21763APPLICANT TO FILL IN INFORMATION WITHIN REDLINES — USE BALL POINT PEN ONLY
Building Project identification
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21763
nere ame. one:
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i/ Contractors Name:
°i —'- Lie. No:
CITY OF CUPERTINO-BUILDING DIVISION
'APPLICATION /PERMIT
APPLICAII NNUBMIl ALDAIE
, — V
�1Architeci/Englneer.
BU_ILDINGaECTRICAL-PLUMBING -MECHANICAL
CATEGORY
CONTROL
Lic. No
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Aaar<,,: /�_.S0B/O�JTPa�'L/�a
' LICFNSIiD CbNTk A�CTJR'S DGCL RATION
I hereby afirmthat l arelicmaed under provisionsof Chapter9(mmmmo
Ingwith Section 7000)0( Divisioo3ofthe Busloessand PrefesslnesCode, and my
license is In foil force and effect.
QTY
- .,..,1, .1...:.. .r
° t ELECTRIC PERMIT
t' FEE )
t '-•.BUILDINGTERMIT'INF0,!,
-' t'
nSSUANCE
a �o
-
APPLIANCESRESIDENTIAL
PANELS
JOB DESCRIPTION
M,i� / [' i
S T�244e,
License Class lic.#
Date cr
Corru
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1—V K. C�l�7L✓jCLb'
201- 1000AMP5
ARCHITECTS DECLARATION
I understand my plans shall be used an public records.
Licensed Professional
OVER 1000 AMTS
SQ. PT. FLOOR S /SQ. Fr,
SIGNS ELECTRICAL
OWNER - BUILDER DECLARATION
[hereby afRrmthatlam exemptfromehe Contnctorb License Law for [he
following reason.(S at1on 7031.5, Business and Profesions Code: Any city or
any stmdvretatemeitshat he is alw requ purmuttot the ravissns of to
anystm mpewtosapermite ,a6orroci,almaimprove,demolish,er ttr
file a signed statement that he b licensed Ascot it the Lion 7") of the
Contractor's License and with 5emp"heo(Divi-
slon3clthe Businesaend Profemlors Code) orthat he Is exempt therc(romand
the basis for the alleged exemption. Any violation of Section 7031.5 by any
appbam fora permit subjects the applicant to a civil penalty clone moe than
I6
--.
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6
O
' VA N
y
5 I'ECIA L CII2CUIT /MISC
TEMP. RORPOLE]
(EWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETSSWITCHESFIXTURES
g
live hundred dollars %SOO).
. ❑Las 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
NEW RESIDENTIAL ELECTR SQ.FI',
STORIES
ECONSTRUCTION
`
sale (Sec 7044, Business and Professions Code: The Contracto /s License law
-
doesnotapplytoanownero( property who builds or improves thereon, and
who doessuch work hlmselforthrough his own employees, provided thatsuch
OCC.CROUP
RES. UNITS
Improvements are not intended oroffered for sale. lf,howwegthebuildingor
Improvement h sold within one yea ru(completlon, the owner - builder will have
I of proving that Medici nor bulldorimprove for purpose of sale .).,QTY,'
owner of the property, am exclusively contracting with licensed
ntractom to construct the project (Sec. 7044, Business and Professions Code:
TOTAL:
':PLUMBING:PERMIT ''t,
PERMIT ISSUANCE -
''FE•E
-
FLOOOZON'E
APN
-
17m Contmctor'a Limnse Law does not apply to an owner of property who
builds or Improves thereon, and who common, for such piujees with a
cgR{actor(s) licensed pursuant to the Contrctors License Law.
LI I am exempt unden Sec. B & P C for this reason
ALTER -DRAIN &VENT- WATER (EA)
'
RACK FLOW PROTECT. DEVICE
'FEE SUMMARY
DRAINS FLOOR ROOF, AREA, COND.
F=RF_S. PER TRAP
SANITARY Y N
RECEIPT p
Owner Date
WORKMAN COMPENSATION DECLARATION
❑[ hereby affirm that I have rti of consent
SCHOOL TAX Y— N
o l ne d spythemo or a
ceni/iab of Worken'Compewstlon lrsurance ors certl(Ied copy thereof (Sec.
