22826 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Buildinx Pro ect Identification PERMITNO.
Building Address:
/0117 ov, d ce .,ef 2252
nr• erre: one:
No Tr S 3 26 CITY OF CUPERTINOQBUILDING DIVISION
. Contractorsldarre: L ue.NDe: APPLICATION /PERMIT /v -7 - 6) 1
14""a r ifv / BUILDINGELECnUCAI PLUMBINC-MECHAMCAL CATEGORY CONTROL N
hit
Arcect/Engineer: Lic.Na:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Addrcu Po g, 2 SELL I'QtMITI55UANCE ❑ ❑ � ❑
LICF.NSIs CONTRACTOR'SunderDECent.f0 pt a/jam/
Ih[hSy on7OODffirm atiamlken3ofthe usiro dPe Chapter9(commen APPLIANCES-RESIDENTIALlngwis JOB DESCRIPTION
Beconsh in full
force anDlWect. the Butlnessand ProfeWone Code,and my L..
Branae Is In fuB force and effect. PANELS KCN Nee rsyA IPV
License Class 6 366 Lic.# N8�5 1 _ (1 Se,
D.104AL.1)hx Contractor L'f(�JG�.. e /)CQ Wt`I'�n c.�
ARCHITECTS ECLA TION 7014000 AMPS
q�q�uu 0 Z-) I understand my plaru shall be used u public records. OVER 1�AMS $/`SQ.Fr
E z() Licensed Pro(essianl SICNSELFiCTRICAL UTE R
< OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC
p., 2i Iherebya(firm that l am exempt from the Contractor's License Law for the / /
followleg matter. 70313,Business and Professions Code:Any city or !/ �/
1 Ot:.� TEMP.METER OR INST. /a d
p� countywhlchrequbesapen tto-mtmd,alter,Wproce,demoilsh,orrepalr
Oa anyatmc mpr dolts Wuane,alsomquimstheapplianlforwchpermitto POWER DEVICES
V -file a signed statement that he is licensed pursuant to if.provisions of the
w0 3 t� Conlractora License Law(Chapter 9(cone resdeg with Section 7000)of Diet.al3ofthe Businessand Pro(esslmesCede)mthat he 6 exempt therefromand SWIMMING POOL ELECTRIC
anVALUATION
S the basis for the alleged exemption. Any violation of Section 70)1.5 by any {} a
655 applicant tons perret subjects the applicant to a civil penalty of nM more than OUTLETSSWITCfIESFIKTURES "N'1 / ZOO
five hundred dollars(;.500). NEW RESIDENTIAL ELECTR SQ.FT. STORIES TYPE CONSTRUCTION
7 ❑I,as owner of the property,or my employees with wages as their sok
C < compensation,will do the work and thesWeture is not intended or offeredfor
❑ sale(Sec.7014,Busbea,and Professions Code:The Contractors License Law
does not apply to an owner of property who builds or improves thereon,and
e,5.. who does such work himself or through hisown employees,provlded that such OCC.GROUP RFS,UNITS
Improvements are not intended oroffered for sale.If,however,the Wild Ing or TOTAL: '
Impmvement6s dwithinoneyearofcmnpl&tb theowner-WBderwill have
thILItarden of Freeing that he did not build or improve for purposes ofsakJ. QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
LTJ L as owner of the properly,am exclusively mneraning with Ilconaed PERMIT ISSUANCE
conlractom m mretmn the project(Sce.7014,Business and Profession Cotle:
The Contractor',License Law does net apply to an owner of properly who ALTER-DRAIN&VENT-WATER(EN
Wilds or improvthereon,
es and who contracts for such ptpte s with a
egpUactar(s)licensed pursuant to the Contractors Llama Law. FEE SUMMARY
LJ I am exempt under Sea B k P C for this mason BACK FLOW PROTECT.DEVICE
•
DRAINS.FLOOR ROOF,AREA,CONED. SANITARY Y N Owner Date RECEIPT#
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCI;OOLTAK Y_ N_
®I hereby affirm that I have o imume of consent to spythemo m . RECEIPT N
cenlflate o(Worken'Comperwtlonlnsuranco eia certified copy thereof(Sec. GAS EA.SYSTEM-I INCAOU`ILM PARKFEE Y N
licy 3NOq Tab CJ / q
CQmpa y -./ RECEIPT#
m ane GAS IA.SYSTCMAVER6(FA)
! �s�'�glsyNy-j`sa) '- BNLDINC DIVISION FEES
M(Cemfled rap is hereby furnished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
CenlEed ropy is filed with the city inspection division.
