23947APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Protect Identification
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PERMIT NO.
23947
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CITYOFCUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BUILDING-ELECTRICAI.PLUMBING-MECHAMCAL
Q
V 2
Ca tranoi. Nam: Lie. No:
Architect/Englneer: - Lle No:
CATEGORY CONTROL
QTY' ,�ELECTRiC PERMIT t IEEE
BUILDING PERMIT INFO
/ /�
Address: 1W (..�R LeJ `p4 Ado s'
❑ ❑ ❑
PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION
I hereby affmn that l am licensed under provlslona of Chapter 9(mmmanc
tngwlth Se ion7000)of Dlvlslon3ofthe Buenmand Pmfesslona Code,and my
Iicenmis InfuB roe deflect..16%
LlmnseClam Lic.11
Data Contractor'
ARCHITECT'S DECLARATION
I understand my planasha° be card o public recorcts
Licensed Professional
' OWNER -BUILDER DECLARATION
I hereby affirm thatI am exempt lmm the Contractors Llcenar Law for the
following mason. (Section 7031.5, Business and Professions Code: Any city or
countywhichrequiresapermittommtruci,alter,Impmve,dem iR k,orrepair
any stm=m prior to Its Issuance, also requires the applicant for such permit to
ale a signed statement that he is Ilconeed pursuant to the provisions of the
Contractor's License Law (Chapter 9(mmmencing with Section 7000) of Divi-
sion Sof the Business and ProfessionsCode)orthat he is exempt therefromand
the basis for the alleged exemption. Any violation of Section 70315 by any
applicant fora permit subjects the applicant to a dvil pena try of not more than
hund
five as ed owner of the pro
1711, ae owner of the property, or my employees with wages r thele sale
not intended oroffered for
compensation, will do Business work and the s Code: The
Code The or impdaesLicensethemon Law
Business and f property
sale (Sec. apply
docs not apply to an owner of property who builds or Improves tberemq and
whodoementsa ohimselfedorough hisor thr offereowne. If,hc es,providedthatsuch
Improvementsarematintended earofco foeeale, thhowever, llder iii have
Improvement Vold withinoneycarolcompletiarytheowner-buadcrwlll have
ttllItIurclen of proving that he did nor build or Improve for purpose of sale.).
11 L as owner of the property, am exclusively contracting with licensed
co
contractors to mratmct the projectsi
(Sec. 7040 Business and Professions Code:
The Communes License Taw dm not apply to an owner of property who
Wilds or Improves thereon, and who contracts for such Inaise s with a
qB smk(6) licensed pursuant to the Contractor's License Law.
c Lj Sm I am exempt under SB & P C for this reason
APPLIANCES -RESIDENTIAL
JOB DESCRRTION "
n v —
14— • Y
PANELS
201-1000 AMPS
OVER 1000 AMPS _ _
AREA
SQ. FI'. rFLLOORp-^
/ •, E. V ' M
T C L i
Jtl N 1 G' l
$/SQ. FT.
,
J
SIGNSELECTRICAL
SPECIAL CIRCUIT/MISCc
7EMP.METER OR POLE INST.
(OWER DEVICES DATE
_
SWIMMING TOOL ELECTRIC
OUTLETSSWI7'CHFSFlXTURES
VALUATION
NEW RESIDENTIAL ELECTR SQ,FT.
STORIES
TYPECONS'IRL'CTION
TOTAL:
QTY. PLUMBING PERMIT FEE
OCC. GROUP
RFS. UNIT'S
PERMIT ISSUANCE
ALTER -DRAIN &VENT- WATER (FA)
FIAODZANE
APN
-
RACK FLOW PROTECT. DEVICE
FEE SUMMARY
DRAINS FLOOR ROOF, AREA, CONI.
FIXTURES PER TRAP �-
SANITARY Y N_
RECEIPT#
Owner Date
WORKMAN COMPENSATION DECLARATION
❑I hereby affirm that I have a mmlficate of consent to self -Insure, or a
certificate ofWorkers'Compensation Laurance or a certified copy thereof (Sec.
