24000APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification
Build ing Address:
a 3 3G , �9G
PERMIT NO.
") A O O O
24000
G 4
• ams: one:
d i
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
7
C lnRor'a /
Name: LIc. No:
(//�
• O L r"V�
' Archit /Frginoxr; LIc. Na
BUILDING-ELECTRICAInUMBINC-MECHANICAL
CATEGORYCONTROLIf
-
QTY ELECTRICPERMIT FEE'
BUILDING PERMIT INFO
Addre••:
,.
PERMIT ISSUANCE
❑ ❑ IV] ❑
LICENSED CONTRACTOR'S DECLARATIONLj}
The yaf(Irm that l am licensed under provislonsoftZhapter9(mmmenc
ingw Seetlon7000)of DiAgon3ofthe Businessand ProfeskmaCode,andmy
Boers Islnfullforceandeffect.
APPLIANCES -RESIDENTIAL
PANELS
JOB D[SC ON
\
Lice se Clam Lk.p
-
V -S\ r
Date Cmdra ctar
UP TO 2DOAH�S
1014000AMPS
ARCHITECTS DECLARATION
I understand my plans shall be used as public records.
OVERIOOOAMPS
SQ. FT. FLOOR AREA
$/SQ.FT.
SIGNS ELECTRICAL
Llour sed Pmf esimed
' OWNER -BUILDER DECLARATION
I hereby affirm that I amexempt from the Contractor's License Law for the
following.... election 7MI.5, Business and Profession• Code: Any city or
cwntywhich requbesa pernit mmlutruct, alley bnprove, demoW h, orrepalr
anystructure priorto its Botvane,alsorequirestheappilcant forsuch permit to
file a signed statement that W is licensed pursuant to the provisions of the
Contractors License Law (CMpler9(commencing with SeRion 7000) of Dlvl-
slon3 ofthe Business and Profenloos Code) orthat he Ls exempt therefmmand
the basis for the alleged exemption. Any violation of Section 7mt5 by any
applicant for a permit subjectsthe applicant to a civil penalty of not onrethan
five hundred dollars ($500).
�1, as owner of the property, or my employees with wages as the&sole
compensation, willdo the work, and thestructum Et not Intended or offeredfor
sale (Sec. 7064, Business and Profession Code: The Contractors License Law
"
SPECIAL CQ(CUIT/MISC
TIME. METER OR POLE INST.
POWER DEVICES
gyrps{f gNG1i�OC ELECTRIC
- pp — —
O E ZTCHESFTXTUL
7-7
VALUATION
WR DPN7IAL ELECTR'
." �--��:�' C'
STORES
- TYPE CONSTRUCTION
-- • - 1_;
does not apply to in owner of property who builds or improves the. , and
whodsuchworkhimvelfwthr ghhisownemployees,provided thatsuch
ImprovementsarenotintendMorofkredfors e. If, however, the building or
Improvementissoldwlthinoneyearofcompletb theowner-buliderwillbave
t1I9.¢urden ofprovingthat he did notbulld or improve forpurposeofaale).
UL as owner of the property, em exclusively mnlractng with licensed
mntnchus to construct the project (Sec. 70K Business and I'mfe talaru Cade:
The Contractors Ltmnrz Law don not apply to an owner of property who
Wilds or Improve• thereon, and who contracts for such ptio a. with a
IDlf�ctorp exempt under roto the Contractors Llcenae Law.
LJ I am exempt under Sec B k P C for this reason
� �oesof of of If
-' ----TOTAL: -
Q°jy, .,''" PLUMBING PERMIT' i ". FEE"'
PLR dTT ISSUANCE -
ALTER -DRAIN &VENT- WATER cEn)
OCO. GROIR'
RFS. UNRS '
FLOOD ZONE
-
- MIN
BACK FLOW PROTECT. DEVICE
I " '-fu SUMMARY"
Owner Date
DRAINS FLOOR ROOF, AREA, COND..
