20440 (6) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POIN PEN ONLY
BuildinA Prowl Identificia
Ion �( /1 PERMIT NO.
Building Address:to 123 Ao.Wt. ti h 'Oy O1 V/1 ` _ , 2 0 4 4 0
Ow
40i4"P
ON
vN o'M1Or) 1m Y -� 1 CITY OF CUPERTIINNO-BUILDING DIVISION A
4� +t�L+ eI c 1. S
ContemmesName: Lie.N.: APPLICATION / PERMIT
BUILDINGnECTR)CA4ML BINGMMC MCAL CATEGORY CONTROL
r. I✓_-��
Archi n En oe _ 7-Ic� d,J
/Ae`NaIO QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
o ao
Address: _ / Q.S/t A W1 PERh9TiSSIJANCE � ❑ ❑ ❑
LIC ENS EDCONlRARO 'S DEC RATION
Ihereby
actkan 7(that)am Rcen3oftheunder simssaprovisions of Cnions odeanenc APPLIANCES-RESIDENTIAL JOB DESCRIPTION
it...I I.fon7000)ofdaffect. (thegualnessand Pro(csslonsCodGand my
limnx la in ml roe and effect, PANELS '
Date Clap�LlcN
DateAlyflN I,
-,`�P Con'mrtor 7'ire'y. 7(II TWO AMPS
ARCHITECused.pARATIO OVER10DIAMPS SQ.F7.FLOOR AREA $/SQ.FT.
pQ?�O I understand my phns ahaB be used u public rcmms
E Od E Licensed Professional SIGNS ELECTRICA
fn
Z,
OWNER-BUILDER DECLARATIONg1.EC CIRCUIT {,S-0 O
I„ y IhcrcbyafOrmthat lamvemptfromthe Contractor.License Law(wthe
following reason.(Benton 7Q)1.5,Business and Professions Code:Any 6,or TEMP. POLEVI .
Kcounty which requires a permit to construct,alter,improve,demolbh,orrepalr
y .a anystructum pdortoits becamealsorcquimstheapplimntforsuch pertNt to
a file a signed statement that he b licensed pursuant to the provbions of the POWER
Ou, Contractors License Law(Chapter9(mmmendngwlth5en1on70sfio(Divi-
30�' sion3ofthe Business and Protections Code)orthat he bexemptthere(romand B POOL ELECT VALUATION
H ,� the basis for the alleged exemption. Any violation of Section 7031.5 by any OUILETSSWITCHES "[� peyy�
605 applicantfora permit subjects the applicant to a civil penalty of not room thanALIA ,]���-r-ly/t�
five hundred dollars(¢500). NEW RESIDENTIAL EL TR SQ.F7.
�n 0I,as owner of the property,or my employees with wages as their colli STORIES TYPECONSTRUCTION
C compensation,will dothe work and thestructure Is not intended or offered for
OIn(Sec.7040 Business and Professions Code:The Contractors License law
$ don not apply to an owner of property who builds or improves t heron,and OCG GROUT' RES.UNITS
a who does such work Noxi(mrthrough hisown employees,provided that such
Improvements am not intended orof(ered forsale.I(hcu, vvr,the Wlldingn TOTAL:
Improvement Weld within one yearotcomplation,the owner-Wilderwill have
thg*men of Pmmng that he dm not build or Improve for purpose o(sale.). QTY. PLUMBING PERMIT FEE
FLOOD LONE APN
LJ S as owner of the property,am exclusively contracting with licensed
contractors to construct the project(Sm 70"Business and Professions Code: PERMIT ISSUANCE
The Contractor's Lle,nse Law does cot apply to an owner d property who
Wilds or Improves thereon, and who contrens for such pbojens with a ALTER-DRAIN&VENT WATER(EA)
m,➢![+ctorW licensed pursuant to the Contractor's License Law. BACKFUIWPROTECT.DEVICE FEE SUMMARY
IN 1 am exempt under Sec. B &P C for this reason
OUTSIDE FEES
DRAINS FLOOR,ROOF,AREA,CONTI. SANITARY Y N
• (Tuner Date RECEIPT p
WOR KMAN COM PFNSATION fcoLA ATION pp(yUgES PER TRAP SCEIOOL TAX Y_ N_
Why affirm that I have•certiBote of conxm Io self-Insure,ora RECEIPT N
rtitl<ate ofWorkers'Compensadmn insurance ora certified copyth mitf(9ec. GAS EA.SYSTEM-1 INCA OUTLETS PARKFEE Y N
3800,Wb C.) - O If
PmRcy.—;qU�-L 03 GAS FA.sYsnmE vER6(EA) DINGRECEIV
Com anv "j BUILDING DIVISION Fr.ES
rC-z"Mropybbam furnish.
