23756 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification � a�
Build ing Address: �/ � 1 \ t &' PERMIT NO.
,o� so Z-0a I,/e7o�C isle" * -- 23756
hers ame: - one:
A bA R A A c -Z6 CITY OFCIPERTINO-BUILDING DIVISION
• centra e:aName: ( .pNo: APPLICATION / PERMIT,
[)Wl )S 6 L V's^'1 tl i 16 G ��(nLie0 i BNLDINGELECTRICALI'LAMBING-MECH LAICAL CATEGORY CONTROL It
Architect/Englneee LIc.No:
a ELECTRIC PERMIT • FEE BUILDING PERMIT INFO
Addrcm: V gak, L PERMITISSUANCE - ❑ ElElLICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter 9(commene APPLIANCES-RESIDENTIAL JOB DESCRI''HON
ingwithSedton7000)of Divisioo3 ofthe Buslnessand ProfeasionsCAde,and my
PFWV
Itcense is in full fo and effect. p PANELS
License Claw L i. Lontr 4R1 J ,w.
Date �j-f "qZ GHIT'E 7 Com' pl-1(100 AMPS '
UP TO 200 A�U
AAC abaft be
s ECLAR TION ``
0T. ]understand my phns ehaBbe used upublic records OVER 1(XIB AMPS SQ.FT.FLOOR AREA $/SQ.FT.
O_
ZIj Licensed Professional SIGNS ELECTRICALI A E p I N
G OWNER-BUILDER DECLARATION
fr SPECWLCIRCIlIT/MISC
F, owing raffirmthallam31.5,B fromthe Contractor'sLlcense Law fort he "
ZO^'3 following reason.(Section 70115,Business and Profealona Code:Any Ary or C
0 M L.,9, TEMP.METER OR POLE INST.
rountywhich requlma perrtdttoconswd,alter,Improve,demolish,arrepalrTa
�F ."ret anystm=mpr rtoibissuance,aMrequimtheappliesntforsuchper tto TER
_ 'U Bit,a signed statement that he is licensed pursuant to the provision of the POWER DEVICES (NI�
3"N Contractors License Law(Chapter9(ce sting with Section 7000)of Divi- SWIMMING POOL ELECT--- � VALU
sion38fthe Buainesaand Profenslans Code)orthathelsexempttherefromand ON
the basis for the alleged exemption. Any violation of Section 70115 by any OI77LE7SSV.7.I'CI{ES.Fl)(7'URFS
�p�p applicant for a permit subj is the applicant to a civil penalty of not more than
c..R five hundred dollars(SW.
I as owner of the pro",or memployees with wa es as their sole NEW RESIDENTIAL ELECTR SQFT. STORIES TYPE CONSTRUCTION
S z S ❑. P Pent, Y B
compensation,will Bothework,and k sCdure is hhatintended orofferedfor
sale(Sec.et apply
Business and f property
ons Code:The Contractors License Law
$ dons oessucy work owner ofrprough who nemplds or improves ovided eon,and
who doessuchworkhimseBorthrough his ownemployeea,provided that such OCC.GROUP RES.UNITS
improvements are not intended or offered for sale.If,however,the building or TOTAL:
improvement is sold within oneyearofcornpletion,the owner-build erwill have
th� rden or proving that he did not bund or improve for purpose of sale.). QTY, PLUMBING PERMIT FEE
L as owner of the property,am exclusively contracting with licensed 1 FT-OOD ZONE APN
fT
PERMIT ISSUANCE
contractors to construct the posted(Sec.7014 Business and Professlore,Code:
The Contractor's License law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
builds or improves thereon,and who contracts for such plojecta with a /• FEE SUMMARY
elf,
dor(a)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
U I am exempt under Sec. B &P C for this reason
OUTSIDEFEES
DRAINFLOOR ROOF,AREA,COND. SANITARY Y N
. Owner ECL S RECEIPT F
WORKMAN COMPENSATION DECLARATION .RAP ,..s SQ{OOL TAX Y N
F-11 hereby affirm that I have a certificate of consent to self-Insure,oraTwrufiEsPERRECEIT N
certificate .Workers'Compensa
C
3800.Lab C.) tion Insurance ora certBlea copy thearm eec. GAS EA.SYSTEM-1 INCAOUTLEIS PARK FEE Y N
RING DIVISION
Policy N GAS EA.SYS1Llf-OVER 4(FA)
Com any BUILDING DI VISION F[GS
[Certified copy e,heed withfurnished.hcity - CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
' rvl Certified copy b filed with the city Inspection division.
W CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANTTARY-STORM EA.2(K)FT. Date Recei t#
(This section need not be completed if the permit is for one hundred dollars
($1 W)orles.)
I ceor leshat N the performance Orme work forwNch this permit is issued, WATERI{EATFRW/VFNT/ELCCTR ENERGY FEE Y N
1 shall not employ any person In any manner so as to become subject to the ATER S /TREATING
Workers'Compensation laws of California.Date PAID
ZZ Applicant NEW RESIDENTIAL PLMB. SQ.FT. Date Recef t#
O NOTICE TO APPLICANT:If,after raking this Certificate of Exemption,you
F- should become subject to the Workeri Compensation provisions of the Labor TOTAL:
CC N Code,you must forthwith comply with such provisions or this permit shall be _ BUILDING FEE
IL > deemed revoked. -
1 O CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there is a construction lending agency for the perforrn- ELECTRIC FEE
Z ante ofthe work for which this permit is Isured(Sec.3097,Civ.C.) T L
V O Lender's Name PLUMBING FEE
Pyr Lender§Address QTY.I ICAL PERMIT FEE MECHANICAL FEE
OW Icedilythat l have madthis applicaHonand state that the above information
1 is correct.I agree to comply with all city and county ofd trances and state lawn PERMITLSSUANCE FEES PAID:
} y relating to building construction,and hereby authorize representatives of this - -
cit to enterupon the above-mentioned for W Ion purposes. ALTER OR ADDTO MECH.
~ ? y(We)agresave,indemnify an d property
the ity of Cpert ino Date - Receipt#
O against liabilities,Indgments,costs and expenses&which may In any way accrue AIR HANDLING UNIT(TO 10,000 CEM) - SUBTOTAL'
against said City in consequence of the gr rating of this permit. AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
1�1�) 9 L CONSTRUCTION TAX PAID:
sofisfure ppBcan/Contrador Date IXHAIA'T HOOD(W/DUCT)
HAZAR DOLS MATERIALS DISCLOSURE
Will the applies rat or future building occupant store or hand le hazardous HEATING UNIT(TO 100,000 BTU) Date Recel t#
material as defined by the Cupertino Municipal Code,Chapter 9.13,and the - /�
Hees itand Safety Code,Yea o
Section 2553on W? HEATING UNIT(OVER 100,"BTU) TOT
Wiiltheapplicant oriwmm ildingo pantuwcquipmentordMces VENTILATION FAN(SINGLE RESiD) ISSUANCE DATE
which emit has moue air contaminants as defined by the Bay Area Air
Quality Management District? BOILER-COMP OHPOR 100,000 BTU)
4Ye n No ~p D
havereadmeh u materials requirements under Chapter 6.95 of BOILER-COMP(OVERIID,000 BTU) 14/
the Glifornu health&Safely Code,Sections 25505,15533 and 75536. I
understand that lithe building does not currently have a tenant,that it is my NEWRESIDE-MALMECH. SQ.FT JUN
_ .a
responsibility to notify the occupant or the requirements which must be rte JUN 1 199
prior to issuance of a Certificate of Om panty. v7s7
CN r trr•
Owner or authorized agent Data TOTAL: ISSUEDBY. v �
OFFICE COPY