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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Praia Identification
PERMITN24352
Building Aaa.e: � v
05 n e✓3/' Daviso
4 3 5 2
cors sent: one:
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CITYOFCUPERTINO-BUILDING DIVISION
APPLICATION I PERMIT
BUILDING-ELECTRICAI PLUMBINGMECFIANICAL
�,l _01?
It Ali (•••
cantngors sent: ut.No:
T a50 r
CATEGORY
CONTROL Y
Architect/Englnrer. Lie. No:
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
��I
Addrmse: O WX—
El ❑ El
FERMITISSUANCE
CONTRACTOR'S DECLARATION
Ihereby affim, that I am Bceneed under provisions ofChapler 9(commanc
ingwithSeMon700@of Division 3 oflhe Business and ProfessionsCode, and my
license le i=11 a affect.
LlcenseC ® LICY X903
Dale Contractor ��`y/
ARCHITECTS DECLARATION
APPLIANCESRESIDEMITAL
- JOBDESCRETION-
V
PANELS
701-I OOO AMI+S
OVER1000AMPS /
SQ. FT. FLOOR AREA
� �pI
.0 ! '. ,. Lam. E ,D
S/SQ.FT.
JJs�7/
IuMentand my pLtu shall be used as public records.
Licensed Professional
SIGNS ELECTRICAL
OWNER -BUILDER DECLARATIONSPECIALCEtCUIT/M75C
I herebyafBrmthatl amexempl fromthe Contractors Linnse Law(orthe
/�1 L�i.J n II i� UTE
`,ej
R
TFd.{p METER OR POLE INST.
following reason. (Section 7031.5, Business and Professions Code: Any city or
countywhich requires a permit torous ruct, alter, Improve, demolish, orrepalr
II
anystmtlure prior to its bursae, also requires the applicant for such permit to
file a signed statement that he Is licensed pursuant to the proviskmat of the
Contractor's License Law (Chapter 9(comemenclng with Section 7000) of Divi-
ivi-
Mon
Mona of the Business and Pro(essimu Code) artful he b exempt therefromand
the Neale for the alleged exemption. Any tviolationcivi of Section 7031.5 by any
app Rant fora permit subjects the applicant to civil penalty of nal came than
flue 1, a.o demodollarthepr).
I, a owner of the property, or employees with wages their ease
POWER DEVICES
DATE
SWIMMING POOL ELECTRIC
OUTLETSSWITCHFSFIXTURES
VALUATION
/ a'� ��a
O`
NEW RESIDENTIALELECTR SQFT.
STORIES
TYPECONSTRUCTION
he
competwtlon, wllidothe work and lhestrodure b not intended or offered for
r
sale (Sec. 706X, BusN,eas and Iarofessloru Code The Conlractore Llceme Law
-
doesnotapplytoanownerofpropertywhoWild. or lmprowa thereem, and
who don such work himself orlhrough hisown employees, provided that such
OCC.GROUP
RES. UNITS
Improvements are not intended oroffered for sale. If, however, the building or
TOTAL:
Improvement hsold within oneyearofcomplelion, the owner-bullderwill have
0A.Ifurden of proving that he did rwt build or Improve (or purpose of sale.).
Lj I, as owner of the property, am exclusively cavtnging with In,au ed
contractors to construct the project(See. 7614, Business and Professions Code:
QTY, PLUMBING PERMIT FEE
FIppD7pNE
APN
PERMIT ISSUANCE
The Contractor, License Law don not apply to an owner of property who
builds or Improve thereon, and who contracts far s with a
for such ploje
cgpjractor(O Bernard punuanttothe Contrador'a License Law.
IJ I am exempt under Sec. B & P C (or this reasonOUTSIDE
--
ALTER -DRAIN &VENCWATER [FA]
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
FEES
DRAINS FLOOR ROOF, AREA, COND.
SANITARY Y_ N_
RECEBT Y
Owner Date
WOR KMAN COMPENSATION DECLARATION
01 hereby affirm that I have • certtllate of consent to self -Insure, ora
mdiRateofWorkeri ComppemaOonlmunnmaranrtifledmpythemo(late.
