22654APPLICANT TO FILL IN INFORMATION'WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro ea Idemifiotion
Budd Address: ^
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PERMIT NO.
G G lM1
2 2 6 5 4
Owner suss: - • _� � one:
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CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION If PERMIT
BUILDING-ELECTRICAL IYLUMBING-MFG LAICAL
•
me: Lic. No:
rmiI SL. �� 1" Vl r��36V
CATEGORY
'CONTROL p
An hlted/Engineer. LIc. No:
' `•"' cot-`
QIYTi;, E4ECTRICPERMIT ( :'iI'EC':
:BUILDING PERI1'IIT,INFO ;.`
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,� •. .
Address:
PERhIITISSUANCE
LICENSED CONTRACTOR'S DECLARATION
(hereby affirm that l am licensed under provisions of Chapter9(cornmene.
ingwith Section7000)mf Division3 ofthe Businessand Professions Code, and my
licensis inre ie.
APPLIANCESRESIDENCIAL
JOB DESCRIPIION
�� PLA pw 11Ao 10v T
PANELS
'o
Dale I. _Cum
��i;IAACHITECI` CLARATI
I taq e4, p §all lK used as public records.
IMIQ200ANTS
201-1000A.MPS
OVER 1000 AMPS -
SQ. ET. FLOOR AREA
$/SQ. FT.
SIGNSELECTRICAL
License roel�--ojosI
1��C
SPECIALCIRCUTT/MISC
OWNER -BUILDER DECLARATION
I hereby affirm that l am exempt from the Contractor's Llanse, Law forthe
county hichre uirts1oecoutt,Business and Professions Code: demolish, ormp it
countywMch requires Issuattoroorequialter, aprovgtforsuormit to
any structuretatemefte Issuance, alsoIs sed pursuant t the nevisihpermlte
fileaaigoM rtcenseLant thathetr9(rodencingitthetion7000) of, the
Contractor's License Law rofesser9(rored orthng with exempt andiet.
Mon 3 ofthe Bueineasand Pro(easions Code) orthat he leexempt Iherefromand
the basis for the alleged exemption. Any violation of Section 7MI.5 by any
appBcant Lots permit subjects the applicant to a civil penalty of nor more than
t
"
_NLA
A71
u�[il
. TEMP METER ORPOLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETSSWITCHES.FIXTURES
VALUATION
M
I��I `g �sl
NEW RESIDDIMAL ELECTR SQ.FT,
five Nuns ed owner ars of the pro
I, as owner o(the properly, or cony employees with wages as their sole
STORIES
TYPE CONSTRUCTION
C mpensatlon,wBlelothe work and thestruaure is not intended or offered for
sale (Sec: 7014, Business and Profeadoes Code: The Contractor's Lieseae Law
does not apply to an owner of property who builds or improves thereon,and
who does such work himself orthrough his own employees, provided that such
OCC. GROUP
RES. TINCTS
Improvements are not intended oroffered forsale. If, however, thebullding or
Improvement lssold w)thinoneyearofcompldion,the owner-builderwWhav�
tlB urden ofpmvingthat he did not build or improve for purpose o(sale./
LJ I, oc owner of the property, am exclusively contracting with Iicenadd
rontractmrs to construct the project (Sec. 7144, Business and Professiora Code:
The Contractor's License Law does not apply to an owner of property w'a
Wilda ar Improves [hereon, end who contracts (or such ptojede with a
onactor(s) Bernard pursuant to the Contmctou. Lirense Law.
LJ I am exempt under Sec. B k P C for this reastV
TOTAL:
,. '.
;-. 4,.P L ]� 'FEES^,'
);ptM1T ISSUANCE'
/t t #
ALTER -DRAIN Q' - A ER
„ .
F(AODTANE
APN
'.'FEE'SUMMARY
F
BAIX LOW
OUTSIDE FEFS
.�.. —_-- -
SANITARY Y_.N "
RECEIPT#
Owner Date
WORKMAN COMPENSATION DECLARATION
❑I hereby atffmr that I have a rertiBate of consent to'self-Iu
nre,
FIXTURE'
S PER 7RN'
_
SCHOOLTAX YN—
or
rnhifiateo(Workers'Compereationlmumnmoramoifled ropytherof(Sec.
