20644APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification
Building Address:
PERMITNO.
-20644
4q blo
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m� 'ame:
X7 A , 0.45`1 Phone:
& Cowl -Z.4
CITY Or CUPERTINO-BUILDING DIVISION
.' APPLICATION / PERMIT
BMDINC-ELECMCALnUMlNGMFCHANICAL
A PPLICAIION SUBMnTAr5XTr—
&Connxfv%N�. :
"K2Z'
CATEGORY
I C""60es
'.IIIUILD�ING PERMIT INFO, t,'
"4 /Frgi , Lic No:
Add..
19TY
PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I ant licensed under provisions o(Chapter9 (commere-
ingwithSection 7000)mDivistce3 ofthe BusinessanciPr6fesslinaCode, and my
license is I. fulljarciLtod effect,PANELS
License Class Date Contractor
APPLIANCES -RESIDENTIAL
JOB DESCRIPTION
—
— LMM2DQAMPS
201-IODO AMPS
ARCHITECTS DECLARATION
I understand my plain shall be used as public records.
OVER1000AMPS
SQ. FT. FLOOR AREA
$/SQ -FT
SIGNSELECTRICAL
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I sinexempt from the Contractor's License Law for the
SPECIAL CIRCUH/M15C A
TEMP. h%Tr:R CREOLE IN41
POWER IVICES
following maxon. (Sechod 7031.5, Business and Professions Code; Any ifty or
cmntywhichrequimsapermitt.c.mtr o,.It,,bnpmve,de=ltsh,ormpair
asystrucume priortottalusuarce, also requireathe applicant forsuch permit to
Ole a signed statement that M is licensed pursuant to the provisiom Of the
Contractors License Law (Chapter 9 (conoreasocing with Section 7000) of Divi-
sion 3 of the Busuessised Pcfeageres Code) or that he Is eximp"heredmen and
the bash for the alleged exemption. Any violation of Section 70313 by any
as04A
.pplj.nt fora permit subjectiahe applicant to a civil penalty oftict more than
Ove hundred dollars ($500).
r 11, as owner of the property� or try employees with wage. as their sole
SWIMM[NLWL
VALUATION
cod
NEW R11%*AftLj1FR
STORIES
cornpcosaflor� willdothe work and thestruclum fis nor intended or offered for
.
FECONSTRUCTIDN
-to (Sec. 7044, B.,I....d PmfxxxJ.o; Code: The Contractor. License Law
TOTAL
�T�Y. L IN 171213''
LSU CE
A "-DMINVENT-1A1 (EA)
N
does net apply to an owner of property who builds or improve, thereon, and
who does such work hinceself orthectigh his own employees, provided that such
Improvements am not Intended oroffered foriale. If, however, thebuilding or
Improvement issold withinoneyearofcomplothoo,the mrer-buflderwili have
the burden of proving that he did not build or improve for purpose of sale.).
M L as me, of the property, am exclusively contracting with licensed
contractors to construct the project (Sce, 7044, Business and Pmfmiom Code:
The Confiractor's License Law does not apply to an owner of property who
Wilds or improves thereon, and who contract• for such InIo)ectax with a
c,.cxxr(.) 11 ... d pursuant to the Contractors License Law.
ffI am exempt under Sec. B & P C for this
OCC.GROUP
FLOOD ZONE
BES UNITS
APN
BACK FLOW PR0TDCT. DEVICE
FEE SUMMARY
OUTSIDE
F17ES
FLOOR ROOF, AREA, COND.
FIXTURES. PER TRAP
SANITARY Y— N
RECEIPT
OwnerD•kDRAINS.
IVI
WORKAN COMPENSATION DECLARATION
now
C31 hereby affirm that I have a cantificate, of consent to self -insure, ora
5CHOULIAX Y_ N_
certificate of Workers'Compematlonlmurance ora certified copythemof (See,
3803, Late C.)
Policy N
RECEIPT N
GAS. EA. 9YSTEM.I INCA OUTLETS
PARK FEE Y— N—
RECEIPT 0
Com
GAS EA. SYSFEM-0VER4(A)
HUI LOING D I VIS ION FE ES
c-c.yifivd copy Is hereby furnished.