Polk IabC3' n/O / � a/
r.L 'T
F'0(Tl1RES PFR TRAP
SCHOOL TAX Y
R_ N NX
GAS EA.SYSCEM-I INC.X OUTLETS
PARK FEE Y N
RECEIPT '
CgTp. a�
Com y ( L(/s �+. /
nee l e copy is here with
Ned copy b filed with the tlty Inspection division.
city
GAS EA.SYSCEMAVER6(EAI
BUILDING DIVISION FOES
GREASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECKFEE
,
CERTIFICATE OF O(EMP('ION FROM WORKERS'
GREASETRAP
PAID
BEWER-SANITARY-STORM EA 200Ff
COMPENSATION INSURANCE
(Thisrection need not M completed if the permit bforone hundred dollars
Date Recei t#
WATER HEATER W/VENT/ELDCTR
ENERGYFEE Y_ N_
(5100).'1..)
I certi(ylhat In the performance of the work forwhich this permit Is issued,
WATIRSYSIEM/TREATING
I shall not employ any person In any runner n n to became subjectto the
Workers' Compensation lawn of California. Date
PAID
Applicant
NOTICE TO APPLICANT: If, after nuking this Certificate of Exemption, you
should became subject to the Workers' Compensation provbiom of the Labor
NEW RESIDENTIAL PLMB. SQ.FC.
Date Recei t#
TOTA '
Code, you must forthwith comply with such provisions orthis permit shall be
dreamed revoked.
CONSTRUCTION LENDING AGENCY
BUILDING FEE
.
SEISMIC FEE
I hereby affirm that there is a construction lending agency for the perform-
an. of the work for which this permit Is named (Sec. 3097, Civ. CJ
lenders N.
Lender'sAddren -
I certifylhatl have read this application and statethat theabove Information
beamed. lagreetocomplywlthalltltyandcounty.Ninanonandstatelawe
TOTAL:
ELECTRIC FEE
PLUMBING FEE
OTY. MECHANICAL PERMIT FEE
MECHANICALFEE-
PERMIT ISSUANCE
FEES PAID:
relating to building construction, and hereby authorize represenlativn alibis
city to enter upon the above-mentioned property for inspection purposes.
(We) agree to save, indemnify an d keep harmless the City of Cu pertbm
against liabilities, judgments, costs and expenses which may in any way accrue
ALTER OR ADDTO MECH.
Date ReCel t#
AIR HANDLING 11NIT(CO 10,000CFhU
SUBTOTAL:
agalrst.aidC In sequences t granlingoft permit
AIR HANDLING UNIT (OVER 10,000CFM)
CONSTRUCTION TAX
cAIL%U5rHOOD(W/DUCTS
CONSTRUCTION TAX PAID:
gvtureof A'Raxm1Contra a te/
HAZARDOUS ATERIALS SCLOSURE
. Will the applicant orfutum building occupant store or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.1 7, and the
Health and Safety Code Section 7S532(a)7
❑Yes No
/ HEATING UNIT (TO 100,000 BTU)
'Date Recei t#
HEATING UNIT (OVER 100,000 BTU)
TOTA .
VENTILATION FAN (SINGLE RESID)
ISSUANCE DATE
Wlllmit the applicant Nre building occupant use devices
the Bay Area Air
whiaheMlhagamenteasriet? contaminants as defined by the Bay Area Air
.,Quality Management Wtrict7
Yea No
BOILER -COMP DFIPDR 100,000 BTV)
BOILER -COMP (OVER 100,000 BTU)
have read the hazy ous materials requiremembe under Chapter6.95 of
the California Health & Safety Code, Sect ions 75505,75533 and 75536. I
undentaand that if the building donor currently have a tenant, that it b my
n
resp6J
prior to Issutyce of aCeheocte of of the requirements which must be met
prior to Lwuanreofay the crupa tofthe reqOccupancy
B 6"
OI/
VV LI r
NEW RESIDENTIAL MEIN. SQ.FC
cr
ISSUED BY:'
Owner or authorimd agent Data
TOTAL:
OFFICE COPY