19710APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Pro'ea Identification -
B °°ding Address°
2-
3Z. sere (Z S�G
PERMITNO.
19710
Phone:
wnera(p�,�rsyyro
-
CITY
OF CUPERTINO- BUILDING DIVISION
APPLICATION / PERMIT
BUILDINGELECTRICAI .I'LIJMBINC- Mif_IIAM.
APPLIMII A
cb��ntr.vmr.Name:. Lie. No:
r:C7a,sc V 6 4fA%eV e` 34
CATEGORY
I
CONTROLS
AichltM /Engineer. Lk. No:
.G
QTY
- -4 a" - -
, ELECTRIC PERMIT
PERMITISSUANCE
- ' .
%,F EE ,,,,
1,2t(p
. I
'`cal" BUILDING PERMIT INFO „
Address: / —z8 ��
�' ` El -
therebyLICI :NSEDCONTRACTOR'SDECLARATION
df irmthat l am licensed under provisions o fChapter9(comment
Ingwith Section 7(IW)of Divlslon3 ofthe Businessandprofesslons Code, and my
Bcense is In s in a effee.
License Cmn_Licx %
Date 7���Tg ace _
ARCHITECD DEC 1
.I understand my place shall be used u public records.
LimnaM Professional -
OWNERe BUILDER DECLARATION
T hereby afNmtlut lam exempt from the Contrector's Wmnse hw for the
following reason. (Section 70315, Business and Professions Code: Any city or
muntywhkhrcqulmsapermittommtmct ,alter,impmve,den it h,orrepair
anystructure prior to its Issuance, also rNulrealhe applicant for such permit to
file a Signed statement that he is licensed pursuant to the provisions of the
Contractor's License Law (Chapter 9(Momencing with Section 7000) of Divl-
.too3 of the Business and Perdresioce Code) tribal he m exempt therefron.rd
the balm for the alle ed e.em ion. An violation of Section 7031.5 an
applicant for a permit Subjects the applicant to a civil penalty of not moothan`
five hundred dollars ($500).
I, as owner o(the property, or my employers with wages as their axle
compensation, widdo the work and thestrocture m not intended or offered for
.1. &c. 7614 Bu,mos, and Professlom Cade: The Contractors License Law
cl.r.mtapply loan owner of property who buildsor lmpmse; thereon ,and
who doessuch work himself orthrough his own employees, prevldecithatauch
Improvements am not Intended orotfurcd for asks If, howevor,thebullding or
Improvement resold within oneyearofcompietlon, theowner- builderwill have
t eden of proving that he did not�bund or knprove for purpose of sale).
�I, as owner of the property, am exclusively contracting with licensed
mntractonto construct the projM(So. 70K Beeonessand Professiece Code:
The Contractor's License Law does not apply to an owner of property who
bu
Wild, or Improve. thereon; and who contract. for such prejecb with a
cg0_t[actor(a) licensed pursuant to the Contraemr's License Law.
IJI am exempt under Sec. B k P C for thin reason
APPLIANCES-RESIDENTIAL
JOB DESCRIPTION
�`^ `' ' j I
_'� t ��rLCd Nle
PANELS
UP TO 200 AhMi
201.1000 AMPS
=OVER1000AMPS
5Q. FT. FL000a1�- 2rAREA -
LII�Z
T
$ /SQ. FT.
SIGNS ELECTRICAL
'
SPECIAL CrRCUIT /MISC
TEMP. METERORPOLE INST.
POWER DEVICES
rr
SWIMMING TOOL HLEC C
OIJILETSSW17C1 FI
VA UATION. D
(J
NEW DENIYA
SIti1RI
1\
TYPE CONSTRUCTION
\�t( h
V l�.J
QTY.
EUINBINC PER
TO AL:
IT
FEEd'
.OTC:
f
GROUT'
y[
RES IJNI'I'S
/
„•''1, „°
PERMIT ISSUANCE -
ALTER -DRAIN k VENT - WATER (EA)
Z
FLOOD TONE.
-'
APN
BACK FLOW PROTECT. DEVICE
OUTSIDE FEES
DRAINS- FLOOR ROOF, AREA, OOND.
