24024APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT,PEN ONLY
Building Project Identification
Bullcling Address: e 6.� ,y. ^l. 'u^\ \f����
a
PERMITI•f(L 4 0 2 4
Z
wnera one:
nn A
CITY OF CUPERTINO- BUILDING DIVISION
APPLICATION / PERMIT
BUILDINGELECTRICALPLUMBING- MECHANICAL
-
APPLICA A
-.
�Z Z
cnrd1 '
� C/j ➢x
CATEGORY CONTROL N
°s
Archlted /Engineer. Lic. NO:
.` ):'ELECTRIC PERMIT
'BUILDING PERMIT INFO'
Address. -
PFRhITISSUANCE
❑, ❑ ❑
- LICENSED LICENSED CONTRACTOR'S CLARATION
I hereby all(. that l am Hcame! under provisions of Chapter9(commenc
Ingwith Sedton7(X0)Ol D(Nsion3otthe Busiressand I miesslonaCode, and my
Lt.ie In full (prcGy� cited.
License Clad `—•? o r Y "t�l�f ..
Date GOnhddOr
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed I'm essiol
v -
OWNER - BUILDER DECLARATION
Iherebleaffirm 'hat I am exempt from the Contractors Llcerm Law for the
following Mason. (Section 7MIS, Business and Protessloro Code: Any city or
countywhich requires a perrok to construct, alter, Improve, demolbh,or repair
any atmcture pnorto lls WUance, alsorequiresthe apphomfa such permin°
file a signed statement that he b licensed pursuant to the provisions of the
Contractors License law(Chapter 9(commencing with Se Man 7000) of Divi-
lion 3 ofthe Busineesand Professimet Code)orthat he b exempt therefcamand
the basis for the alleged exemption. Any violation of Section 7031.5 by any
applicant fora permit mbjeds the applicant to a dAl pemlty d nu more than
five hundred dollars ($SM.
1711, as owner of the property, or my employees with wages ae their w
wk
compensation, will clothe work and thestrudure is not Interceder offered for
sale ( Sec. 7044, Busmen and Professions Code: The Contractors License Law
does not apply to an owner d property, who builds or Improve thereon, and'
whodoessuchworkhimselforthrough his own employees, provided that such
improvemonbare not Intended or offered for sale. Khowevegthebuildingor
improvement bwid withlnoneyearo fcompletiomtheowner- bu0derw111 have
ft-tiudenofproving that he did not build orlmprove for purpose ofuls.).
L_j L as net of the property, am exclusively contracting with licensed
contractors to corstrud the projM (Sec. 7064, Business and Professions Code:
The Contractor's License law does not apply to an Owner of property who
buids or Improves thereon, and who comrade for such p(ojeds with a
op4ado4s) licensed pursuant to the Contracore Lkanse Law.
LJ I am exempt under Sec. B & P C for this reason
APPUANCESRESIDENTIAL
- JOB DISC ON
1� ✓
PANGS
-
201- 1000AMPS
OVER 1000 AMPS
SQ. FT. FLOOR AREA 5 /SQ. FT.
ve
SIGNS ELECTRICAL
SPECIAL CII4CUIT /MISC
TIME. METER OR POLE INST.
-FINALE
POWER DEVICES
SWIMMING I'OOI, ELECLRIC
-rE ON
OUTLE7SSWITCHFSF7X'1'URFS
NEW
NEW RESIDENTIAL ELECTR
S$ORIES -
TYPE CONSIRUC'I'ION
- -
l3CC.GROUP
RES.UMTS
QTY.
TOTAL:
",:'; PLUMBING PERMIT �c t'j
) FEE
PERMIT ISSUANCE
ALA -DRAIN &VENT - WATER (ErU
FLOO DZONR
-
APN
BACK FLOW PROTECT DEVICE
'�it�. �c FEE SUMMARY, tI
Owner Date
DRAINS FLOOR ROOF, AREA, COND.