F-]CariBed copy is filed with the city Inspection division. GREASE/INDUSML WASTE INTERCEPTOR PLANCi-IECK PEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAPPAID '5-
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200FT. Date RCCCI t#
(Thissection need not be completed tithe permit b for one hundred dollars
($100)orless.) WATER HEATER w/VENT/EL@CTR ENERGY FEE Y_ N_
I cem(y that In the performance of the work forwhich this permit Is issued,
I shall not employ any person In any manner m as to become subject to the WATER SYSTEM/TREATING
Workc%Compensation Laws of California.Date PAID �I'��q
Z Z NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
licant NEW RESIDENTIAL PLMB. SQ.Ff. Date Recei tJl .7V1`-V
should become subject to the Workers'Comperwtlon provisions of the Labor TOTAL: a
¢
w mCode,you=at(orthwithcomply with such provisions orthis permit shall be BUILDING FE /�.
W deeed revoked.
M 0 CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hercbyat@mthat there is a construction lendingagenry forth.perform, TOTAL: ELECTRIC FEE
M Z ante of the work for which this permit b Issued(Sec.Som,Cw.c.) PLUMBING FEE
Q O Lenders Name
LL F Lenders Address QTy-j MECHANICAL PERMIT FEE MECHANICAL FEE
W I certdythatl have macithlsapplicatlonand statethat theabove Information
O
1 bmrren.Iagma to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
relating to building construction,and hereby authorlu representatives of this
I" N city to enter upon the above-mentioned property for inspection purposes. ALTFRORADDTOMECH.
_ 2 Date- Receiptq
(We)agree to save,Indemnl(y an d krep harmless the City o(Cupe Urtino
AIR HANDLING UNIT(TO 10.000 CFM)agaWtlbbNues,pd ts,mpsand expenses which may in anywayaccom.rue SUBTOTAL:
against w1 I nence
of the granting of this permit.
AIR HANDLING UNIT(OVER 1p"CI I) CONSTRUCTION TAX
ignsmreo pplinn Contractor iDate IXHAUST HODD(W/DUC'D CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALSDASCLOSURE
Willtheapplies u
nt orfume building occupant store or handle hamous HEATING UNIT(TO 100,WO BTU) Date Recel tit
material as defined by the Cupertino Municipal Code,Chapter 9.1Z,and the
I ealth and Safety Code Section 25532(a)2 HEATING UMT(OVER 100,000 BTU) TOTAL:
Yes M No VENTILATION FAN(SINGLE REs1D) ISSUANCE DATE
Will the applicant or future building occupant uequipment or devices
which emit haeamous air contamlm rats as defined by the Bay Area Air.
Quality Management Dixtrict? BOILER-COMP PER'OR I W,IXID BTU)
hyes ave mad the havrZNaratenab requirements under Chapter 6.95 of BOILER-COMP(OVM 100,00)BTU)
the Califrola Health&Safety Code,Sections 25505,25533 and 25534.1 I
understand that if the building does not corrently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.IT.
rexponsibility to notify the occupant of the requirements which most be met 't JL lOi g 'gCl'
prior to issuance of a Certificate of Occupancy. u yt t'A
Owner or authorimd agent Date �ISSUED
TOTAL: Y1�J\Z'U'
OFFICE COPY