3800,1ab C.)
RECEIPT #
GAS EA. SYSTEM -1 INCA OUTLETS
PARK FY N
PolIt
#
EA. SYSTEM -OVER 4 (EA) •'
CommGAS
,fP Y
DING DT
BUILDING DIVISION FEES
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s)_ J Certified ropy, is hereby filed the
CerlBied copy V (lied with the city Inspection division.
GREASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE
GREASE TRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thlasection need not be completed if the permit V for one hundred dollars
PAID
Date Recei t#
SEWER -SANITARY -STORM EA 1BBFr.
h)-
($100).rfy thatabo theed,
Illnot thato theperformance
I shag not employ any pereon in any manner m az to become subject to the
preco a In an (mannerhework so as tobcome, this subject
W lawn ofGllfomla. Date
WATER HEATER W/VENC/ELECTR
ENERGY FEE Y N —
'
PAID
WATER SYSTEM/TREATING
ca'Compensatlon
Applicant
NOTICEco APPLICANT: a after making this Certificate of Exemption, you
should ode,yo most
me thwitect to [co Workers' such provisionsor thions of s permit s Labor
Code, you must forthwith comply with such provisioro orchis permit shall W
deemed revoked.
Date Reeei t#
NEW RESIDENTIAL PLMB. SQjrL
'T'OT'AL(
BUILDINGELE
co
-TOTAL:
SEISMIC FEE
ELECTRIC FEE
1, 117
CONSTRUCTION LENDING AGENCY
Ihereby affirm that there is a construction lending agency for the perforrry
ance of the work for which this permit Is Issued (Sec, 3097, Civ. CJ
Lendere Name
LenderaAddreas
I cenlfy that have read this application and state that the above Information
QTY: MEG"ANICAL;PEIt1NIT FEE,,
PLUMBING FEE
MECHANICAL FEE
FEES PAID:
Is corned. l agree to comply with all city and county, ordinances and state laws
PERMITISSUANCE
relating to building coratmetton, 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
ag Inst liabllRies,judgments, moused expenses which may In anywayaccme
ag Insto ld Ci i cot uenre of a granting of this permit.
IB —21I
'Date
ALTERORADDTOMECH.Date
AIR HANDLING UNIT (TO 10,000 CFM)
Recei t#
P
SUBTOTAL'.
'
AIR HANDLING UNIT (OVER 10,000 CFM)
CONSTRUCTION TAX '
Signature of PER ant Ctractor
on
EXHAUST HOOD
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (To ID0p00 BTU)
Will the a ppllant or future building occupant store or hand Is hazardous
material
and defined b te�M Cupertino Munlclpal Code, Chapter 9.12, and the
Fkalth and SafetyC Ion 2S532(a)7
❑ Yes No
Dale RCCeI f#
BEATING UNIT (OVER 1013,0010 BTU)
TOTAL:
VENTILATION FAN (SINGLE RESID)
ISSUANCE DATE
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Willthe appllanI r turc building occupant use equipment or devices
which emharo
emit hazardous air .nevieants as defined by the Bay Area Air
Qua lllyManagement st 7
q Yes No
have read the
theCalifornia Health Codrlalsrequl 25505, 5533unde'rChapter6.95 of
Health Safety Sections 25505,25533
BOILFR-COMP(311P OR 100,000 BTU)
BOILER-COMP(OVER 100,000 BTU)
NLW RESIDENTIAL METH. SQ.I7.
he building does a tenant; that
understandyton that if notify thldingdoes of t e rrentlyhaers wench that It is
to notify the occupant of the requirements which must be met
2
psor toilmua
priorm lasuance ofa Certlticate o(Ompanry.
9 V^
]SSIIHD 6Y:
Ownerorauthcm.dagent .' Date
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TOTAL:
OFFICE COPY