FTXTURE4I'ER TRAP
SANITARY Y N
RECEIPT If
WORKMAN COMPENSATION DECLARATION
QI hereby, affbm that I have • wtHOcate of camm�t to sell -Inure, or
SCI100L TAX Y N
mrtlficateofWarken'Compematlon IoauranceoraceAlfWmpytherea((Sec.RF
38W, Lab C.)
Poll p
Policy
MK
S
GAEA. SYSTEM -1 INCAOUILES
PARK FEE Y N —
RECEIPT p
Com
Com any
copy is herebytumbhed.
�CehRed copy Is filed with the city Inspection division. -
GAB -EA. SYSEFMAVERdIRA)
GREASE/INDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
PLANCHECICFEE
GREASE TRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This version need not be completed lithe pared[ is !Drone hundred dollars
h -
($100)otifythat
Icerum thatoy an person
work for whlcbcomethis esmitb4o the
I .,khe not employ any person In any manner so
any n to become subject to the
Workers Compensation Lawn of California. Data
Applicant
NOTICE 70 APPLICANT: If, after nuking this Certl(Icale of Exemption, you
vhmldy=tu aubFcttothe Worken'Compematlonpmvbdoru ofthe Labor
Code, you multforlhwith comply with such proWiav orthb permit shall be
deemed revoked.
PAID
Date Reeel t#
SEWEJi-SANITARY STORM EA 200F'T
WATER HEATER W/VENT/ELLCTR
ENERGYFEE Y N
—. —
PAID
Date Remi [#
WATER SYSTEM/TREATING
NEW RESIDENTIAL PLMB. SQPG
TOTAL:
"
BUILDING
CONSTRUCTION LENDING AGENCY
I hereby affirm that there b a mretmction lending agency forthe perform
anceoftheworkforwhlchthispermitbimed Ce.3097,CIv.C.)
- L.
SEISMIC FEE
ELECTRIC FEE
Lenders Name
Lenders Address
I certitythatl Mvereadthisapplicationand statethethe above mformation
1
Qiy. " "I MECHANICAG.PERMIT" FEE -7
PLUMBING FEE
"
MECHANICAL FEE
-PAID-
Is correct. I agree to comply with all cityand county ordinances and nate laws
relating to building mmtmction, and hereby authorize representatives of this
city to enter upon the above -me lloned property for inspection purposes.
(We) agree to save, Indemnify an d keep harmless the City of Cupertino
PERMrrISSUANCE
ALTERORADDTOMECH.
FEE
Dale ReC01 t#
a abut RablIf ,Ndg cats, mYa whih may In anywayaccrue
a amat as tty, N sequen gr" Ing of thio permit.
—S
AIR HANDLING (NIT(TO 10,ODO CFM)
- SUBTOTAL:
AIR HANDLING UNIT (OVER 10,000CFM)
CONSTRUCTIONT X
EXHAUST HOOD(W/DUCT)
CONSTRU AX PAID:
m reo Ap nnctor IAte
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT CID 100,000 BTLB
Willtheapplicanl orfuture building occupant store or handle hazardous
rnaterulas defined by the Cupertino Municipal Code, Chapter 9.17, and the
Health and Safety Coder.-S�ection 8537(•)7
I] Yes II No
a Regie' #
HEATING UNIT (OVER 100,000 BTU)
TO
VEMILATION PAN (SINGLE RESID)
ISSUANCE DATE
P p
M iD
Will the applicant orfutum WIldingocmpantuse equlpruntordevices
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management District?
ct7
4 Yes N No
have readtheh. ous materials requirements under Chapter 6.95 of
the Califernla Health A Safely Code, Sectiow 75505, 25533 and 75536. 1
BOILER -COMP HPOR 100,000 BTLD
O
BOILER -COMP (OVER 100,000 BTU)
NEW RESIDENTIAL METH. SQ.Ff
understand that if the building does not currently have a tenant, that It is my
respOrdflilily to notify the occupant of the requbements which mu at be met
prior to Issuance of a Certificate of Oavpincy.
JUL�� ��� '
{ii i. 2 ��
CIl'Y �,: r u
ISSUEDBY:
Owner or authorized agent Date
-
TOTAL:
OFFICE COPY