20031APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project identification - -
Building Address: -
h Ate, �,� c7
•%Ebner:
PERMIT NO.
/1 O 0 ^ aj
G 3 I
song.
v
CITY OF CUPERTINO- BUILDING DIVISION
APPLICATION /PERMIT
BUILDI NG -M ECTRICALML BING- MILHAMCAL
A
'7
�co ncto•aN u=. No!
I . ` /=D�a6/ J •S, 2:1 —
CAT�ARY
CONTROL p
' rchltM /Engineer. Lic. N.
- -
'QTY
`,t 1 ,.¢ELECTRIC PERMIT, ''
' ',TEC -,
BUILDING PERMIT INFO, .,'.,.
'
Address
PERMITISSUANCE
FITZIT
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am ficensed under provWons of Chapter9 (commenc
ingwith Sedian7000)ofDlWsion3ofthe Businessand PmfstlonsCAdgand my
license 1. in full fqry and affect. q
cens
Lie Cla m Lic.# SS / 2- /.S
Date /2 LS1- Ht' Contractor
ARCHITF.CI75 DECLARATION
I understand my plans shall be used as public records.
Licensed Professional,
- OWNER - BUILDER DECLARATION
I hereby affirm that l am exempt form the Contractor's License Law for the
following reason. (Section 703 1.5, Business and Professions Code: Any city or
comity which requires a permit to construct, alter, Improve, demolish, or repair
any structure prior to its issuance, also requires the appBant for such permit to
a elgaed statement that he b pursuant licensed pu to the provisions of the
Contr2ore License Law (Chapter 9(commencing with Section 70nO)of Diel-
alon3 of the Buslncsa and Profesoora Code) orthat he b exempt ehere(romentl
the basis for the alleged exemption. Any violation of SectionJB]LS any
applicant for permit subectithea applicant to a civil. dlnolmo� than
ePP P =a I PP P= 7�
five hundred
owner the /
� e as owner ll the property, or my employes with wages r their sole
compensation, wllldothe work endlhe simduM lenm intended or offered for
Bale (Src. 709d, BusOUw and Professions Code: The Contractors Llanse law
does not apply to an owner of property who Wilda or impress thereon and
who doessuchworkhtmselforthrough hisown employees, provided that such
improvements are not Intended orofferedlorsle . If, hcwevcq thebuilding or
Improvement issoldwithin oneycuofcompidioRtheowner- bullderwlll have
1F den of proving that he did nor Wild or improve for purpose of sale.).
as owner of the property, am exclusively mntrading with Ilmmed
contractors to construct the project ( Sec. 7044, Basin em and Pro(esslans Code:
The Contractor's License law does not apply to an owner ni property who
Wilds or Improves thereon, and who contracts for such pSoje to with a
cg6[facum(s) licensed pursuant to the Contractor's License Law. .
LEI am exempt under Sec. B & P C for thin reason,
R.I
APIANCESRESIDENTIAL
W
- jOB DPSCROTION
PANELS
UP TO 200 ANTS
201 -1000 AMPS
OVER 1000 AMPS
SQ. FT. FLOOR AREA
s /SQ. FT.
SIGNS ELECTRICAL
SPFGIALCIRCUIT /MLSC
-
TEMP.METPR OR POLE INS!.
POWER DEVICES
SWIMMING POOP. ELECTRIC
-
ETSSWITCHESFIXTURES
VALUATION
O
�Qtl
V
NEW RESIDENTIAL ELECTR SQ.FT.
STORIES
TYPE CONSTRUCfIO,
T o "'
� t
QTY,
-
--
- TOTAL:
. rt .';'��PLUM$I $I C ERMIT ,'
pp(MCf ISSUANCE
L
;' FEE'
I'�„QO
OCC. CROUP
RIS. UNITS
FLOOD ZONE
APN
'ALTS - DRAIN. VENT lEI2 (EA)
-
BACK FLOV PROTECT' mk
",', „" ",!FEE SUMMARY•.,
-1 �Tll DE FEES
DR1NS;iikO0j ROO
-
FIX PER
12 LW
�aRECEIPT'
W
1W
SANITARY Y N_
p
Owner Data
WORK MAN COMPENSATION DECLARATION
❑I hereby affirm that I have a rertlflate of consent to opyt sure, or a
artlflate of Workers' Compensation Insurance ma cert ified ropythemo((Sec.
