21918APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification -
Building Address:
-
- PERMIT NO.
, 2191 &
wades - one:
�_
-
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION I PERMIT
BUILDING -ELECTRICAL PLUMBING -MECHANICAL
A
Contmdoej m
as A I�A.W a Lm. N.
CATEGORY
CONTROL p
rchited/Engineer. Llc. No:
QTY' ELECTkICPEFiMIT •TEE',,-'
�.•BUILDING PERMITINF0, .,''
Address:'`)' naq'�,,,
PERMIT ISSUANCE
❑ ❑ ❑
LICENSED CONTRALTO 'S DECLARATION
Ihereby aBtrmthat l amlicensed under pervisonsof Chapter9(commen
ingwith Sedion7000)of Divlaion3ofthe Businwsand ProfenionsCode,andmy
'licence Isla (a effed.
Llcen Lin. #,b
Date Co I r
ARCHITECTS DECLARA-H iN
I understand my plaro shag be used as public records.
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that am exempt fronethe Contractor's License Law for the
following reason. (Section 70X.5, Business and Professions Code: Any city or
county which requires permit to..trud, alters Improve, demolish, orespair
anystrudure pdortoits Issuance, also requireslheapplicanl forsuch permit to ru
file a signed statement that he Is Ilreprovisions of pursuant to the provisioof the
Contractor's Liceelaw(Chapter9(commencing with Section 700) of Divi-
sion3 of the Business and Pmfe.kms Code) arthat he bexempt therefromand
the basis far the alleged exemption. Any violation of Section 7031.5 by any
applicant fora pemdtsubjectathe applicant to a civil penalty of not morethan
five hundred1,asoinerdelof he pr .
I, as owner of the properly, or my employees with weeds r thele dole
and theatrodurebout Intended o loffered ..cL(or
comp c.7044, Business and
sale (Sec. et apply to ainow and Professions Cade: The Contractor's Impovethe me Law
does oessuch oanowneeofproperty
rough who builds
at and
who ovementsworkhimself ed oroaghed own employees, .If,ho provided thatsuch
pro provided
improvements am intendedor offered forests. theower-Wilderwilingoe
Improvement boving that he did rofcbmpidbn,the owner-budderwBlhave
the_kurdeno(pmving that he cwt build or Improve for purpose of sak)
LJ I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7614, Business end Professions Code:
The Contractor's License Iaw does not apply to an owner of property who
Wilds or Improves thereon, and who contracts for suchcta
ptajewith a
myl(7ador(s) licensed Pursuant to the Contractor's License Law.
L6 I am exempt under Sec. B &'P C for this reasnn
—APPLIANCES -RESIDENTIAL '-
JOB DFFSCRB'TION
,
' -, ,xJ • v�.� - '
( l,J](�.J�
' PANELS
20AMI'S
OVER VER1100 AMPB
SQ. FI. FLOOR AREA
'
LED
'lP�q IIIA N.
T R
$/SQ. FT.
I
SIGNS ELECTRICALrx
SPECIAL CIl2CUIT/MISC
TEMP. METER ORPOLE INST. ajaNfi
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETSSWITCFIESFI%'TURES
A710N
NEW RESIDENTIAL ELECTR SQAT,
STORIES
TYPE CONSTRUCTION
TOTAL:
QTY. ,PI:II(VIBIiyG',PERM71 .:FEE'.',
OCC,GROUP
RES. UNITS
FLOOD ZONE
APN ,
PERMIT ISSUANCE
-
ALTERDRAIN &VENT - WATER (EA)
BACK FLOW PROTECT. DEVICE
;FEE";SUMMARY '
DRAINS FLOOR, ROOF, AREA, GOND.
