20032APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Project IJendfkatl®
Bu Ing /" �' / r
PERMIT W.
20032
Own 40: IyyPPeo
-- -733
CITY OF CUPERTBVO-BUILDING DIVISION
APPLICATIONIPERMIT
BUIL.DINGELECTRICA UMBINGMECHAMCAL
,
3
C.ntrs era//y/J/�fy_= Lk'Na..
r -' I
CATEGORY
CONTROL.
Architect/Engireem IY No:
.QTY'. ELECTRICPERMFF FEE .
BUILDINGPERMIT•INFO
PERMTIISSUANCE
❑ O ❑
LICENSED CONTRACTORS DECLARATION s
[ hereby affirm that l am lkmsed under prwlalom of Cha peer 9(comnne
Tngwith Semon 7000).! Dh,hion 3 ofUe Budness and prcfe .Code, and
APPLIANCES -RESIDENTIAL
JOB DESCRIPTION
-
liceneelaInft;deffect
PANELS
,
Date_ 4 ontrador
tr••l4'-�s"/--'.lH,�
201-tf)flp
iNITECI' fit,4,ge N
YYFypltmclshall
Iumenm6e unedu public record&
OVERIOOOAMPS
SQ. Fr. FLOORAREA
$/SQ -ET.
SIGNSI]FLTRICAL
Licensed Profmbnal
-
SPECIALCIEtCUIT/M
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Cocarecter's Lkeese Law fee the
following reamn.(Sectlon 7m15, Business area Profmlons Code: Any dty or
o ntywhk requlmaper wmms d,aher,impmve,demoash.ormper
=M ORPO ST
anyam,turtprbrtolteissuance, aleorequlmiheappaantfaeumpermitto
Ole a signed l tement that he L homsed pursuant to the proalby of the
POWER DEW r
r
r
sxnNMNG IW
Contractor's License Law (Chapter 9 (en.eing with Serino 7(00) of DIA-
aon3 of the Business and Pmfembv Cade) or that he In exempt therefrom and
VALUATION
'tk hnb for the alleged exemption. Any violation of Section 7MI5 by any
apphantforaperm wbjeclstheappB ttoatl 1penakyofna omthan
.�
Ove hundred dollars (9500.
❑ L as owner of the property, or cry employees with wages as tt a sole
RESID EN
STORIES
TYPE CONSTRUCTION
compe uxelon,willdo the wale and the stmmare b not Wended or offered for
Bale (Sec 7044, BW imm and Pmfemiom Code The Contractors License Law
Pj
dace not apply to an owner of property who Wilds or impnwn thereon, and
whodonauchworkhm lfcethr.gh Mlsownemploym,p.Wv dthatwch
OCC. GROUP
RIS UNITS
lmprovemenroarewtlntmdedorofferedfwm)e. U,howtoeethe Wildingor
TOTAL: -
Impmvement iasol In oneyuracomplelbrs the ownerbW WerwW love
-
t nien of prewingthat he did not Wild orlmprove for purpose ofsalle.).
"I, as owner of the property, am exch.Ncly contracting with arensed
contrators to mrulmct the project(Sae. 70K Boamem and Pmfeaalons Code:
QTY, PLUMBING PERMIT FEE
FLOODZONE
APN
PERMIT ISSUANCE
The Contractor's License Law don notapply to an owner of property who
builds or imp. thcaon, and who contracts for eucb pM"whM.a
tctorb License law.
u¢actor(O Orenaed punt to the Cmn
ryuan
LJI am exempt under Sec B & P C for thio reason
ALTERI)RAIN &VENT - WATER (EA)
-
FEE SUMMARY -
BACK FLOW I'RCYI'ECT. DEVICE
OUTSIDE FEES
DRAINS FIDOR,ROOF, AREA, CONI).
SANITARY Y. N_
RECEIPT If
Owner - Dee
WORKMIAN COMPENSATION DECLARATION
❑I hereby affirm that I have • cemfiate of consent m sea-Inanre, o a
certiflate of Workes'Compevelaslraurtnce ce a mrdfled mpythetmf(Sec.
