21974U
iTs
H F0
cc j
LU
a
D 2
U2
LL
OW
>, (L
F_N
2
U—
"'vl
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY.
' Building Pra'ca Idemlfimtlan
Building Addmu:
Z Z Z` y
- P�TN21974.
ere arse: one:
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BUILDINGELECTRICALPLUMBINGMFLHAMCAL
A
— ri j
_C V
Co traeme Na r Lax. N.
G `��v
CATEGORY CONTROL
,F' ;' BUILDING PERMIT INFO-
-ArehRaa/Engineer, - Lic. No:
QTY`?;_ "".ELECTRIC P6RIv11T :•.'.FED
..
Addreec
1 PERMITISSUANCE Z 06
�yj ❑
1�1J
LICENSED CONTRACTOR'S DECLARATION
' withSeI hereby affim ion7Othatlamlkensed 3ofthe er provisiors usinemandrlrfChapter sion&9(rommenc
limnsoh infian 7000onDieffect ofthe Buelncuand ProfnelonsCode,and my
liens:le In (uU And effect
Limn ss Lk.S
Date Contin
ARCHITECT'S DEC ATIO
I understand my glare shaUbe used upublicrecords.
Licensed Professional .'
OWNER -BUILDER DECLARATION
I hereby affirmthat I am exempt from the Contractor's License Law for the
following reason. (Section 7031.5, Business and Professions Cade: Any city or
cauntywhkhmquU aFmr trommtmMa)ter,impmve,de=l6h,ormpalr
anystmcwre priorto Its lesame, alsorequiresthe applicant forsuch permit to
file a signed statement that he Is licensed pursuant to the provisions of the
Contractor's License Law (Chapter 9 (comrrtncing with Section 7000) of Divi-
sion3 of the Business and Professions, Code) orthat he is exempttherefrom and
the basisfor the alleged exemption. Any violation of Section 7031.5 by any
appUantforaper lsubi"theapplicanitoadvilpewltyofnan mthan
five hundred dollars ($SM.
n I, as owner of the property, or my employees with wages as their sole
rompensanon; will do the work and the structure ct not intended or offered for
Ole (See. 7004, Business and Professions Cade: The Contractors License Law
does not apply to an owner of property who builds or improves theame,and
who doss such work himself or through hie own employees, provided that such
Improvements arc not intended or offered for sale. If, he weveq the building or
Improvement issold within oneyearofcomplaioo, the mvner-builder will have
tlq Lden of proving that he did nabuild orimpmve for purpose ofuleJ.
1, As owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7014, Business and Professlom Code:
The Contractors License Law dam net apply to an owner of property who
' Wilds or improves thereat, and who contracts for such PPket. with a
�gtB(.aart9)based! pursuant m the contmetar. Lt... Law.
off,021 21 exempt under Sea B A P C for this reason
APPLIANCES-RESIDENTIALing
J00 DESCRIPTION
L l an
f(`C�
r
PANELS
201ER 100015
OVER TWO AMPS
SQ. FT. FLOOR AREA
S/SQ. FT.
"
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MIST
7FMP.MEIT72 OR POLE INST.
pp RDEVICES
SWIMMING POOL ELECTRIC r�
�. �-•
OVILms%VfT'cHESpD LREs �l
VALUATIONA{�
O D v
,
NEW RESIDENTIAL ELECTR SQ.FL
5 EFS
TYPE CONSTRUCTION
TOTAL:
QTy, PLUMBING PERMIT FEE
OCGGROUP
RIS. UNDS
FLOOD yANE
MIN(_f
pEgOIT ISSUANCE
( � OO
ALTER -DRAIN &VENT- WATER (EA)
BACK EnwiPRorEcr. DEVICE
"' FEE SUMMARY
-
DRAINS FLOOR ROOF, AREA, COND.
FIXTURES- PER 7g0p U
SANITARY Y N
RECEIPT p
Owner Date
WORKMAN COMPENSATION DECLARATION
MI hereby affirm that I have a eminate of consent to sass.Insure, a a
artlBate a(Workeni CompewHonlvurana ora aHifled copytheraci;c.