CERTIFICATE OF IIXEMPHON FROM WORKERS' GREASETRAP - PAID
URA
COMPENSATION INSNCE
(fhb section need na W completed the permiSURA,is for one hundred dollars SEWER-SANITTARY-STORM EA XpFI. Date Receipt"!
m00>nrlm.) WATER HEATER w/v75Nr/F).ECTR ENERGYFEE Y N—
I conify that N the pertereasnce of the work forwhlch this permit is issued, WATER
I dull not empty any person in any manner at ss to berome subJM to the WATER SYSTEM/,TREATING
Workeri Compensation Love of Gllforn6. Date PAID '
0 Z Applicant Date Recei 1N
Z O NOTICETO APPLICANT.If,after nu king this CertlfWle of Exemption,you NEW RESIDENTIAL PLMB. SQ}T.
should berome subject to the Workers'Compenatlon prov6lonofthe Labor TOTAL:
N Code,you must forthwith comply with such provialmomthls pemdt,hallbe BUILDING
W'j deemed revoked.
W p CONSTRUCTION LENDING AGENCY SEISMIC FEE
S I hereby affirm that there 6a construction lending agency forth,perform SEISMIC
ELECTRIC FEE
D Z anceoftheworkfo-which Nis permit 6issued(Sm.3097,CIv.C.) TOTAL; ACs/
U O I.Mc,'.Name 4 PLUMBING FEE Ado
LL F Lenders Address QTY.I MECHANICAL PERMIT FEE MECHANICAL FEE
O W Iconilythat l have readthisapplfationam statethatthe above Information
S isrorrett.Tagreetocomplywith all cityand muntyordiname,and statelaws PERMIT ISSUANCE FEES PAID,.
W relating to building ronstruction,and hereby authorise repenestatives of this _ -
Z city to enter upon the above-mentioned property for inspection pu rpoms. ALTERORADDTOMFCH. DRIC R2CC1 fl1
— (We)agree to,save,Indemnify an d keep barrettes the City of Cu pedlno P
against liabilities,judgments,coats and expenses which may In any way accrue AIR HANDUNG UNIT(TO 10,000 CFM) SUBTOTAL'
against said City In o sesequence of the granting of this permit,
- AIR HANDUNGUNIT(OVER IO,WOCFM) CONSTRUCTION TAX
Signeture of Applicant/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Willthcappll st or future building oasapantstoreorhandla haaardous HEATINGUMT(TO100,0DOBTln Date Recei t#
matcr(al as defined by the Cupertino Municipal Code,Chapter 9.17,and the
ITealth and Safety Code Section 75537(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL
Rill
2Na
Ill the appllant cur future Wild Ing part use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit harardom air rontareleanls as de0ned by the Bay Area Air
. Quality Management Distrid? BOILER-COMP Of 11?OR I WMp BTU)
ftkv
4 the o
havernia ealthhe a frty Code,
rcons 2555,2SS3 aChapter.1 of BOILER-COMP(OVER 100,000BN) Lc
lhn California to Health h Sa(ety Code,S.t i rm7tly h,25.t,and 755M.I (3 y, N�
understandytontify the occupant
note requir haves tenant,thatb met NEWRESIDENTIAL'MECH. SQ.f•T. f �J�r
responsibility to notifytheoatte 9f o(therequlremenb which=at be met
prior to issuance ofaCerli(late ofOau rye
ncr orahDate
orlmd agent
ISSUED BY:
TOTAL:
OFFICE COPY