FIXTU2Er` PER'IRAP
SANITARY Y N
RECRUIT
WORKMAN COMPENSATION DECLARATION
❑I hereby aHlrm that I have a cedllate of consent to self - Insure, or a
certificate of Workers' Compensation Insurance or a unified copy thereof (Sec.
3E00,Lab CJ
Policy N
SCI100L TAX Y N ,
RECEIPT N
GAS FA. SYSTEM -1 INCA OUTLETS
PARK FCE Y N
RECEIPT It
Co�misaed
I ICertltled copy I. filedwtume city
enlfled spy b filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE -
(Thbsectlon need not be, completed if the permit is for one hundred dollars
(SI1- nifess3
I shall not employ Person in any so as to become eenmt ct to ti ,
1 shall not employ any person in any manner w as to become subject 10 the
e'Compensatlon Lawa of California,
la, Date -
Applio nt
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you
should bamme subject to the Workers' Compensation provbloes of the Labor
Code, you most forthwith comply with such provisions or th is permit shall be
deemed revoked.
CONSTRUCTION em is LENDwc acragcY
I hereby ao work that there i a construction Is belt Id (Sec. agency for the pedorrt.
once of the work (or which this permit b owed (Sec 3097, Civ. C.)
1 <nder'e Name
Lenders Addmss
I cortifythat I have read thbappliatienand datethattM1cabove information
bcoimd. lagreeto complywith all cityand county ordinances and state laws
rdalinglobuilding corstrodlon, and hereby authorize rcpresentativee of this
city to enter upon the above- menlloned property for inspection purposes.
(W.) .gm to save, Indemni/y an d keep harmless the City of Cupedlno
against liabilltka, judgments, coisand expenses which may In any wayaccme
.ga lost said City in consequence of the granting of this permit.
GAS EA. SYSTEM-OVER 4 (EA)
GREASE /INDUSIRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
PLANCHECK FEE
PAID
Date RCCei t#
GREASE TRAP
SEWER- SAMTARY- STORMEA.20017,
WATERHEATERW /VFNT /ELECTR
ENERGY FEE Y N —
PAID
Date Recei t#
.
ATER SYSTEM /TREATING
•.
NEW RESIDENTIAL "H.— SQ.h7.
TOTAL:
DUI NG FTE
-
SEISMIC FEE
ELECTRIC FEE
QTY.
MECHANICAL PERMIT
PERMIT ISSUANCE
ALTER ORADDTOMECH.
AIR HANDLPNC UNTT(I010,000 CFM)
FEE'
PLUMBING PEE'
MECHANICAL FEE
FEES PAID:
'
Date Receipt#
SUBTOTAL:
AIR HANDLING UNIT (OVER 10,000CFM)
CONSTRUCTION TAX
Signature of Appilant /Contractor Date
' HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building Occupant store or handle hazardous
nutensI as defined by the Cupertino MumcipaI Code, Chapter 9.1 2, and the
Heahhard Safety COda ion 25532(.)7
❑ Yes No
Will the applicant rfv rc building ouupart use equipment ordevius
which emlt hazardous all contamimnbas dented by the Bay Area Air
Quality Maiugement EX d2
Yes
have read the h ematerlals requlrcmenh under Chapter fi.95 Of
the Glifomialln)th &Saf Code,Sediov255W,25533 and 25534. 1
understand that ifthe building deer rtcnt ly haven tenant, that it b my
respmsibilitym n6tity theomapa (th'requiremenb which must be met
prl aCenlflca O an -,
EXHAUST HOOD(W /DUCT)
CONSTRUCTION TAX PAID:
`
HEATING UNIT (TO 100,000 BTU)
Date RCCCI t#
HEATING UNIT (OVER 100,00) BTU)
_
TO A
VFNRLATION FAN (SINGLE RESID)
ISS{f
V ANCE DATE NNy�
JUL
Qf FIV Qq
CI J�
Tr ur Curt
ISSUED BY,.!�.
BOILER -COMP DHPOR 100,000 BTU)
BOILER- CAMP(OVQt 100,000 BTU)
NEW RESIDENTIAL MICH. SQ.FT
Owner or authonzed agent Date —
TOTAL:
OFFICE COPY