3SM, lab C.)
"Policyp
SCHOOL TAX Y N
RECEIPT N '
GAS SY .1 CAO S
^
.Cx��
PARKITEE Y_ N
RECEIPT#
GAS EA. STEM VERB )
Cog any
BUILDING DIVISION FEES
❑PCa fied copy is hereby himiahed.
❑Certified copy h filed with the city impMion division.
CERTIFICATE OF ]EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This sedion need sat be completed If the permit U for one hundred dollars
($l0B.rless.)
I artily that in the performance of war forwhi=h this permit is Weed,
I shall not employ any reon In an tors r m s to become subtle to the
Workers' Courpensa l6n 'w.eS/ fo .Date 3 -�_�_ ,'�
Applicant /
GREASE /IN SIRL WA
PLANGI-IECIC FEE
-L-�aa
PAID �^Z /-7xa 5vSO
Recai I#
{'O'LL..�J
GREASE TRAP
SEINER - SANITARY -DBte
WATER HrATTAw
/EL,
ENERGY FEE Y N
-
Z
PAIn'y- ��' S55�9
Date Recei ht
,
WATER SYSTEM/ RATING
NEW RFSIDI=A PLMB. SQ.rr.
NOTICETO MP IC NT:I, Ifter mildrytNtiCartificate of Exemption, you
shwld become eub}'ct to the Workers' Compensation prow loo o(the tabor
Code, you must forthwith comply with such provisions or this permit shall be
deemed revokrd.
CONSTRUCTION LENDING AGENCY
Ihereby affirm that there is a construction lending agency for the per form -.
once of the work for which this permit b Issued (Sec. 3097, Civ. C.)
lender's Name
Lenders Addreaa
I certlfythatl have read this appfiationand gate( at theabove informatlon
bcorred.Iagree to cagplywhh all city and countyordlnances and slate laws
relating to building construction, and hereby authorize representatives of thls
city to enter upon the above- mentioned pmperty for inspection purposes.
(We) agree to save, Indemnify and keep harmless the City of Cupertino
against liabilities, judgments, costaand expenses which may In anyway accrue
against said City in consequence of the granting of this permit.
TOTAL:
BUILDING FEE
SEISMIC FEE
L
TOTAL:
1L �a-�
�91�
ELECTRIC FEE
ELECTRIC FEE
a�
QTY.
- - -
". MECHANICAL PERMIT ,
FEE_'
MECHANICAL FEE
',1 00
PERMIT ISSUANCE
,,7s
I t,A-a
FEES PAID:
ALTERORADDTOMECFL
AIR HANDLING UNIT (TO 10,000 CFM)
23�
Date - Receipt#
SUBTOTAL:
AIR HANDLING UNIT (OVER IO,BBOCrid)
CONSTRUCTION TAX
Signature of Appliant /Contractor Dram
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orf vture building occupant score or handle hazardous
material as dell tied by the Cupertino Municipal Cade, Chapter 9.12 and the
I lean 'and Safety Coder �Section 25532(a)1
- �Ys u No
Will the applicant orfuturn building occupant use equipment or devices
which emit hannelous air contaminants as defined by the Bay Area Air
Quall Management DkWct7 -
Yes nn No
hvom.dihehazai..US terlalsrequlmmentsun der Chapter6 .95 of
the Cailfomu Health & Safety Code, Seelmes 25505, 25533 and 25534. !
understand that if the b/dp7t sn mrrenlly have atemnq that ltkmy
rspo Iiity to motif t, hrequlremenls whi ch must be metvp' oWVanceo C/ ccv n
� ry 3 —z
IXIIAUSTPIOOD(W /DIKTI
`LW
:CONSTRUCTION TAX PAID:
'
HEATING UMT(TO 100,00) BTU)
Date RCC2i t#
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
s
VWIT LATION FAN (SINGLE RESID)
-
Lilcl)
ISSUANCE DATE
-
MAR
vV
ISSUED BY: 8
BOILER- COMP (3tIP OR 100,0(q BTU)
BOLER-COMP (OVIM 100,000 Dili)
NEW RESIDENTIAL MECF {. SQd7.
net or autho red ag rat Date
Data
TOTAL:
O.OtD
OFFICE COPY