23030 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Preis idemlfiatlon PERMITNO.
Bandin A dress• 23030
o l��$or�
caner aces: / Vh — APl'U�lliJNhUbMrM—Ar=
CITY OF CUPERTIN0.BUILDINC DIVISION '.r1
• con ado a sea. APPLICATION /PERMIT ice`
VC
BUfLDINGELECTRICAGPLUMBINGM[CHAMCAL CATEGORY CONTROL
ArchltM/Engineer. Lk.Na
QTY ELECTRIC PERMIT FEE BUILDINGPERMITINFO
Address: PERMIT ISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
Ihereby ellon licensedunder provldonsuf Cs3imsC de,and APPLIANCESRESIDENTIAL JOB DESCRIPTION
inenseISection 7000)df Dl effect (the BudwsandlsrofmdonsCode,and my
licence lain (o dd(M. PANES `
Licon Chea IqR IRCi' •I`y�•'/,
' Dale Conhactot
ARCHITECTS DECLAR ON 201-1030AMPS
pQ+ 70- I understand my plan shall be used as public records. OVER 1000 AMPS SQ.FE.FLOOR AREA $/SQ.FT.
E Licensed Pref.ional SIGNS ELECTRICAL I ® n1 1
L 6 OWNER-BUILDER DECLARATION I V
�+ SPECIAI:CIRCUIT/MISC
ZF Thereby affirm that I -BUILDERexempt the DECLARATION
License Law for the
po following reason.(Sectlon 7031,5,Business and Professions Code:Any city or
Z i. TEMP.METER OR POLE INST.
cnystmchpe rtraapermittocowtequialttheaphmtfwwch, erepair 3
�§ any at signedprbrtoltshaa a Is
t Rthe fmsuchpermltto
e TOWER DEVICES y Z
� n
floe a signed statement that het licensed me pursuant to the provhi00)of the I 7
On,Iii nq
Contractor's License Gw(Chapter9(commencing with Section 7000)of avi- SWIMMING IDOL ELE
X03 aion3ofthe Buslneseand Profemlotu Code)orthat he h exempt thercfromard CfRIr VA ATTON
Q X the basis for the alleged exemption. Any violation of Section 7031S by any OUTLETS-SWITCHES FIXTURES
applicant for a permit abjess the applicant to a civil penalty of ns more than
$ Ove hundred dollars(SSM, NEW RESIDENTIAL ELECTR SQ.FT.
❑I,as owner of the property,or my employees with wages as their sole STORIES TYPE CONSTRUCTION
cempensalion,will dothe work and the stmenam h nor Intended or offered for
�J
Is(Sec.7044,Busman and Prodigal..Code:The Contractols License law
{a $ does not apply to an owner of property who builds or ,Improves thereon and OCC.GROUP RIS.UNITS
C. who doessuchworkhmnalforthrough hlaownemployees,providedthalach
Improvements are nil Intended oroffered fcrsale.If,however Ihebuilding or TOTAL:
Improvement hsold within omyearafcompldWMtheowner-bullderwlll have
IhW.kurdenaf provingthst he did not bulldor Improve for purpose ofukJ. QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
LJ L ae owner of the property,am exclusively contracting with licensed PERMITISSUANCE
contractors io construct the project(Sec.MCI,Business and Professions Cade:
The Contractors License Law does nor apply to an owner of properly who ALTER-DRAIN VENT-
Wllds or improves thereon, and who contracts for such projects with a WARM —^
cgR(fadur(s)licensed pursuant to the Cantradmstilanse Gs.. BACK FLOW PROTECT.DEVICE FEE SUMMARY
�I I am exempt under Sec. B k P C for this Mason
DRAINS FLOOR.ROOF,AREA,GOND. SANITARY Y N�
FE
Owner Date RECFJPTN
WORK MAN COMPENSATION DECLARATION pIX. pRPER TRAP SCHOOLTAX Y N
I hereby afforke that I have o I...e of.comm to copy
therm,(Sa RECEFT M
rtl cele o(Worken'Compematlonlmurana ora cortifkd copy therrof(Set' GAS EA.SYSTEM-1 WCAOUTLIDS PARKFEE Y N
3800,Lab C.ii ..s,s//�� ' 1
Policyll GAS EA.SYSl7M-OVER d(EA) RECEIPT M
Com anv 1T BUILDING DIVISION FEES
Certified copy is herebyfurnished.the city GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECRFEE
.Affled copy h(Teed with nis sty inspection division.