FD(TURFS PER TRAP -
SANITARY Y_ N -
RECEIPT p
Owner Date
WORKMAN COMPENSATION DECLARATION �j
hereby affirm that 1 have a certificate of consent to self -Insure, or
eEMilt teofWorken'Compe timI uranceoraredlfW.pythereof(Sec
38 ry bC.)�l1.17. (I \
Toil M I.CJ"� �/' - 1
SCHOOL TAX Y_ N_
RECERT M
GAS EA. SYSTEM-11NC.40UTLh1'S
PARK FEE Y_ N
RECEB']' p
GAS. EA. SYSTEM-0VER4 MA)
Co any ,I
BUILDING DIVISION FE ES
�Semned copy Is he d with t e city -
etlitied copy b (fled with the city Inspection division.
CERTIFICATE OF CCEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be complded if the permit Is torons hundred dollars
($10)orfess)
laact thatoy in anhe y
Pa...1.sayerformance he rest.work as become subject to the
Workean Compensation laws of Gll(omla. Date
Applicant '
NOTICE TO APPLICANT: If, after making thia Certificate of Exemption, you
Amid become subject to the Workers' Compensation provisions of the Labor
Code, you must forthwith comply with such provisions orthb permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
Ihereby aftirenthat there is a construction lending agency for the perform
ance of the work for which this permit Id issued (Sec. 3097, Civ. C.)
Landare Name
Lender's Addnaa
I certBythatl have read this applichbonand statethattheaboveinformation
brorred. Iegreetocomplywlthallcityandcouatyordinaaceeand elate laws
reining to building construction, and hereby authorize representatives of this
citytoenterupontheabove-mentioned property for inspection purposes.
(We) agree to save, indemnify an d keep barmiess the City of Cupertino
ments,c sandexpenwswhichmaylnanywayaarae
sequenm ft egra Lingo tl IsPerri It. r' 1
'1
XQHA�RDOUSMATERhkjo
GREASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE
PAID
Date Recel t#
GREASE TRAP
SEWER -SANITARY -STORM EA. 20017T.'
WATER HEATER W/VENT/ELECTR -
ENERGYFEE Y N
PAID
Date Recei t#
WATER SYSTEM/TRFATING
NEW RESIDENTIAL PLMB.SQ.FI'.
TOTAL:
BUILDING 'E
SEISMIC FTE
TOTAL:
ELECTRIC FTE
t .
dTY. ,. 'MECFIANIGAC''PERMIT
PLUMBING FEE
MECHANICAL FEE
,.
PERMIT ISSUANCE
FEES PAID:
-
-
ALTERORADDTOMECH.
Date Receipt#
AIRHANDLMG UNIT(TO 10,000CFM)
SUBTOTAL-
AIR HANDLINGUMT(OVER 1f1,00CFM)
CONSTRUCTION TAX'
/Contractor D. a
ISCLOSURE -
Willtheapplicantorfulure building occupant store or handle azardous
materblasdefinedbythe Cupertino Municipal Code, Chapter 9.1$ and the
Health and Safety Code Section 25532(a)7
F1Yea NN.
Will the applicant or future building occupant use equipment or devices
which emit hazardous air coataminants as defined by the Bay Area Air
Quality Management District?
� No
4haveYea (madthebaza�ouematerialsmquim enisunderChapter6.95o(
the California Health &SafetyCode, Sodium 25505, 25533 and 25534.1
understand that lithe building sow not currently have alenanq that ltbmy
'responsibility to notify the occupant of the requirements which moat be met
'prior to Issuance of a Certificate ofOmpancy.
IXHAUSTHOOD(W/DUCT) -
CONSTRUCTION TAX PAID:
HEATING UMT(T010,00 BTU)
-
Date Recei t#
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
VENTILATION FAN (SINGLE RESID)
ISSUANCE DATE
-
pr' ,
/yry 7 +]e q6Q�,.
APR 'h 1 !U/ZJT
..
Go saaat� 1ww,�
' � �L 4usFllf,�-�1
�4, R�
75SUEDBY:��_`"'�`—��'
BOILER -COMP OHP OR 100,00 BTU)
BO ER -COMP
NEW RESIDENTIAL MECH. SQ.IT.
Owner or aulhoriud agent � Date
-
TOTAL:.
OFFICE COPY