22960APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Idemlfkadon -
Bu Eaing Address:. ,.^
PERMITNO.
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CITY OFCUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BRLDING-ELECTRCA4PLUMBINC- MF-CHAMCAL
AFFLICAlIONSUBMITTAL A
` 1.
Co^tractoei,Name: / //Lic.NO:
tiEFF y1CF10A) LQ/Wj
CATEGORY
_
CONTROL#
Architect/Engineer. Lie. No:
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Addreu: _
- PERMITISSUANCE
06U` PLUMB MLL11
❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l are licensed under provisions of Chapter9(comment,
Ingwitht...1 Section force effem3o(the Businmeand ProfeedonsCpde, and my
Ilcenx le In force end effect.
APPLIANCESRESIDENHAL
708 DESCR^IPHON
PANELS
s
License Cla® LION
Date Cantnctor
s
201-1000 AMPS
ARCHITECTS DECLARATION
I understand my plane shall be used as public records.
OVER1000AMPS -
SQ. FT. FLOOR AREA
$/SQ. FT.
SIGNS ELECTRICAL
LlcenxM Professional
-
OWNFR-BUILDER-DECLARATION
I hereby afift. that I. exempt from the Contractor. License Law forth,
-
SPCCIAL CIRC[AT/MISC%
TPMP.MEfER ORIOLE INSl.
followingmamn.(Section 7015, Business and Profession Code: Any city or
c ntywhkhrequire,aper ttommtmtt,alfa*Improve,demoluh,orrepair
anystruaum priorto its umance,auorequlmstheapplicant forsuch permit to
file a signed statement that he In Memand pursuant to the provisions of the
Contractor'sLicense Law (Chapter 9(commencing with Section 700D) of Divi-
slon3 ofthe Bustnes and Pr000kma Code)mthat he 6 eumpaherefmmand
the bash for the alleged exemption. Any violation of Section 7011.5 by any
applicant fora permit subject, the applicant to a civil penalty of net room than
five hundred dollar, (55001.
F1 1, as owner of the property, or my employees with wages as their sole
POWER DEVICES
SWIMMING POOL EUCTRIC
ATIOkkd,
a-� VALUV
O OQ
2 ,
OUTLETSSWITCIIESFIXTURES
NEW RESIDENTIAL ELECTR SQFr.
STORIES
TYPE CONSTRUCTION
compensation, will do the work, and the structure isnot irdended Or Offered for
ssle (Sec. 7034, Buslmu and Professions Code: The Contractor, License Law
it. in apply to an owner of property who builds or impreves thermn,and
who doessuch work himself Or through hlsown employees, provided that such
OCC. GROUT'
RFS. UNITS
Improvements arc not Intended proffered for sale. If, however, the building or
Improvement la sold within oneyearofcompletion, the owner-bullderwlll have
TOT 1
pfsala3.
tc toowner of the tt pr he did property,
a build or imp ove contracting
a owner tr the property, am exclusively contracting with Licensed
with
co e BusinessCode:
doeect ( ec.nes, 7044,
QTY. PLUMBING PERMIT FEE
PERMIT ISSUANCE
FTAOD ZONE
APN
CotomtOcomicenuct
Law
Contractors License Law does h apply et an owner Of propert)/who
apply owner of
onlids or Improves therm., and who mnlror's ins such PW v/Ith
the Contactor. Llmnx Law.
"i ameexempt under Sec.
1_I I em exempt under Snc. B k P C for thin remon
L,IER A VENTTMATER
1� ,� n
-
BAC(( PLOW PROTECT. DEV1CFi�
FEE SUMMARY
OUTSIDE FEES
•s {DRAINS If kROOF,
,.
pD(TVRES PER TRAP
_
SANITARY Y_ N_
RECEIPT#
Owner ' Date
WORKMAN COMPENSATION DECLARATION
Of hemby affirm that I have a certificate of consent to self-inwrei ora
certificate O(WOrlors'Compmeatlon lmuranm Ora onrtNed copythereo (Sec.
SCHOOL -TAX Y_ N
RECEIPT p
-11NC.60UTLETS'
PARK FFR Y N "
RECEIPT N
3800, Lab C.)
Polity #
COT
Cor^ ^Y
-
GAS EA. SYSTEM -OVER 4 (EA)
BUILDING
BUILDING DIVISION FEES
❑ Certified copy la filed with the city Inspection division.