3800, Tab CJ ,
Policy #
AX7I1RES 7'ER TRAP
SCHOOL TAX Y_ N_
REO9PI If
GAS EA. SYSIFM-t ]NC.t OUTLETS
PARK FEEY N
REC'FIPT I
CAS EA. SI'S"TF]sI-0VER A (EA)
Com ray
- BUILDING DIVISION FEES
Certified copy is hereby fumished. "-
ert lfied ropy i, filed Mth the my oupe tion division.
GREASE/ENDUSIRL WASTE INTERCEPTOR
PLANCHECK FEE
GREASE TRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
PAID
COMPENSATION INSURANCE
(Thlasetbn need not be completed Rthe permit a for one an
hundred doa
SEIVFR-STOW-SNRM EA. 2OQ+C
Dale Reoel t#
'
WATER HEATER W/VFM/ELECTR
ENERGY FEE Y N
(SI00orlm.)
I certify the U the performance of thewmk forwhic'h this permit Is blued,_
WATER SYSI3M/TREATING
I shallnot employ any pensmt b any manner m n to bemma ,objet to the
Workers' Co rpematbn Law. of California. Dee
PAID
NEW RESIDENTIAL PLMB. SQFT.
Applicant
NOTICE TO
Date Remi tri
APPLICANT: If, after making this Certlrlateor Exemption,you
ahould become subject to the Wurker:Compewtlon pmwloru o/toe Labor
TOTAL:
BU ILDING FEE
Code, you mut fmthwlth comply with such pmvtslom orthts permit. l be
deemed revoked.
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is aco4mcthm lending agency for the perform
ance of the work for which thio permit es toned (Sec. 3097, Civ. CJ
lamer. Nan,'
[,coos Addmes
Irxnt. INnertocreadlMsappllayandcotatyordihexere and
nd stateless
bmrr c lagrteto canplywlth alndhreb muntyoNUsnm andaetelaws"
TOTAL
ELECTRIC FEE
PLUMBING FEE
QTY. MECHANICAL PERMIT FEE
MECHANICAL FEE
FEES PAID:
I'FRMIRISSUANCE
im,andhereby authorize rcprexnpurpo of this
relating to building the
d ( to Wr)aeree to teabavo- rationed property (a inspection purposes.
(We) .ghee to mare, sole an d keep hemam the City of Cupertlro
-
ALTF3i OR ADD TO MiECFI.
Date Recei ted
AIR I3ANDLING UNIT CEO 10,010 CFM!)
UBTOTAL:
SUBTOTAL-
agenew Utica, dud en mkaem expensawhichmeyinanys yamue
.9
. alts dC lie ft MU .!this m
Ra I B a
U,E lR
AIR I-IANOI-TNG unrrr rovER lo,arnctT,n ''
CONSTRUCI70N TAX
Slgneur of Applicant/Contractor Date
EXHAUS'rHOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERMLS DISCLOSURE
HEATING UMT(TO IW,0006RJ) -.
Date Recei [N
Wal[he applicant or future Wading oovpant store or handle havrdous
m terbl as dented by the Cupemro Mu Ndpal Code, Chapter 932 and the
,
IDEATING UNIT (OVER 100,000 BTU)
TOTAL:
'
Health and Safety Code Semon 25532(a)r
❑ Yes r) No
VENTILATION FAN C31NCLE RFS[))
ISSUANCE DATE
Will the applicant or future Wilding occupant use equipment or devices
which ."t hazard., air mntamdrunb as defined by the Bay Area Air
Quality Mlanegan,nt Dutr{d7
YenNo
4Yaveread heft a'3vamae a req rem nsunderChaper6.95o(
gOn co{pMPOOHP OR 100,0(0 BTU) -
BOILER -COMP (OVER 100,0110 RTI)'
the California Health & Safety Code, Sections 755(6, 25533 and 75534. I
underetand that if the Wading don not currently have a tenant, that It 6 my
responlbaty to notify thi occupant of the requirements which muss be met
NEW ELSE DEMIAL MECFL SQFr
prioraCe fiat foavparcy.
Own Zth&Iza a cot date
ISSUEDBY:
TOTAL:
OFFICE COPY