23089APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification
B Edmg Address: -
PERMIT NO.
22a g4#c ST— L'uPsoniv
23089
yJ�' ma: r�-77 nae:
G.QEM P0.5ACA oavr'— "'6'1
CITY OF CUPERTTNOLBUILDINGDIVISION
APPLICATION I PERMIT
ContrasprsName: - 'LIc'Nm
lvl
BU,rLDINGELECTR[CAL-PLUMBING-MECHANICAL
CATEGORY
CONTROL X
Architect/Engineer, Lie No:
QTY ELECTRICPERMIT FEE
BUILDING PERMIT INFO
.❑.,
-
•
'
Add.. '.
PERMITISSUANCE
❑
LICENSED CONTRACTOR'S DECLARATION
I herebytefflmo that l am licensed under provisloes of Chapter9(commene.
ingwlth Se ton7000)o1DtN.ion3ofthe B.M...ad ProfesslonsCode,andery,
ma is Ins foroeand effect.
APPLIANCES -RESIDENTIAL
- JOB Ul O
� %
PANELS -
Vh. Clam LIff c
SIe Contractor
ARCHITECTS DECLARATION
I understand my plans shall be used as public rem
Licensed Profe®iatul
'
_
XC�1fV' I�r i /
ADD/'-
201 -IOW AMPS
-
OVER IOOO AMPSade. ..
^SQ. Fr. FLOOR AREA $/SQ. Fr.�
SIGNS ELECTRICAL
OWNER -BUILDER DECLARATION
IhercbyafBrm that[cam exempt fromthe Contractor's License Law far the
following reason. (Section 7031,5, Business and Professions Code: Any city or
muntywhichrequimsopert ttommtmd,altegimpmve,dennllsh,orrepalr
SI'ECIALCE{CUIT/MISC
-
✓ ,
TEMP M= OR POLE INST.
anystructurs prlorto its Bauance,also requires iheappliant forsuch permit to
file a signed statement that he is licensed pursuant to the provlale ru of the
Contractor's License Law (Chapter 9 (commencing with Section 7000) of Divi-
Man 3 of the Busmom and Professions Code) or that he I. exempt theref amand
the basis for the alleged exemption. Any violation of Section 70315 by any
applicant for a permit subjectathe applicant to a civil penalty of not more than
POWER DEVICES .
SWIMMING TOOL ELECTRIC
VALUATI09skas
/_ Ono ..►�
I
L OUTLETSSWITCHESFl)"rI1RE5
ve dred dollam f&5001,
owner of the property, or my employees with wages as their sole
NEWRESIDENTIALELECTR SQF7.
STORIES
TYPE CONSIl2UCTION
pemation, will do the work and the structure is rot intended or offered for
(See 70dq Business Professions
a and Code: The Con/actora License Law
does not apply to an owner of property who builds or improves thereaR and
whodoessuchwark himself orlhnough hisownemployees, provided that such
-
OCC.GROUP
RFS. UNITS
improvements are not Intended proffered formic. lr,however,thebulldingor
improvement Iuld withinoneyearofcompletion,the owner-builderwill have
trys�aMen of proving that hedid not build oromprove nor purpose ofsale.).
LJ L as owner or the property, am exclusively contracting with licensed
contractors to construct the project (Sm 70th, Business and professions Code:
T ;
QTy, ;. PLUMBINGPERMIT
PERMIT ISSUANCE -
-
FLOOD ZANE
APN
The Contactor's License Law does not apply to an owner of property who
bullda or Improves thereon, and who contracts nor such pWiects with a
M61licensed pursuant to the Contractors License Law.
I am exempt under See B & P C for this reason
7FE
ALTER -DRAIN &VENT- WATER (EN
BA f7TFGT. E
� .. -. �y
FEE SUIMMARY
DRAINS FLOOR'ROOF, t
AREA, GOND.
TRAPi00L
PER d
I it
SINITARY Y N
RECEIPT
Owner Date
WORKMAN COMPENSATION DECLARATION -
❑I hereby of lmt that I have a certi0ate, of consent to self-insurr/or a
TA% Y_ N
rertlfian uaU
teorWorkeComperonlwunnce w a certified copytheanf(Sec.
