22721APPLICANT TO FILL IN INFORMATION WITHIN REDLINES —'USE BALL POINT PEN ONLY
Building Project Identification - - -
Building Address: L
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PERMIT NO.
°2 2 7 21
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CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION I PERMIT
BUfLDING-ELECTRICA MUMBING-MECHAMCAL
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Cant �'a�'ame: S 5
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CATEGORY
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Tti t�; EI.ECTRICPERhIiT}4 ta'FEE1
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Address:
PERMIT ISSUANCE '� -
❑ ❑, ❑
- LIC ENSEDCON'TR
under rDECLARATION
Ihereestion7000)oby affirm that Div H=3ofunderleassa dProfessions 9(mmmrnc-
DlvF.d. ofthe BusinessandProtesslonsCode,and my
'nenseISemler farm
'license lain force end ic.It 6
Llcen CW LIe, p U
APPLIANCESRESTDE
JOB DLSCRR'I70N
`
PANELS
...�M_
Dat Cmnhactor �//`S_'
ec
1-1
- ARCHITECTS DECLARAT N
I understand my plans shall be used as public records.
O AMPS A
54' FT, FLOOR AREA
$/SQ. FI'.
N ELECTRI
Licensed Professional _
IALCIRC -
OWNER -BUILDER DECLARATION
I hereby affirm that l am exempt fromthe Contmdor'-License Law for the
TEMP. METER O POLE INST.
following reason. (Section 7031.5, Business and Professions Code: Any city or
cmntywhich mqu res a perrrdtto mmtmd, altep lmpmve, demollsh,orrepair
`
anystmMmpeortoibl mance,abomquW stheappli=tforeuchpermitto
file a signed statement that he b licensed pursuant to the provisions of the
POWER DEVICES
SWIMMING POOL ELECTRIC
Contractor's License Law (Chapter 9 (commencing with Section 7000) of DWI'
ston3 ofthe Busmossand Pmfemlom Code) orthat hell exereptthomimmand
'VALUATION
the basis for the alleged exemption. Any violation of Section 70315 by any
apPHcant fora perret subjects the applicant to a civil penalty afoot more than
OUTLE7SSW[7CHESF[XTURES
`
-
• NEWRESIDENTIALELEGTR' SQ.FT.
f6,tmdreddollxrs($500).
❑I, as owner of the property, or my employees with wages as their sole
STORIES -
TYPE CONSTRUCTION
compensation, wllldo Ne work andthe structure is; not intended or offered for
.It (St.7044, Business and Professions Code: The Committees License Law
does not apply to an owner of property who builds or improves threaten, and
whodoessuchworkhlmselforthr ghhisownemployees,providedthatwch
OCC,GROIIP
RES UNITS
Improvements are not Intended or offered for sale. If, however, the building or
improvement le; sold within oneyearofcomplation, the owner-builderwiil have
tFakurden of proving that he did not build or improve for purpose ofs k)
L j L as owner of the property, am exclusively contracting with4levesed
contractees to constwd Professions, project (Sec. 7054, Business and ProfessioCode:
TOTAL:
•.1,, :,,;,„
QTY : ;;.FEE`";t
-LANE
.';�,t ,l ,LUIV($ING.(?EIiMI`F
- PERMIT ISSUANCE
FLOOD
APN
The Contractor's License Law does no apply to an owner of property who
builds or Improves thereon, and who conhade for such pkejece with a
co� 6tt{{ador(s) licensed pursuant to the Contractors License Law.
fI am exempt under Sec. B & P C for this reason
--
ALTER -DRAIN &VENTWATER (EA)
..,
. f d't '.FEE+SUMMARY?
BACK FLOW PROTECT. DEVICE
OUTSIDE
FEES
DRAINS FLOOR RODF, AREA, COND.
FATUBES PER TRAP
SANITARY Y_ N
RFAEQYfB
Owner Date .
WORKMAN COMPENSATION DECLARATION
❑I hereby affirm that I have a certificate of consent to self -insure, or a
cenHlrateofW�or[lee/n''Comperuatlon l�r+inuranre aramnifled copythereof (Sec.