_;;ramfied copy ii� filled with the city inspection division
GREASE/INDUSTRIL WASTE INTERCEPTOR
PLANCHECK FEE
GREASE TRAP
CERTIFICATE OF EXEM PTION FROM WORK ERS'
COMPENSATION INSURANCE
(rhl.iicctionneed maix,crunplenedifthe permit fifor one hundred dell..
($100) or Ing.)
I certify that in the performance ofthe work forwhich this permit Is Wurd,
I shall Act employ any person In any mancer w as to beetsubject to the
PAID R Z
Dille —..-;fit#
I (Ck CV7
SEWER -SANITARY -STORM EA. 200FT.
WATER HEATER W/VENT/ELLCTR
ENERGY F�EEY N
WATER SY51MM/TREATING
Workars' Compensation Laws of California. Date
Applicant
NOTICETO APPLICANT' If, after ki=,fificate o/ Exemption, You
should become gib)ect to the zr= Compensation provisions ofthe Labor
Cude, you at forthwith comply with such provisions or this permit shall I he
deemed revoked.
CONSTRUCTION LENDING AGENCY
Iht.byaffl,m that the. I. a construction lcndi.gag ..... ...
once .fthevm,Ix f.rwhich this permit Is issued (Sec.3097, Civ. C.)
IQ9
PAID Ct '
ecei t#
e
NEWRISIDENTIALPI.MB. SQjrr.
T TA11L-
t
-!i!'CV
B G
—ToTAL..
FE
SEISMIC F
1:x
ELECTRIC FEE,
baa
r
Lender's Name
Lenders Address
I certify that I have madthis appucatiomand gate thattheidsvelitimmani on
QTY' MECHANICAL PERMIT FEE
P
PLUMBING FEE
-
MECHANICAL FEE
PAID:
hicurrect. I agree to comply with all city and county ordinances and gate laws
PERMIT ISSUANCE
—
relating to Wilding construction, and hereby authorize representatives of this
city to enter upon the above-monfloned Property for inspection purposes.
(We) agree to save, indemnify an of keep haronless, the City of Cu pen too
.g.i.Wbilifies'Pcifirmotis, A. and expenses which my In anywayaccrue
.g.i I try in con . the granting of this permit.
A
ALTERORADDTOMECFL
—
AIR HANDLING UNIT (to 10,000 CFM)
—
Date Re CI t#
;;A
qIflRT TAI-
AIR HANDLING UNIT (OVER 10,fififiCEM)
CONSTRUCTION TA
Si m.fApplicsm,,..,.cr Date
A7"
EXHAUSTHOOD(W/DUCT)
CONSTRUCTION TAX AID:
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (TO 100," BTU)
Will the applicant orfuture building excupartstore or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.1 Z and the
Safety CodeSection
I With and.2 "S"W?
I—) Yen No
Date Recei
HEATING UNIT (OVER IDOOW BTU)
TOTAL:
x�o�
VENTILATION PAN (SINGLE RESID)
1 �NCE DATE
—"%,
L to,
CY
U
r
illth, Ildlcg occupant use equipment or devices
applicant
which emit twearel.., I, centandiu.t... defined by the Bay Area Air
Quality Management District?
M Yea MN.✓
I have mad the hazy mus materials requirements under Chapter 6.95 ofBOILER-CDMP
the Cii1ifinni. Health &S.IdyCode, Sections 25505,25533 and 25534. 1 .
understardthat ifthebullifingdoes note,irrentlyluiv tenant, th I I is
le '
responsibility to net c requirecrem:.ehich must
notify the art of the 'I be ZY
BOILER -COMP QHPOR 100,000 BTU)
(OVER 100,000 1310)
—
I NEW RESIDENTIAL MECTL —SQ.FT
prio nuance of a ificato !Occupancy.
pyo
ISSUED BY��All
agent D�)(
TOTAL:
. I
OFFICE COPY