22903APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
6u11din Ponied Identification
.Budding Addmss:
2 l,�bl -k� �t+DFU
- PERMITNO.
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mere one:
CITYOPCUPERTINO- BUILDI G (VISION
APPLICATION,(P
BUILDINGELECIRICALPLUMBi -MECI IANICAL
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naact eNa e LIc. No:
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CATEGORY.•
CONTROLN
Architect /Engineer. Lie. No:
'617Y�'
�; i�'ELECTRIGP A IT*
BUILDING PERMIT INFO
PERMITISSUAN
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PLUMB �/
L-Li , LY
Address:
LICIINSED CONTRACTOR'S DECLARATION
.I herebyaffirmthat l em Bcensed under provbionsof Chapter9(commwe-
Ingwlth Section 7000)of Dlvlslon3ofthe Buslnese.ed ProfeeconeC-ode, and my
license In In full f and effect.
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CwCo.N /
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APPLIANCES-
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JOB DESCRIPTION
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Da Contractor
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ARCHITECT'S DECLAR TION
I understand my plane shall he used as public records.
Licensed Profemianal
V 000 AMPS
SQ. Fr. aFLOOR �AREA -
$ /SQ. Fr.
ewx
sm.-18
SIGNSELECTRIC
OWNER - BUILDER DECLARATION
I hereby aWrmth at I am exempt from the Contractor'. Llcenw Law for the
following Mason. (Section 70313, Business and Pmfesslone Cade: Any ctty or
countywhich requlreaa permittocoruWa, alter, Impmve, de=lbh,orrepair
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)
SPEC C
SC
PO INS.(,
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anystmcture prior to lblswance, also requirestheappticent for such permitto
Ole a elgbed statement that he b licensed pursuant to the provision of the
Contractor's License Law (Chapter 9 (commencing with Section 7") of Divi-
sloes3of the Business and Professions Code) or her he e. exempt therefwmand
the basis for the alleged exemption. Any violation of Section 7MIS by any
applinntfor a permit subjects the applicant to a civil penalty of not nnrethan
ro
D
CES
G LELECTRIC
UTLE TCHESHXTUItF5
VAL/VA'TION '
5 I i
M &, J
NEW DENIAL ELECTR e'Q' FL
five hundred doll..($SOO).
❑ 1, as owner of the property, or my employees with wages as their sole
STOWFS
TYPE CONSTRUCTION
compensation ,wllldotheworkandthestmqurebnot Intended or offered for
-
sale (Sec 7044, Bdemes. and I'mfeselov Cade: The Contractor's Liceme Law
'
-
don not apply to an owner of property who Wilda or lmprovn t herean ,and
who doessuchwork himself orthrough his owe employest, provided that such
OCC.GROUP
RES, UNITS
Improvements am not intended oroffered for sale. If, however, thebuilding or
Improvement h.oldwithln oneyearofcomplMion ,theowner- bullderwlll have
th�rdenof provinglhat he did not Wed or improve for purpose cleats.).
I, as owner of the property, am exclusively contracting with licensed
contractors to construct, the project (Sec. 7044, Business and Profession Cade:
'&Y.
TO
jI,l� PLOIVMBIIVG•PERINIT,`�'
PERMIT ISSUANCE
;'FEE'
FLOOD ZONE
APN
'
The Contractor's License Law don net apply to an owner of property who
Wilde or Imprwn themron, and who contracts far such pNKcts with a
ro, �ttjjaaor(s)Ilceneed pumuant to the GanbdctOr 'sLcense Law.
LJ I am exempt under Sec. B k P C for this mason
ALTQt -DRAIN kVENT -WATER (EAT'
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.,..,
,i;'4•'� ° "'FEE'SUMMARY
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BACK FLOW PROTECT. DEVICE
OUTS IDE FEES
DRAINS FLOOR ROOF, AREA, COND.
p1XTURES PER TRAP.:.... —. --„
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SANITARY Y_ N_
RECEIPT N
SCHOOL TAX Y— N_
Owner Date
' WORKMANCOMPENSATIONDECLARATION
❑1 hereby efflrm that I have a certificate of consent to eelFln or a
'certificate of Workere'Comperuation buumnm ora mdiflea ropy thereof
3800, ISb C.)