Po evJeb C./Tlld �_ �% / 9 - 93
SCHOOL TAK Y N
RFC= p—
GAS EA. SYSTEM -1 INCAOUTLETS
PARK FEE Y N
RECE[PTp
GAS EA: SYSTEM -OVER 4(EA)
Com ann� `L-�/-G
BUILDING DI SION FEES
[�Cchilled copy b herebyfurnished.the city -
ert8ied copy is filed with the city lr�e)xctlon division. -
GREASE/INDUSIRL WASTE INTERCEPTOR
PLANCHECK FEE
GREASE TRAP
CERTIFICATE OF EXEMPTION FROM WOBRIBES'
' COMPENSATION INSURANCE
(This section need net be completed lithe permit is forces hundred dollare
PAID
Dat /Reizeiptilt
SEWER -SANITARY -STORM EA. 200FT.
T
�A / U
ENERGY F N
PAID
($1000 m lea')
ce
Irtify that In the perfmorammofthe work forwhich this permit le e
I shall not employ any person In any manner w as to become wbje ISthg
Workers' Compensation laws of California. Date
Applicant -
NOTICE TO APPLICANT: If, ager making this Certificate -d Exempt) you'
should become subject to the Workere Compensation provi.lov of th. Labor
a Recei int
'k&VR D ALL SFT.
TOTAL:
Code, you most forthwith comply with such provisions or this. permit shall ya
deemed revoked. -U
BUIL E
SEI$ I EE
CONSTRUCTION LENDING AGENCY.
I hereby affirrethat there U a conrtrudlon lending agency for the perform-
ante of the work for which this permH b issued (Sec. 3097, Civ. C.)
Leader's Name .. '+
Lender'sAddress -
IrerEfylhat I have read thisappHrationand.tatethatdheabove i mcnetwe
correct.I agreeto complywith all dlyand countymelinancesanddam law.
TOTAL:EL
RI FEE -
'
., ..' , . • . , ,.. ....
QTY' MF;,C''_HA_NICALI$ RVIIT •:''FEE,'O
�' PERMIT ISSUANCE
PLUMBING FEE
MECHANICAL
FEE$PAID:'
relating to building wrubuctlon, and hereby.uthorkm 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 Ce Jeanine
ALTERORADDTOMBCFL
Da be R'eeiIq - P
SUBT TAL:
against liabilities,judgments, was and expenses which may In any way accrue
against said City In censxryenre of the granting of this permit.
-
AIR HANDLING UNIT (TO 10,MO CFM),
AIR HA NDLING UNIT (OVER 10," CFM) �'
CONSTRUCTION TAX
Signature of Applicant/Contractor sData
EXHAUST How(W/DUCT)
CONSTRUCTION TAX P D:
I HAZARDOUS MATERIALS DISCLOSURE
_
HEATING UNIT (TO TD0,000 BTU)
- `
Will the applicant or future building occupant store or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.12, and the -
Health and Safety Codq�`,gRon 25532(a)i
❑ Yes - No
Date Recei t
HEATING UNIT (OVER 100,000BTU)
TOTAL:
VENTILATION FAN (SINGLE RESID)
-, ISSUANCE DATE
qq-
6�]F/j
Will the applicant r lure building occupant use equipment or devices
which emit hazardous air contamimnts as defined by the Bay Area Air
QualityManagement Dish 7
4 Yes No
have read the us materials requirements under Chapter 6.95 of
the California Health & Safety Code, Sections 25505, 25533 and 25534. 1,
BOILER-COMP(3HP OR 100,0M 8771)
� BOILER -COMP (OVER 100,000 BTU) A. rao'-
NEW RESIDENTIAL, MECH.' SQ.FT
understand that if the building does not currently have a tenant, that it is my
ay
responsibility to ua(tonotify lafti occupant ofthe requlremeniswhich must be met•�-
'ortoissua ofs rtificateo(Ompanry.
J
.
5 9
P7/(
9
neroraulhor a et Date
"
- TO
ISSUED B
OFFICE COPY