FIX'1URF_S PER TRAP
Iy
^1 a
SANITARY Y_ N_'
RECEIPT x
Owner
-Date
'i WORKMAN COMPENSATION DECLARATION
,c[]I hereby affirm that 1 have o I n urne of consent to copy o (S a
,certificate of Workeri Compensationlceurance ors certified copy thereo ((Sec.
- XPolic Gb C)
Policy
SCHOOL TAX Y_ N_
RECEIPT x
GAS F.A. SYSTEM -1 INCAOUTLEfS
PARK FEE Y N
RCCEB'Ip
GAS EA. SYSTEM- OVER
Coco any -
BUILDING DIVISION FEES
�Cerlffled copy IS hereby furnished.
'
�CenNed ropy m /lied with the city inspection divlslon. �
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION
(This section need not be completed the INSURANCE
ot Pcom ATIONINSURANCE
it m torone hundred dollars
($100)orless)
I certify that In the performance of the work forwhich this penniHassued,
Worker of employ any person In any manner w as to become subject to the
n'Compeceatlon Laws of California. Date
Applicant
CREASE /INDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE
PAID Z—/ Lb--it
Date Recei tit
GRFASETRAP
SEWER- SAMTARY -STORM EA. 200FT.
WATER HEATER w /vENr /eLECTR
-
ENERGYFEE Y_ N_
PAID_ ` ➢ Z
Date Recei tH
�.UY
-
”
WATER SYSTEM /TREATING
NEW RESIDENTIAL PLMB. SQFr.
NOITant
NOTICE TO APPLICANT: E, after making thin Certificate of Exemptkn, you
Should beerrk subject to the Worke m'Compeceation provisions of the Labor
Code, you mu at font hwith comply with.uch provisions or thin permit shall be
courted revoked. -
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency teethe perform-
ante of Lomlerl Name foryyy�yy��thin permit (Sec. 3097, GIV. C)
Lenders Name O �-' -
Lender's Address Yom—
leertilythalhave rc`aTthmapplicallonand <ate that theaboveleformatfon
bmrrect lagreeto complywfthallcityand rountyoNlnanm and elate law.
Mating to building mmtructlon, and hereby a. horim representatives of this
city to enter upon the above - mentioned property for Inspection purposes.
„(We) agree to save, indemnify an d keep harmless the City of Cu panino
against liabilities, judgment., co and expenses whichniymatywayaceroe
u ( the grunting of thle ermlt
-
TOTAL:
G
x
BUILDING FEE
7s�i
SEISMIC FEE
(�(
TOTAL:
,e��
r,W
ELECTRIC FEE
00
QTY.
-
MECHANIGALPERMIT'
FEE
PLUMBING FEE
L
ZI
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID:
'
ALTERORADD'TOMECH.
,
Date Receipt#
AIR HANDLING UNIT (TO 10,000 CFM)'
^
SUBTOTAL:
AIRHANDLINGUIMT(OVER10,000CI7,I)
CONSTRUCTION TAX
ratureot pit /Contractor a
pit MATERIALS DISCLOSURE '
Will eapplicant or future building occupant stormor handle hazardous
mat I as defined by the Cupertino Municipal Code, Chapter 9.12, and the
I lealth and Safety Code Section2S532(a)7
❑ Yes
Will the appllcarildF futum building occupant use equipment or devices
which emit hazardous air contaminants as defined by the Bay Area Air
Ouality Management Dutrigt 7
'fi 1 Yes p
haveread theh to Soct I25S05, under Cha 5346.950(
il theo does not currently have tenant that It Is
lfytheo tof the requiremenlswhkh must be mot
(' Occupancy.
ow ebuilding Safety Code,otcurrently have a tand25534.L -
Da IAUST HOOD(W /DUCT)
CONSTRUCTION TAX PAID :
HEATINGUNIT(TO1e0,000871)
Date - ReCei tit
HEATING UNIT (OVER 100,060 BTU)
TOTAL:
s
VENTILATION PAN (SINGLE RESID)
-
ISSUANCE DATE
:U ISSUEDBY
BOILER -COMP (3HP OR 100,000 BTU)
°OILER- COMP (OVFR 700,000 BTU)
NEW RESIDENTIAL MCCFL �, .I7.
gent te
IOTA L:
OFFICE COPY