CERTIFICATE OF EXEMIxHON FROM WORKERS' GREASE TRAP PAID -
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 200Ff Dale Recei iN
Qhi,section need not be composed If the permit h furom hundred dollars
(5100car fess.) WATER HEATER W/VENT/E.ECTR ENERGYFEE Y N
I snotdify emplhat oy
anperson
performance of any
he nuu irk.as towhich this permit
subj c hoed, — —
I shall not employ any person f any manner m m to become abJM to the WATER SYSTEM/TREATING
Wakcrs'Compeneatlan Gwa o(Cali(amla.Date PAID
O Z Applicant
Z O NOTICE TO APPLICANT:If,a her making this Certificate of Exemption,you NEW RESIDENTIAL PLMB.__SQ.FG Date Recei t#
should become subject to the Workers'Compemalion provisions of the Labor TOTAL:
~ N Code,you mum forthwith comply with such provlslom orthh pertnit shall be BUILDING
cc > deemed revoked. FEE
W
G CONSTRUCTION LENDING AGENCY SEISMIC FEE
Iherebyaffirm that there Is a com ucion lending agency for the perform, ELECTRIC FEE
D Z ance ofthe workfor which this permit is Issued(Sec.3097,CIv.C.) TOTAL:
OO Lenders Name PLUMBING FEE
LL LendersAddress QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW Icertlfy that have read this applimtionand elatethat theabovelnformatlon �.�
1 Is d.I agree to comply with all city and county ordinances and stale laws PERMH`MUANCE FEES PAID:
} N relstingtobuloding coestrodion,and herebyauthodre npremntmivesofthh
H Z city to enter upon the above-mentioned property for impaction purposes. ALTER OR ADDTOMECH. Date ReCCI 1N
(We)agree to save,Indemnify an d keep harmless the City of Coped lna
ago lost liabilities,0dgmens,mats and expenses which may in any way accrue AIR HANDLING UNIT(E010,000 CFM) SUBTOTAL:
ag n said City in consequence of the granting of his permit -
i, AIR HANDLING UNIT(OVER I0,WOCFM7 CONSTRUCTION TAX
ii alumm Applic . on odor to EXHAUST HOOD(W/DUCD CONSTRUCTION TAX PAID:
HA2ARDOUSM TE IALS DIS RE
Will the applicant or future builds occupantstom handlehazardous HEATING UNIT(TO 100,000 BM
chs er9.lZandthe Date Recei tN
Health and defetyCode Cupertino Municipal Code, pt
Health and SafetyCode Section 25532(a)7 HEATING UNIT(OVER 100,000 B'EU) TOTAL:
❑ It No
Wl enut appllantor core building occupant usethe Bay re.devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emithazardousairrict? ntaasde(Ined bythe Bay Area Alr
Quality Management Dbtr BOILER-CAMP pF3'DR 100,000 BTU)
No
Yas nn No
4vef�/q� [�
hamadthehaza�ousraterialsrequirerncntsunderChapoer6.95of BOILER-COMP BNIP
) A 9 D
the California Health A Safety Code,Sections 25505,25533 and 25534.T
understand that lithe building does not currently have a tenant,that It is my NEW RESIDENTIAL MECH. SQ'IT' DEV,mapoosib0lty to notify the occupant of the requlrcemma which must he fret 9A�
Prior to issuance of a Certificate of Om pa racy. , 's7
011
tY k�+r
Owner or aulhorlad agent Data ISSUED
TOTAL: B
OFFICE COPY