3800, Lab C.)
Policy pcrt
SCHOOL TAX Y N'
RECEIPT N
GAS EA. INC.40UTLETS �
PARK FEE Y_ N a
RECEIPT p
Com any ( ( s
CC1B copy em famish
�Certlficd ropy V flied with the city inspection division.
CERTIFICATE OF O(EMPTION FROM WORKERS'
COMPENSATIONINSURANCE
(Thlsucilon need nor bee.pleted tithe isforom hundred dollars
($100oriess.)
I certify that In the performance ofth. work r which this permit is issued,
I.hall not em I aype on in i mann o u to onat the
Workai C� 'AWea )f `nl e ..J Gr�7�
Applicant f
GAS EA. SYSTEM -OVER 4 (EA)
BUILDING DIV] SION FEE S
GREASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECKFEE
PAID
Date Recel tin
GREASETRAP
SEWER -SANITARY -STORM EA. IOOFT.
WATER HEATER W/VENT/ELFCTR
ENERGY FEE Y N —
PAID
DatC RCCCI t#
WATER SYSTEM/TREATING
NEW RESIDENTIAL PLMB. SQFT,
NOTICET CANTIf,after nal mgt ertlflcate of Exemption, you
should become subject to the Workers' Compensation provhWu of the Labor
Code,you at forthwith comply with such provislom or this permit.hall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
I herebyaffirm that there le a construction lending agency for the perform,ELECTRIC
ante of the work far which this permit is issued (Sec. 3097, Civ. C.)
Name
Lenders Address -
IartilythatI havereadthisapplicati.eand stater ,atheabove Information
is canna. I agree to comply with all city and county ordhancesand state laws
relating to building mnvtmaloa, and hereby authorise representatives of this
city to enter upon the abovo-nantloned property for Inspection purposes.
(We) agree to Ove, indemnify an d keep harmless the City of Cupertino
.gal at llab. ties, judgmen costsandexpenenwhlchens In ywayaccrue
tax City in con ns, of the gating of this permit
-
TOTAL:
FEEC1d
-131JILDING
TOTAL: 1 640lenders,
SEISMIC FEE
FEE
",. ."t.
QTY. 'i MECFIANICAL�PERMIT,, '!"FEE
PLUMBING FEE
,d
MECHANICAL FEE
PERMIT ISSUANCE
ALTERORADDTOMECH.
AIR HANDLING UNIT DO 10,000CFM)
FEES PAID:
Date RCCCI fin
SUBTOTAL:
6
AIR HANDLING UNIT (OVER 10,000 CFM)
CONSTRUCTION TAX
'
Signamm of Applicant/Contractor IDate
HAZARDOUS MATERIALS DISCWSURE
Will the appUcant.future building occupant store or handle hazardous
material as deflrud by the Cupertino Municipal Code, Chapter 9.17, and the
Health and Safety Code Section 25537(.)7
n Yea �o s
Illtheaft applicant rco.tramengompantuu the BayscluipmartArea devices
which emithagementaairrict? ants as defined by the Bay Area Air
Quality Management District?
Yea No
4bevereadthe haza�ouematerials requlremensunderChaper8.95o(
the Glilornis Health k Safety Code, Sectsoun 25505, 75533 and 75534. I
hait the building don not currently have a tenant, that it is my
y to notify the ccupant of the requirements which multi be
nC ofa Cc is cofocmpucy.
4acrthors g Date
" -TOTAL:
DmAUS'I HowM/DUCT)
CONSTRUCTION TAX PAID:
"
HEATING UNIT (TO 100,000 BTU)
-
Date RBCCI fin
HEATING UMT(OVER 100,000 BTU)
—i�
TOTAL:
QQ
VENTILATION FAN (SINGLE RESID)
ISWAJDDATE
-AL �nQ'1t
t -AR 2 6 1
City of Cuf)(ir-a q
P
ISSUED BY: _
BOILER -COMP pFIPGR ]OO,IXD BTU)
BORER-COMP(OVER 100,00 BTU)
NEW RESIDENTIAL MECH. SQ.FT.
OFFICE COPY