RECENT M
GAS EA. SYSTEM -1 INCA OUTLETS`'
PARK FFR Y N
RECEIPT 0
3800, Lab C.)
Policy p
CUMBUILDING
GAS. G. SYSTEM -OVER 4 (EA)
DIVISION FEES
�Certllled copy is hereby furnished. -
❑Certified copy la filed with the city Inspection division.
-
CREASE /WDUSTRL WASTE INTERCEPTOR
PLANCIJECK FEE
i S �C�/
iyz.
GREASE TRAP
CERTIFICATE OF EXEM PTION FROM WO R KERS'
COMPENSATION INSURANCE
(This.v&Nn need not be completed lithe permit Is for one hundred dollars
(9300)orless) t -
I mdtfy that in the performance of the work for which this permit is Issued,
I shall not employ any pennon In any manner an as to become subject to the
Workers'Compensation laws of California. Date
3
PAID
Dd1C RCCeI IL#
SEWER STORM FA.200F 1'.
wnTEIt HEATER w /vENr /E[•ECTR
ENERGY FEE Y N —
PAID
WATER SYSTEM /TREATING
NOTICE E
r0 subject to mImakingthisatfix. lore o(Exempllon, you
Curls, octavos surth to the Workers' Campewtlonprovhiomofthe Labor
Cede, you most forthwith comply with each provisions orthis permit shall be
deemed revoked.
Date Reeel t#
NEW RESIDENTIAL PLMB._SQFF.
TOTAL:
MUILDING FEE
O 0
Tonne:
SEISMIC FEE %p
ELECTRIC FEE
a
CONSTRUCTION LENDING AGENCY
Ihembya(Brm that there is a construction lending agency for the per form
ance of the work for which this permit is issued (Sec. 3097, Civ. CJ
Icnder's Name '
Lender's Addmaa
I ceA By that l have mad this application and Mate that theabove in formation
-
MECHANICAL PERMIT`,
-
.FEE'
PLUMBING FEE
MECHANICAL FEE
FEES PAID:
Is correct l agree to comply with all city and county ordinances and state laws
PERMIT ISSUANCE
relating to building co structlon, and hereby authorize representatives of thin
city to enter upon the above. mentioned property for Inspection purposes.
(We) agree to save, Indemnify an d keep harmless the City of Cupertino
aga Wt liabilities, judgments, mass and expenses which may in any way accrue
against said City In cone ceaf the as Ing of thls rtnit.
ALTER OR ADD TO MECH.
AIR HANDLING UNIT (TO 10,000 GPM)
Date Recei t#
P
- SUBTOTAL:
AIR HANDLING UNIT (OVER ItlMOCM)
CONSTRUCTION TAX
hignstor f pua ct
nt /Contaor Data
EXHAU5THOOD(W /DUCT)
'CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (TO 100,000 BTU)
-
Will the applicant or future building occupant store or handle hazardous
material as defined by the Cupertino Municipal Cade, Chapter 933 and the
I lealth and Safety Code Section 25532(a)?
r-1 Yen M No
Date Recei t#
HEATING UNIT (OVER IDBOOD BTU)
TOTAL:
VENTILATION FAN (SINGLE RESID)
ISSUANCE DATE
Will the applicant or futureinuldhigeavp.m.sesquipmem ardevims
which emit hazardous air contarmnants as defined by the Bay Area Air
BORER -COMP 0HPOR 100,000 BTU)
Quality Management District?
n Yes dN
Ihave znu o m aterialsreq uirements under Chapter 6.95of
BOILER- COMP (OVER 100,000BTU)
the California Health & Safety Code, Sections 25505, 25533 and 255M. I y
understand that if the building does not currently have a tenant, that It ism
responsibility to notify the omvpart of the requirements which most be met
prior to Issuance of Certificate ofOmpancy.
MAY .r ^ (�
1 4 1591 '.•
r
city
NEW RESIDENTIAL MECH.' .MA
of Cu
ISSl1Ep
Owner or aulhoriaed agent Data
TOTAL:
OFFICE COPY