RFOEI''f N
� 1 C O
PARK FEE `Y_.N!
Policy N
RECEIPT N
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Coco any
BUILDING DI VISI ON FE IS
Certified copy b hercbytume city
Certified copy b (heed with the oty Inspection division.
CERTIFICATE OF EXFM PTION FROM WORK CRS'
COMPENSATION INSURANCE
Rhbsectionneed not WcomplMed Rthe permitan
ie fororm hundre oi
G
ND EPTOR
PLAN�1 -IECK FEE
1AND I C (,.t
PAID �b^7�_1/-
Date Re i t#
`wad
EASED
SEWER- SANITARYSTORM EA 200Fr
($1IU)orl th -
I shall n t employ oy any performance on in any so Aw to become permit c to the
I shall not employ any person in any manner w v to become wbjett to the
W Compensation Laws
on wa of California. Date
WATER HFATER W /VENT/ELECTR
SYSTEM /TREATING
-
�F'NERGY FEE Y N-918
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pAlp
N "�
Applicant
NOTICE co MPLIC subject to the after making t his
sationlcate of Exemption, you
Code, at co ply wishstich erwtlonpmthl,p Labor
Code, you moat forthwith comply with such provisions orthls permit shall be
be
deemM revokes.
Date Rece t
NEW RESIDENTML' PLMB. —ITT•
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- TOTAL:
13UILDING "E
SEISMIC FEE
O
CONSTRUCTION LENDING AGENCY
I hereby affirm that them is a construction lending agency for the perform-
ance of the work for which this permit is bored (Sec. 3097, C1v. C.)
T
ELECTRIC FEE
iender.Name
Lender's Addreas -
I certlfythat l have read this applimtlonand slatethat theabove lnforrmtlon
Is cored. Iagrce to comply with all city.ed county ordinance. and state laws
mlztieg to building m umorton, and hereby atthorize rcpresemaRVee of this
QTY.,
-
MECHANICAL PERMIT'
.�
FEEL
PLUMBING PEE
GFEE
MECHANICAL E
PERMIT ISSUANCE
FEES PAID:
ALTERORADDTOMECH.
Y
city to enter upon the above- mentioned pmperty for Inspection purposes,
(We) Agree. to save, indemnify an d keep harmiese the City of Cupertino
against liabilities, j dgmer"...and ch may In any way acme
aga last said Cit en a gof the. pe
AIR HANDLING UMT(TO III,= CrM)
Date Receiptit
SUBTOTAL:
AIR HANDLING UNr1'(OVER IQOIOCFM)
_
CONSTRUCTION TAX
gwmre ppI t /Contractor Date
EXHAUST HOOD(W /DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS SCLOS RE
HEATING UNIT (TO 100,000 BTU)
Will the applloa at or future building ocwpast store or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.1 7, and the
Date tIf
HEATING UNIT (OVER 100,000 BTU)
-
,Rceei
TOTAL:
Heallh and Safety Code s- S,eRlon 75532(a)?
❑ Yes l No
VENTILATION FAN (SINGLE RESID)
ISSUANCE DATE
p '
Will the applicant oruture building occupant use equipment or devices
which emit hazardous air contaminants as defined by the Bay Area Air
BOILER -COMP OHPOR 100,0X0 HIM
Quality Management District?
4 Yes J No
ar aCheple of
havemia
Ali) '
AY n,
NAY
BOILCR- COMP(OV1R 100,000 BTU)
lealth
the Gltandt Healthk building Code, ntly have mram'that.I
Safety Code, Sections 25505, 5533 .I
understand that lithe the gdaes not a mq.immnts which that it lsut
responsibility to racily the ocwpant of the rcquiremente which must be na4
prior to lssuanceofa Cerfflateof Occupancy.
Inn
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/ Y OF �y,��;�J7'�y
- UNrn111 -1 UJ
NEW RESIDENTIAL MEIN. SQ.FT
D
ISSUEDi r
Owner or autherlud agent .• Date,
OFFICE COPY