21299APPLICANT TO FILL IN INFORMATION WITHIN RED LINES,— USE BALLPOINT PEWONLY
- Building Project Identification
Building Address:
PERMIT NO. /� a�
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C� 2J-lii L JAI Nfe 2
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one:
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CITY
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OP CUPERTINO- BUILDING DIVISION
APPLICATION /PERMIT
BUfLD ]NGELECTRICA4PLUMBING- MLCHAMCAL
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APPLICATION SUBMIT IAL
D j, _YD -'
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con ,ctor'.N.nne u.Nn:
- ° ^�✓S,$a
CATEGORY
CONTROL#
.
Anclumd/ gineer. Llc. No:
�TT",i',
tiliLECTRY PER[vfIT 7' ��t-
,iFEFrj'
•�)" 'BUILDIN6_PERaM�IT,WFO
Address: /
PERMITISSUANCE
•❑ �, �X ❑
L�
LICENSED ONTRAC'TOR'S DECLARATION
Iherebyattlrmthat l am licensed under provisions of Chapter 9 fxmmen
APPLIANCFSRESIDENTIAL
-JOB DESCRIPTION
PANELS '
ingwith Sedion7000)of Dlvision3ofthe Bus(nemand ProfessionsCede,and my
it is In fu8 deffect %�/ / -
Date Contnttor n
ARCHITECTS DECLARATION
I understand my plans ahalbe used aspublic records.
l
AMPS
OVER 1000
OVER 1000 AMPS)',- .\� �
, SQ. FT. FLOOR AREA
N
SIGNS ELECTRICAL
Licensed Professional
SPECIAL CIRCIIIT /MIS[ a"
--
' OWNER - BUILDER DECLARATION -
Iherebyaffirmthat lamexempt fromthe Contractor's Llcenselawforthe
followingreason.(Section 70315, Business and Professions Code: Any city or
=ntywhichmquresapert ttoc6mtmcpalwr ,impmve,demoWh,orrepalr
anystructure prlorto its issuance,alsorequirestheappllnnt forsuch pernotto
file a signed statement that he is licensed pureuant to the provisions of the
Contractor's License Law (Chapter 9 fmmmencing with Section 7000) of DWI-
sion3ofthe Business and Professions Code) or that he se exempt therefrom and
the basis for the alleged exemption. Any violation of Section 7011.5 by any
applicant fora permit subjects the applicant to a civil penalty of not more than
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TMUl ORPOLE INST.
pOVyER DEVICES*
, --
SWIMMING POOL ELECTRIC •' ..�I_
OUTLETSSWITCHEEI- F1' RES
VALUATION -
-
•'
NEW RESIDENTIAL EL ETR SQ.FT.
five hundred dollars ($500). - -
71, as owner of the property, or my employees with wages as their sole
compensation, will do the work and the structure is not intended or offered for
STDWEB
TYPE CONSTRUCTION
s
sale ( Sec. 7094, Business and Profesions Code: The Contractors License Laiv
does not apply to an owner of property who builds or improves thereon, and
who doessuch work himself or through his own employees, provided that such
-
-
OCC CROUP
.
IFS. SJM'f5
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Improvementsare net intended oroff ered for sale. If, however, the building or
TOTAL:
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Improvementis sold within one yearo( completion, the owner-build erwlll have
th,e�aben of proving that he did net build or improve for purpose of sale.).
Lj L as owner of the property, am exclusively contracting with licensed
contraemre to mwtritct the pmject (Sec. 7094'Businew and Professions Code:
(2'('4,,
4,'x ty,`•p[:' WG pERMITt'}
;; .FEEik
,- ..
,
FLOODWNE
APN
'
PERMIT ISSUANCE
A D
—!/
The Contractors License Law does not apply to an owner of property who
bulge or Improves thereon, and who contracts for such IaWjects with a
cgpllactoKs)Iicensed pursuant to the Contractor's Lkenm Law.
LI I am exempt under Sec. B & P C for this reason
ALTER -DRAIN &V ENT- WATER (EA)
y,
(;;t't't;F6E;$UMMARY *'t4,'• "','g
B` CK �W PROTECT' DEVICE'
OUTSIDEFEES
DRAINS FLOOR ROOF, AREA; COND.
SANITARY Y N_
RECEIPT#
Owner - Date'
WORKMAN COMPENSATION DECLARATION
hereby affirm that I have a cord( sate of consent to self -Insure or a
rtl care ofWOrkere Compensation lruunna oragerti(ied copy thereof (Sec.
