21188 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Project Identification - PERMIT NO.
Building Addles: (�
3 St✓+sCr� lv� G o IT JS
one: A
CITY OF CUPERTTNO-BUILDING DIVISION
C °''•� S ' tide ° �-Il APPLICATION I PERMIT
'/�J BUILDINGELECTMCALPLUMBINGMECHANICAL CATEGORY CONTROLN
ArchitectEngineer. LIB No:
QTY ELECTRIC PERMIT',.` FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE '�s� I� ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
T hereby affirm that l son Bcensad under provisions of Cha plot 9(mmmen APPLIANCES RESIDENTIAL JOB DESCRIPTION
IngwlthSmi0n7000)OfDivision3 ofthe Businessand ProfesslonsCode,and my
liana b in full force and effect. PANELS
License Clam LIc.N
Date Contractor
ARCS iECTg DECLARATION 701-1"AMPS.
�7 l understand my plans shall be used as public records OVERIMOAMPS SQ.FT.FLOOR AREA S/SQ.FT.
CO
dg Licensed Professional SIGNS ELECTRICAL
<� OWNER-BUILDER DECLARATION SPECIALCIRCUT/MISC '
71.., E 1herebyafflrmtiat lamexempt from the Contractors License Law for the
following recon.(Section 7Ml5,Business and r-r fessions Code:Any city or
O' TEMP.ME'I'CR ORPOLE INST.
r couany ty stm m rcqulresa permit
cealsmtsuct,esthe aprovcdemouor ch,orto
anyasiped taismeibhat hely ebensed realhe nolle provisions
permit e POWER DEVICES
0 floe a stgned License
that he b licensed pursuant to the provisions of the
�3µ� Contractor'sLlceveawChaper9(mmmendngwith&Section SWIMMING POOL ELECTRIC VALUATION
O� sion3ofthe Business and ProfemlomCode)mthat hell exempt therefromand
S^ the basis for the alleged exemption. Any violation of Section 7ML5 by any
65 a licant for permit subjects theapplicant to a civil mal ann more than OUTLETSSWITCfiESFl%711RF5 y7
PP Pe Mpe ty 8 Ou C�
c. flue hundred dollarshepr. NEW RESIDENTIALELECTR SQ.ET. S'TOIUFS TYPE CONSTRUCTION
GG11 �n ❑I,as owner of the property,or my employees with wages r their sole
compensation,wllldotheworkandlbe structureCode:The
Intended or ot. for
M sale(Sec appy Business and f property
Code:TM or Impn wt License law
�$ don not
assuchtoanowner ofproughhisobuilds nemporlmprovesthereoRand
P• who doneuchworkMmselforthrough hlaownemployen,provided that such OCC.CROI,' RFS I1Mf5
Improvements am nm Intended oroffered formic.If,however,thebuilding or TOTAL:
Improvement bsoldwithlnoneyearofcomplelbn,the owner-bullderwill have -
theburdenofprovingthathedidnabuildorimprove for purpose of sale.). QTy, PLUMBING PERMITFEE FLOODZANE APN
u 4 a•owner of the properly,am exclusively ronlratllng with licensed p r IT ISSUANCE
contractors to construct the project(Sec.7094 Business and Professions Code:The Contractor'•License Law does na apply to an owner of property who ALTER-DRAIN h VENT WATER(EA)
builds or Improves thereon,and who common, for such pM lojewith a
cqDI[+dons)licensed Funguses the Contractor's License Law. RACK FLOW PROTECT.DEVICE FEE SUMMARY
U I am exempt under San mason BACK k P C for this masT-^ t
OwnerDate DRAINS FLOOR P ND./� Tj I-' ,I ISA N0 a N
RECE
WORKMAN COMPENSATION DECLARATION FDCEURESPER TRM ._ . �I 1 X Y N
❑I hereby affirm that'I have a certificate of consent to self-insure,or a Z RFLEBef N
certificate ofWorkers'Compensation Insurance ora mrti(led copythereof(Sec. l e
3800,lab C.) GAS PA.SYSTEM-IWC OUTLETS Y_ N
Ponos GAS FA.SYSTEM-OVER 4(PA) ECEB'T N
Cn _ BUILDING DIVISION FEES
Certified copy b hereby furnished. GREASE/INDUSTR WASTE M}RCEI'TOR PLANCHECICFEE
❑Certified copy b filed with the city Inspection dNI.I.r. _
CERTIFICATE OF E(EM PTION FROM WORK ERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-yAN1.1•ARy-STORM En zooPl, Date Recef IM
(This stolon need not be completed If the permit is fororm hundred do:oan
(81I cordlyth WATER HEATER lir/VENT/ELECTR ENERGYFEE Y N
Ill not that emIs ploy
any person
ain anynce of manneworkr
so as,to b cornN.permit tc booed, —
I shall not employ any pease.in any manner eo es to borons subject to the WATER SYSTEM/TRFATING
Workers'CompenseHon laws e(Gllfomla.Date PAID '
Z Z Applicant NEW RESIDENTIAL PLMB._SQFT. Date Remi t#
O NOTICE TO APPLICAM':[f,after msking thbml
Cflcele of Exemption,you
Hshould become subject to the Workers'Compemwtlon provisions ofthe Labor - TOTAL:
N Code,you twat forthwith comply with such providers or this permit shall be BU NG FEE
LU j deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
O. thereby affirm that there in a construction lending agency forthe perform ELECTRIC FEE
ZO an ofthe work for which this permit is Issued(Sec.3097,Civ.C.) TOTAL: a 0-
U _ Lender's Name - - - PLUMBING FEE
LL F Lendae.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O LU
lndifythatlhavereadthbappolateenandstatethatlheabove(nformetlon
(U Lscormn.I a gree tocempoy withal)city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
>. W relating to building construction,and hereby authorize representatives afthis
H Z city to enter upon the above-mentioned property for impmion purposes. ALTERORADDTOMECH.
(We)agree to save,Indemnify an d keep harmless the City of Cu ped Ino Date Recel t#
V against llabillties,judgments,casts and expenses which may In any way accrue AIR HANDLING UNIT TCO 10,000 CFM) SUBTOTAL:
agalutseld Cityi nem�enca ofthegra ga this permit. -AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Slgradnn.f Appll /Con nor me EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID: -
BAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfuture building oavpant store or handle hazardous HEATING UNIT(TO 100,030 BM DBIC RCcei (#
'materia:as defined by the Cupertino Municipal Code,Chapter 9.1 7,and the
I lealth and Safety Code Session 7S537(a)7 HEATING UNIT(OVER IOO,OW RTI, TOTAL: 11 q.0 6
❑Yes No
Will theapplinnt Moo building occupant use equipment ordevices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit harardous air contaminants as defined by the Bay Area Air
Quality Management District? BOILER-COMP DEEP OR I170,IX0 BTI) AJD
Yea ❑No
haveread the h &Safer Code,Se rcons 255 5,2553 aChapter.1 of BOILER-COMP(OVER 100,000 BTU) T
the
erstandt Health hildingoes not currently
haven tand755M.] Nr,�sP
understand that notify
the occupant
nottmrteuir heats with that It lsct NEW ItESIDFN77ALMGCH. SQ.Ff. sR'.!'r
responsibility Issuer c of a Certificate
ofocflhercquiremente which must be rant
prior to issuance of a Certitlute of Ocevpanry.
co o'r�ycu�Jm�gvpy
Owner or authodmd agent Data TOTAL: ISSUED BY: �L�4/4'10�z`LJ a''a-v.aae.
OFFICE COPY