GREASE/WDUSTRL CCPTOR
WASTE IN77R
PLANCFiECK FEE
GREASETRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(INauction need not be competed If the permit ularpns hundred tlollaa
(S1 W)Or
I malty that In the perfomunon of the work for which Permit this peit 1, usual,
I shall not employ any Faxon In any manner w as to become subject to the
Workem'Compenution Laws of California. Date
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you
should become subject to the WOrkem' Compematlon provisions of the Labor
Code,you must forthwith comply witheuch provulom orthu permit shall be
doomed revoked.
rimre
PAID.
Date Recce t#
SEWHILSANITARY-STORM F.A.20017
WATER HEATER HEATER W/VENT/ELECTR
ENERGY PEE Y N
PAID
Date Recei t#
WATER SYSTEM/TREATING
NEW RESIDENTIAL PLMB.__SQFT.
- -
TOTAL:
^e
N
- IOTA.
SEISMIC FEE
ELECTRIC FEE '
CONSTRUCTION
CONSTRUCTION LENDING AGENCY
I hereby affirm that there la a construction lending agency for the perform
anon of the work for which this permit u bi ued (see 3097, Civ, C.)
Lander'. Name
Lender. Add mee -
I certlfythatl havereadthu application and nate that Neaboveinformation
-
QTY. MECHANICAL PERMIT .. - :FEE
PLUMBWGFEE
MECHANICAL FEE
FEES PAID:
Date R*Cel p
ucorma. lagreetOcomplywlthaRcfty, and county ordinance and statelaws
relating to building commmetim and hereby authorise representatives of this
city to enter upon the above-mentioned property for Inspection purposes.
(We) agree to ave, indemnify an d keep heartens ens the City of Cupertino
agaWtllabililegjadgme, andexpenses whkhmaylnanywayaccrue
against said City In f1 °ming of this permit.
PERMIT 156UANCE
ALTERORADDTOMECH'
AIRHANDLINGUNIT(TOto,"CFM)
SUBTOTAL,
AIR HANDLING UNIT (OVER t0,000CFM)
CONSTRUCTION TAX
SI atuMof Applican ontrader - to
! BOGUS MATERIALS DISCLOSURE
EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HEATING UNIT (TO 100,000 BTST)
--
Wllltheappll ant Orluture building occupant atom or handle haeardous
mte
arial m defined by the Cupertino Municipal Code, Chapter 9.12, and the
I lealth and Safety Code Section 25532(a)?
[—]Yes M No
Will the applicant or future building Occupant use equipment or devices
Date Recei t#
HEATING UNIT (OVER 100,000 BTU)IOTA
.
VEND LATION PAN (SINGLE RESID)
"y'
F: A�-y, &CE DATE
which emit harardom air contaminants as defined by the Bay Area Air
Quality Management District?
qYes M No
have Mad the ta°° Safety u5533 and 255re.95 of
the Healthk Code, Se rcons 25505,
Coesnot lons7550$2e
�I
IIOv �+$ 19ne/
s7r
BOILER -COMP OHP OR 100,0(* BTU)
BOILER -COMP (OVER 100,000 BTU)
NEW RESIDEN77AL MECH. SQ.R.
understan t building a tenant, that I1
ocipmlandlhal ifthethe icgdcet not a mquiyhavea tenant, that ltumy
rapomlbluty of the requirements which must be mitt
CITY Ut laUterrl I INV
Cthe l-W.fOccupant
ce Ole
prior to Issuance ofd CertlRcate ofOavpanry.
'-" -
ISSUED BY7M
Owner Or auth riaad agent - Data
-
TOTAL:
OFFICE COPY
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IN ACCORDANCE WITH THE, CITX Ol9
CUPERTINO '
CODES''AND ORDINANC
DATE r>
SIGNED
This set pfrpians aqd specihcaboiis'tQ ,:w
be kept on;'tha lob a4 ali trmas and itis
lawful to make any changes or alterati S '; ,
on some without wntteit pQrmsslon,P
the bulldIng-:Dep-
The
rigDepTho fife mprdgYDtlhfs+plan` dy s 4
SHA4t N :oe freed. Lm :or-
opproval.of.,the Vwfation of any
jf an nce'ors ate Lbw
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