3800, Lab C.)
RECEIPT X
RK FEE Y N
G EA -1 INCA_
Policy X
ftECEfi'f X
CffCa
BUILDING DIVISION EEEByO
.ert
pybheyfumlh
❑ Certified copy is filed with the city Inspection division.
CREASE/WDUS[RL INTERCF7'TOR
_
LANCHECK FEE
GREASE TRAP
CERTIFICATEOMPE SATION N FROM WORKERS'
COMPENSATION INSURANCE
(Thos d section need not complcted If the permit V (Drone hundred dollars
(51 OD) arfess)
I cent that In employ an person nce In an theworkso as to b ca penult is issued,
Y shall not employ any person In any manner so as to became ubjM to the
W Compensation l�we of California. Date
ApplicantOTICERESIDENTIAL
.NOTICE TO APPLICANT: If, after making p. .tion ate of Exemption, you
ikiNM become subject to the Workers'Compersatlon provltlomoHb. Labor
Code, you at forthwith comply with such pmvisioro orthls permit shall be
deemed revoked.
X
PAID
Date ReS2! t#
SEWER -SA Y -STORM EA 2WFr.
WATER TER W/VENT/ELECTR
ENERGY FEE Y N '
PAID
Date Revel t#
WA SYSTEM/TREATING
PCMB. SQ.Fr.
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TOTAL:
I �'
TOTAL:
SEISMIC FEE
ELECTRIC FEE.
CONSTRUCTION LENDING AGENCY
' I hereby af0rmthat there lad mrswciion lend Ng agency forthe perform-
ance of the work for which this permit Is Issued (Sec 3097, Cie. C.)
Leder'sNamr
Leaders Addcertify ress
I rtify thatl have reacithis appliadonand statethatthe above infomuHon
.. <:,,,.. :. ..
QTY:'' MECHANICALPERMIT FEE''
PLUMBING FEE
.
-
MECHANICAL FEE
FEES PAID:
ismrrect.I agree to comply with all city and county ordinances and state lawsPERMIT
ISSUANCE —r
relating to building comtuction, and hereby authorize representatives of this
city toenter upon the abovo-mentioned property for inspection purpoex.
(We) agree to save, Indemnify an d keep harmless the City of Cupertino
against llabl111lee, judg sand expenses whmce
ich ayminyway.ra.
aga last said City in ern fthe granting of this permit.
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ALTER OR ADD TO MECH,
AIRHANDLINGUNTr TPO]O,DOOCPM)
Date • Receipt#
SUBTOTAL,
AIR HANDLING UNIT (OVER IO,WOCPM)
CONSTRUCTION TAX
sigre 0! a Coniactor Dae
IXFWUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
IIIZARDOUS MATERIALS DISCLOSURE
11
HEATING UMT(TO 100,DJ0 BTU)
-
Will the cap ant or(ulvre building occupant store car handle hazardous
material as defined by the Cupertino Municipal Cde, Chapter 9.12, and the
Heallh and Safety Code Section 25532(s)7
F1 Yes N No
Date ReCCI t#
HEATING UNIT (OVER 100,000 BTU)
TOT
VENTILATION FAN (SINGLE RESID)
ISSUANCE DATE
1'
' A 1 D
DEC 12 egg'
,
CITY OF CUPEHI 1,
ISSUED �/
Will the applicant or future building occupant use equipment or devices
a
which emit hirdousalr mnlamltutra s defined bythe Bay Area Air
Quality Management District?
4 Yes g No
have readthehuar pus mate rials requircmentaunderChapter6.95 of
the Glifemla Health&Safety Code, Sections 25505,25533 and 2:534.'1
understand that ifthebuiodingdoes not currently have. tenant, that It Ismy
respmsibility to notify the occupant of the requirements which moat be mat
prior to Issuance of a Certificate of Occ'upa acy. -
RORER -COMP (3HP OR 100,DM BTU)
BOILER -COMP (OVER 100,000 BTU)
NEW RESIDENTIAL MECH. SQ.FT
Owner or xulhorized agent Datey
AL.
OFFICE COPY