23939 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
SWIMn Project Ide tilk.ti.n PERMIT NO.
Building Address: 23939
UWTr—
Z To
� CITY OF CUPERTTN0.6UILDING DIVISION
Contract./.Name LIc.No: ► Z
APPLICATION /,PERMIT
�- a �� BUILDINGELECTRICALMUMBING-MECHANICAL CATEGORY CONTROL N
A ect/Englnrer. o– aaa,S asie eN
U.N.:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: a PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am keened under provisions of Chapter 9(mmmenc APPLIANCESRESTDENTIAL JOBDFSCRB'IIONing ^
liar.is
fares
fd effe w3o(the8uslnemand Prof¢slonsCode,and my w
Ikerue le a full faro))and Division
PANES
License Clam LILY �5� ,
Date Contractor UP TO 200AMPS
ARCHITECTS DECLARATION 211-1000 AMPS
{opiw�oy I understand my plans shall be used as public retards. OVERIOODAMPS SQ IT. ' AR 5/SQ.FT.
E d Licensed Professional SIGNS ELECTRICAL a �"') Q
6 OWNER-BUILDER DECLARATION u' 1
Fn SPECULCIl2CUIT/M75C
t.., IherebyafRrmthatlam exempt(romthe Contractor.License Law forthe
09Ly following Mason
.(Sedlon 70315,Busin..adProfe.al .Cad)):Anydtyar TEMP.METER OR POLR INST.
Pa vntywhichrequimaperautWmmMd,alter,lmpmden lbh,orrepalr
g ystructam prlorto its issuance,also requlmtheapplicant forsuch permit to POWER DEVICES
li S ia signed statement that he Is licensed pursuant to the provisions of the
Qb 3 u, ntractor))License law(Chapter 9(commencing with Section 7000)of Divi-
an VALUATIO
SOS. n3ofthe Business and Professions Code)or that he is exempt therefrom and SWIMMING POOL ELECTRIC OCy
6 the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETS-SWITCHES-FIXTURES
applicant for a permit subjects the applicant to a civil penalty of not more than
five hundred dollars($500). NEW RESIDENTIAL ELECTR SQ.FT. STORIES - TYPECONSIRUCTION
1,as owner of the property,or my employees with wages as their sale
7a compensation,will do the work and the structure is not Intended or offered for
p sale(Sec.7094,Basions.and Prefea toms Code:The Contract.(.License Law
$8 does notapplytoanownerofpropertywho Wilds orimproves thereon,and - OCQ GROUIs RES.UNITS
who does such work himself or through his own employees,provided that such
Improvements arc not Intended or offered for sale.If,however,the building or T
improvement bwld withlnoneyearofcomplrtlon,the owner-bullderwill have
t1iji,tiumlen.(proving that he did net bang or Improve for purpeaeufsals.). QTY, PLUMBING PERMIT FEE
FLOOD ZONE APN
4 as owner tr the property,am exclusively Business
contending with licensed PERMIT ISSUANCE �..
contractorseContto construct the projects nor apply
Business and of pro ons Code:
The Contractor's impr'a License Law does nut apply tc an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilda tr Improvre thereon,and who contracts for such p(ojesb with a FEE SUMMARY
cgp((a are exempt
under
to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
LJ I am exemp under Sec. B&P C for this reason
DRAINS FLOOR ROOF,AREA,CONED. SANITARY Y N�
Owner Date RECEIPT N
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOL TAX Y_ N_
pl hereby affirm that I have a certlRrate of consent to self-Insure,or
cerlifi¢te of Worken'Comparo atlon Insurance ora certified re
copy theof(Sec. RECEIPT N
3800,Lab CJ CAS EA.SYSTEM-1 PARK FEE Y_ N—
Policy N
Pollry p GAS EA.5YSTEM-0VER 4(FA)
m any BUILDING DIVISION FEES
rtified copy is hereby famished. GREASE/INDUSTRL'WASTE INTERCEPTOR PLANCHECK FEE
Certified copy V filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE EA 200FT
(This section need nut be completed if the permit Is for one bund red dollars SEWER-SANITARY-SfOHM Date Recelt#
00)
(51Icertea.J
14ATp2�TE4N,/VENT/ELECTR ENE•RGYFEE Y N
I¢or lmat la the pedarnan¢.(the work(orwmcto this permit la issued,
1 shall not employ any person in any manner w as to become subject lathe WATER SYSTEM/TREATING
Workers'Compensation Laws of California.Date PAID
-
z Z Applicant NEW RESIDENTIAL PLMB. SQ.FT. Date IZecei t#
Z O NOTICETO APPLICANT:If,after making this Certificate of Exemption,you
should become sub)eet to the Worken'Compematlon provisions of the Labor TOTAL'
fN Code,you at forthwith comply with such provisions or this perrrdt shall be B FEE
W j dremed revoked.
LU CONSTRUCTION LENDING AGENCY SEISMIC FEE l
IherebyafRrmthat there is a construction lending agency for the perform- T _. ELECTRIC FEE
Z ...of the workfor which this permit is Issued(Sec.3097,Civ.C.) -
V O Lenders Name PLUMBING FEE xas�N
1– Lender's Address QTY. .MECHANICAL PERMIT FEE i`
O U I certlfythat l have read thisappllcationand statethatthe above information MECHANICAL FEE
CL iscorred.lagena,complywith all cityand county ordinancesand&ate law. PERMIT ISSUANCE FEES PAID:
} N relating to Wilding construction,and hereby authortu representatives of this -
} city to enter u Pon the abovcmendaned property for inspection purposes. ALTER ORADDTO MECH.
? (We)agree to save,hot smrdty an d keep harmless the City of Cup)) Date Receipt#
V
.8.irqt liabilities,N dgments,cants and nsea which ma any c AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
again nam City) ns lien¢. ting of til t. AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
S nature of Applicant/Contractor at EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUSM IALS DISCLOSUR
Will the applica nt or future bulldia occupantstomorhandlcharamous HEATING UNIT(TO 100,000 BM _ ttY Recel 1#
morrlalasciefined by the Cupertino unielpal Code,Chapter 9.12,and the rv_
Ilealt,and Safety Code Section 25532(a)? HrATING UNIT(OVER 100,00)BTU) TOT L.
No
IIIIheappllcant oes �
turee building occupant'use equipment ordevims VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which taut haNandous air contaminants as defined by the Bay Area Air
Quality Management District? BOILER-COMP QHP OR 100,000 BTU)
Yes n❑No yes No
read the hazamous materials requirements under Chapter 6.95 of BOILER
-COMP(OVE2100,000BN) ( B®
the California health&Safety Code,Sections 25505,25533 and 25534. I
understand that if the building does not currently have a tenant,that It ismy NEW RESIDENTIAL MECH. SQ.FT {{//
responsibility to notify theoccupant Ditto,requircnena which most be met Y �'' '
prlortoissuanceo(a CcAillateofO=pancy. {a`s//
Gh CZ
Owner or authurlmd agent DateTO ISSUEDBYC=s
OFFICE COPY