3800, Lab C.) - //I
Policy N
FD(TURESS PER TRAP
��
SCITOOL TAX Y_ N
.. RF = M
GASEA.SYSTEM- 1INC90UTLEl'B
PARR FEE„ Y_ N
. RECEIPT M
GAS EA. SYSTEM -OVER d (EA)
Coco y 1 ?l
jJ''
BUILDING DIVISION FEES
tifiedd p, LS steer —by Wished.'
Meddled copy is filed with the city irepirtion division.
CARCASE /INDUSTRL WASTE INTERCEPTOR
PLANCHECIC FEE' .
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GREASE TRAP
'PAID
CERTIFICATE OF EXEMPTION FROM WORKERS'
- COMPENSATION INSURANCE
(Thlasectlon need net be completed if the permit is for one hundred dollars
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SEWER-SANITARY-STOW EA 200FC.
Date.' ReCel I#
WATER HEEATERW /VENT /ELLCTR
q
V
ENERGY FEE Y_ N_
($100) or less')
I certify that In the performance of the work !.,which this permit i. issued,
WATER SYS M/RATIG
I shall not employ any pemon In any mnner o as to bemm wbjeR to the
Workers' Compensation Laws of California. Date
PAID
"
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NEW RFSIDFN77AL PLMB, SQ.FT.
Applicant
NOTICE TO APPLICANT: If, after making this Certificateof Exemption , You ,
should become subject to the Workers' Compensation provisions of the Labor
Code, you swat forthwith comply wltA such provisions orthls permit shall be
deemedrevoked. -
CONSTRUCTION LENDING AGENCY
Date - Recei t#
TOTAL:
BUILDING FEE
^
SEISMIC FEE"
'I hereby afftrmthat there is a construction lendingagenryfortheperform-
ance of the work for which this permit Is Issued (Sec. 3097, Civ. Q
].ender'. Name
Lenaer.Addre.. -
Icedifythatlhaverea dthlsa pplicationaMsmtethatlhe .boveinformation
. isommet.lag.tocomplywith all city and county ordinances and'etate laws
' '" TOTAL:
D
ELECTRIC FEE'
-
PLUMBING FEE
7
QiY:
i MECFIANi AG;PF,RIYIIT "x +�
" "`,FEE4`t
MECHANICAL FEE
•' -
PERMIT ISSUANCE
FEES PAID:
,
relating to building com uctlon, and hereby authorize 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 Cupertino
against lWbilitles, judgments, "sand expenses which may In any way acme
'
ALTERORADDTOMECH.-
Date ROCelI1t#
AIR HANDLING UNIT (TO 10,000 CFM)
"' SUBTOTAL:
against said City in consequence of the granting of this permit
''
00
AIR HANDLING UNIT (OVER 10,0 cm
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CONSTRUC TION TAX ^
Signatureot Applicant /Contractor Data
EXHAUST HOOD M /DUCT)
CONSTRUCTION TAX PAID:
sRecel
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HA7ARDOUS MATERIALS DISCLOSURE
Will the applicant orfutem building occupant store or handle hazardous.
HEATING UMT(TO 100,000 BTU)
Date t#
material as defined by the Cupertino Municipal Code, Chapter 9.12, and the
Halth.ed SefetyC a ton 25532(.)7 - 1. °, ."
HEATING UMT(OVER 100,000 BTU)
TOTAL:
Yes No
Willthe applicant re buildingompant use equipment or devises
VFNDLATTON FAN (SINGLE RESID)
JS•CRi�1 DATE ,
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management Dfs ct7 '^-
n❑ ,Yes No
Ibave read met us materialstions ementsunde,Chapter.1 of
q"
nr,Y 1'90
7Fi
BOILER.COMP QHPOR 100,000 BTU)
BOILER- COMP (OVER 100,000 BTU)
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the California Health &Safety Code, Sections ru 75505, 25533 and 25539. I
under�tand that lithe bulldingdoee not r fly taveatenanq that It is my
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NEW RESIDENTIAL MECH. 5Q.FT.
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s1hilitytonAi the omP o(te iremente hichmustbared
pilsa nt p�
^ a
Port issuance a Icate
,rOm _.
ISSUED BY: V kLu
Ckj ec, r uthodved agent ; : Date -,
TOTAL.
OFFICE COPY