3800, Tab C.)
Pollry p
SCHOOL TAX Y_ N
RECEIPT M
CAS EA.SYSIEM-1 INCA OUTLETS
PARK FEE Y N
p
RECEGAS.
FA. SYSTEM -OVER 4 (PA)
Com any _
DING DT
BUILDING DIVISION FEES
ffCertllled copy E hereby famished.
❑ Certified copy is filed with the city Inspection division.
CERTIFICATE OF FXEh1PTION FROM WORKERS'
COMPENSATIONINSURANCE
URA
(This section need not Ir completed the permitSURA Is forone hundred dollarsSEWER-SANITARY-SIDRM
(S1 W)or lcss3
I minify that In the performance.f the work for which this permit is issued,
I shall not employ any person In any manner so as to me subject to the
Work crs'CoreQensntlon La f Ifornia. Date tt_
Applicant I,��. (�[�
Appal aAPPLICA LaRerrtaking this Certificate of Exemption, you
should become subject to the Workers' Compersetion provisions of the Labor
Code, you must forthwith comply with such provisions orthh permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there Is a construction lending agency for the perform
anre of the work for which this permit is Issued (See. 3097, Civ. C.)
LeMer'a Name
Le.dee.Address
I cemifythat l havemadthisapplimtlonand eatethatthe above Information
Is correct. I agree to comply with all city and county ordinancesandsatelaws
relating to building constmctian, and hereby 1uth.r ae representatives of thio
city to enter upon the above-mentconed property for hopeedon purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino
against]]abilities,judgments, mks and expenses which may In anywayaceme
agal cal Cityinmns enceofthe antingofthiepe
GREASE/INDUSIRL WASTE INTERCEPTOR
PLANC14ECKFEE
PAID
Date Reeef t#
GREASE TRAP
EA. 20(IFT.
WATER HEATFd(W/VPNT/ELECTR
ENERGY FEE Y N —
PAID
Date Recel t#
y/pTFg SYS71iM/TREATING
NEW RESIDPN'ITAL FILMS. SQ.FF.
TOTAL:
BUILDING FEE
SEISMIC FEE
-
ECTRIC FEE
-
QTY.' MECHANICAL PERMIT FEE
PLUMBING FEE
�•
MECHANICAL FEE
'
PFRMITISSUANCE
FEES PAID:
ALTER OR ADD TO MECH.
AIR HANDLING UNIT (TO 10,000 CFM)
Date ReCei t#
SUBTOTAL:
AIR HANDLING UNIT (OVER 10,(00 CFM)
CONSTRUCTION TAX -
Sig reof Applicant/Contractor to
HAZARDOUS MATERIALS DISCLOSURE
Will theappBcant or future building occupant store or handle havardous
matcelaI as defined by the Cupertino Municipal Code, Chapter 9.1 2, and the
IiralthaMSafety Code&dion25532(a)?
F1 Yes �] No
Will the applicant or future building occupant use equipment or devices
which emit haaardomair comlb
ntananae defined by the Bay Area At,
Quality Management District?
4Yes g No
have is Hee th & Sa ty Code, Sections n(Si, 25533 and255Chapter 6.95 of
at if the building Safety Code, Sect1onsntly h ve a terndt,that 1
the Cali(odthat
undentand thatn tifytheoccupoes not erequiru encs tenant that It Wis mymet
responsibility to ndlty theompant of the rcqulremcnts which most be met
prior to Issuance of a Certificate of Omrpa nry.
D(HAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HEATING UNIT (TO 100,ODO BTU)
Date Recei t#
HEATING UNIT (OVER IOD,000 BTU)
TOT 51
l7
VENTILATION FAN(SINGLE RESID)
-
bQ jSSUANCE DATE
v`
11
s7
Vi -
LL/"r
ISSUED BY:
BORER -COMP OHP OR 100,DM BTU)
BOILER -COMP (OVER 100,000 R71)
NEW RESIDENTIAL MLCH, SQ.Ff
Owner or authorimA agent Data
IDTAL:
OFFICE COPY