#
ate Contactor kNDfrAft
ARCHITECTS DECLARATION /rJL 201-1000AMN
OVER 1000 ANTI'S FT.FLOOR AREA 'S/SQ.FT.
u den rad V shag seeds blicremrdw =-Q�
rn
jyN�ri,b h.rYSG wLicensed Prfessional SIGNSELECTRICAL
OWNER-BUILDER DECLARATION
fd he SPECIALCIRCUIT/MISC
7a, owing a(Rmn dion7exempt(roossa Contractor's License LawAny cit or
following reason.(Section 71D15,Business and Professions Code:Any tlty or
TEMP.MEM ORPOLE[NST.
Pcwntywhich rcqulresa perMttoconstruct,eltap lmpmve,demolish,orrepair
S ray structure pgorto lnbmrar;ce,alaorequlmthaappRant(orsuch pemdt to ({OWER DEVICES
file a signed statement that he b licensed pursuant to the provielom of the
3w
r^ Contractors License Law(Chapter 9(commencing with Section 7000)ofDlvl-
Oslon3 olthe ButlneesandPro(reel.mCnde)arthat he is exempt therefromand SWEs1MINC POOL ELECTRIC as VALUATIW,
6 5 the basis for the alleged exemption. Any violation of Section 7031S by any OUTLETSSWITCHFS.FD(TURES / O (((afar
appllantfora pertaublectstheappganttoacivilpenaltyofnot morethan 1 l O
five hundred dollars(5500).
I as owner of theproperty, NEW RESIDENTIAL ELEC7R SQFT. STORIES TYPECONSIRIKTION
,>�n ❑, la or my employees Is with wages r thele dole
sale CSm 7ton,Businessl do work andthes Code: Is net Intendedo icense,L for
�O ale(Scc 7044,Business and Professions Code:The ContractolsUcerse Taw
'2 does not apply to an owner ofproperty who builds or Improves therms.and .00C.GROUP RFS.UNITS
whodoeswchwork himself orlhrough hlsown employees,provided thatsech
Improvements arc not intended mattered forale.If,however,thebuilding or TO
Improvement bsold withlnoneyearo/complettoMtheawner-buRderwill have 145 kE
tlBLIiurdenofproving that he dM notbulld arlmpreve(orpurpoae o(ale.). QTY. PLUMBING PERMIT FEE FLOOD wedE APN
u L as owner of the property,am exclusively contracting with licensed
contactors to construct the project(Sec 70141,Business and Professions Code: PERMIT ISSUANCE
The Commetar's License Law does not apply to an owner of property who ALTER DRAIN k VENT WATER(EA)
build. or Improves thenar,and who contracts(or such p(ojecas with a
c7faI,ctor(s)Ilcenaed pursuant to the Comadera License Law. FEE SUMMARY
LJ I am exempt under Sec B A P C(or this rescan BACK FLOW PROTECT.DEVICE aetee
DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y N
OUTS 1011 FEES
Owner Dae RECERT N
WORKMAN COMPENSATION DECLARATION - SCHOOL IA)( Y N
❑I hereby affirm HXIl1RES PER TRAPthat I have a certificate of consent to self-Insure,or ftFLEB N
labb CJ S #
ceniflaolWorken'CompersaUonlaurance orattrtifled copytheseof(Sec. GAEA. INCA PARK FEE Y N
Policy N RFLER'1'#
GAS EA.SYSTEM-OVER 0(EA)
Cam any 8UILI2INC DI VISION FEES
Certified copy b hereby Entrusted.
city CREASE/INDUSTR,WASTE INTERCEPTOR PLANCHECK FEE ..a.
Certified copy b filed with the dry inspection division. `
O O
CERTIFICATE EXEMPTIONGREASE TRAP OF
EXEMPTION FROM WORKERS' PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 200FT Date Rctti t#
(This stolon need net be completed lithe permit b forone hundred dollars F
(5100)rtifyt.) WATER HEATER W/VENT/ELFLTR ENERGYFEE Y N
I nnet that In the parsmbneeof thewcek(orwhich ca penult is owed,
,I shake net employ any person in any manner at a to become wbjM to the WATER SYSTEM/TREATING
Workean Compenation laws of California.Date PAID
z Z ApplicaNOTICE
NEW RESIDENTIAL PLMB. SQ.FT. Date Remi t#
Z O =' ldyb TO APPLICANT.If,after making this Certificate of Exemption,you
H .hwld.:Zo subFct to the Workers'Compensation provisions of the Labor TOTAL:
cc y Code,you meat fort hwlth comply with such provlsloro rrthts permit shall be
> deemed revoked. BUILDIN FEE .�•
ac CONSTRUCTION LENDING AGENCY SEISMIC FEE
�
I hereby atBrm that there b a construction lending agency for the perform Z once o/the work far whichthb permit Is heated(Sec.3097,CIv.C.)
ELECTRIC FEE
. 02 Lander.Nam= PLUMBING FEE
LL ~ Lc"dee.Adana QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW Imalty that have read lhbappllation and gate that the above Information
C bcorned.I agree to comply with a R city and county ordinance dna gate laws PERMITISSUANCE FEES PAID:
>. relating to building construction,and hereby authorise reprewntativesofthb
F Z city to enter upon the abova-mentlo"err property for inspection purposes. ALTER OR ADD TO MFCH. Date Recel [#
— (We)agree to ave,indemnify as d keep harmless the City of Cu Perrino
aga ' billtks,jedgments,cog andexpenseewhichmoyin anywayaccrue AIR HANDLING UNIT(To 10,000 CFMJ SUBTOTAL:
a a old City sen ttu'f yanting of this pe
ZZ 71 AIR HA NIXING UNIT(OVER 10,"CFM) CONSTRUCTION TAX
Sig m o AppOant/Contractor I Date, EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the a pp0ant or future building occupant stare or handle hazardous HEATING UNIT(TO 103,000 BTU) Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.7d and the
Ilealth and Safety Code�+.�Section 25532(a)I HEATING UNIT(OVER 100,000 BTU) - •I•
RYrs L_I No
ill the appRorat or future building occupant use equipment or device- VENTILATION PAN(SINGLE RESID) - ISSUANCE DATE
wMcheMnaement air District? anteas defined by the Bay Area Air
Quality Management axardou DbWct} BORER-COMP 0I-0'DR1W,IXq BTIp
Yes ❑No' p
ave read the M1avrdous rateriabrc requirements under Chapter 6.95 of BOILER-COMP 100,000 BTU) M
the Gll(oraia Health k Safety Code,Sections 2S505,25533 and 25530.I
uoderstx rad thalif the bu llding does not currently have.meant,that it is my NEW RESIDENTIAL MF.CH. £Q.FT.
responsibility to notify the occupant of the requirements which mu at be,met 'JUL22 1992
prior to issuance of a Certificate of Occupancy. F/�����y.��,���, /��,,
Owner or authorized agent - Data ISSUNE B </LV.1'A/TSAIM(,f
TOTAL: aM r A
OFFICE COPY