21684APPLICANT TO FILL IN-INFORMATIONVITHIN HED LINES USE BALL POINT PEN ONLY
-
Building project Identification ., -
Building Address: - ... `.Z
PERMIT NO.
A-rJ i�LC b2.I Ve �(?i'�TfjO ck 9sd
1 6 8 4
nes site:
PL 6 �4WI'P 7
..APPLICATION
CITY OF CUPERTINO-,DUILDING DIVISION
APPLICATION / PERMIT.
BUILDING-ELBCTRICALFLUMBING-MECHANICAL
A a TE
•� Z._-�% /
` L
^n acts .Name:' Lie. Na:
t—�4 _ I v
CATEGORY
CONTROL
Architect/Engineer. : Lic. Na
S 1
-�lIO
.:'•B.U.. IL.D. ING PERMIT
EpoA4
Address:..130 SPR[ UiS Lo
PERh9TISSUANCE '
LICENSED CONTRACTOR'S DEC' ARAT N
Ihereby af(irmthxt l am licensed under provisions of Chapter 9(commenc-
ingwlthSedion 7000)of Divl.lon3 ofthe Businessand ProfessionsCode,and my,
license I. I. fti (orc defied. / 9 ! p� � 1
License Cl w IY Llc p �l-b / iaoy[$fF
APPLIANCES -RESIDENTIAL
JOB DESCRIPTION
PANELS
Date -J?��Cor -
UP TO 900 A MRSp
,�
1/:� 7
201-I ODO AMPS
Ir E
ARCHITE B DECLARATION
r�e�a plags aha �9.tyEe�,g�g�pc rglc(i!.
OVER 1000 AMPS
SQ. FT. FLOOR AREA
$/
SIGNSELECIAICAL
—�I
Licensed rofess Wal L•a �tW 4 '6 �1
SPECIAL CIRCUIT/MISC
" OWNER -BUILDER DECLARATION.
I hereby affirm that I am exempt from the Contractor's License Law forthie
-
TEMP. METER ORPOLE [NST.
_
.. POWER DEVICES -
following reason. (Section 7031.5, Business and Professions Code: Any city or
countywhichmquUsapermitWmmtmct,alter,improve,demolish,orrepair
anystrudure prior toits Issuance, alsorequiresthe applicantforsuch permit to
file a signed statement that he b licensed pursuant to the provisiom of the
,-
SWIMMING POOL •GTRIG
Contractor's License Law (Chapter 9 (commencing with Section 7000) of Dial.
cion 3 of the Business and Professions Code) orthat he V exempt therefrom and
VALUATION B
O
OUTLE LIES
the bash for the alleged exemption. Any violation of Section 7MIS by any
ofothan
applicant fora permit subjectstheapplicanttandvilpemltynot mre
%
/ -O O
( `
NEW RESID EL �'�'
five hundred dollars($500).
61'. owner of the property, or my employees with wages as their sole
6
SIO -
- 777PE CONSTRUCTION
-19
c mpensatlon,willdothe work andthestrudure is not intended or offeredfor
.Is (Sec. 70K Business and Prdeadons Codi The Contactor s License Law
does not apply to an owner of property who builds or improves thereon, and
who does such work himself orthrough his own employees, provided that such
OCC.GROUP
RFS. UNITS
-
Improvemeats are nd inteaded or offered for sale. If, howevep the building or
TOTAL:
Improve Lssold withinoneyearo(completion,theowner-bu0derwlll have
thi�burden ofproving that hedid net build orimprove for purpose ofsale)
L1 L as owner of the property, am exclusively contracting with licensed
contractors to conatrod the project (Sec. 7044, Business and Profeeslora Code:
- ,. •, ,,.
.+t" _ j?j;•" •ING'EBR +•'+��•;FEE{;:'
FLOOD ZONE
APN
'
T I55 C
The Contador's License Law does nor apply to an osvner d property who
Wilda or improves thereon, and who contracts for such plojects with a
c�trame(s)licensed pursuant to the Contractor's License Law.
Li I am exempt under Sec. B & P C for thin mason
LTER-DRA & - A
AIX FLOW PR EVI E
n[TTq Inv
vvvq
DRAINS ,AREA, ND.
SANITARY Y N_ '
- RECEIPT
Owner Date..
WORKMANCOMPENSATIONDECLARATION '-FIXTURES.
01 hereby affirm that I have a certificate of consent to selFfirsure, or ,a
rkea'Comperaation lraurance oracedi(led ropy thereof (Sec.
3800, Lab
Polic # CJ
Poiicytl
SCHOOL TA% Y_ N_RECEIrf p
GAS EASY -1 C.40UTLM
-
PARKFEE Y N '
RECEIPT N.
GAS EA. SYSHM-OVER 4 (EA)
_
Cam any
BUILDING DIVISION PEES
ECertitled ropy is hereby furnished.
F-1Certifiedcopy T liked with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
GREABB/INDUSTIIL WA51E IN1-ERCEPTOR
PLANCHECKFEE
yg
PAID' T.� s`i6sl
?°t.
'
GREASE TRAP'
COMPENSATION INSURANCE -
(Thissamon need not be complded if the pernat isfor one hundred dollars
. SEWER -SANITARY -STORM EA. 200F(.
Date Reeel t#
WATER HEATER W/VENT/ELECTR
ENERGYFEE Y N
�--/1
J
I certifythat in the performanceof thework forwhich this permit is issued,
s WATER SYSTEM/TREATING
I shall not employ any person In any runner so ea to become subject to the
Workers' Compsasadon laws of California. Date
PAID
Applicant
NOTICE TO APPLICANT: If, after nuking this Certificate of Exemption, you
should becomesubject to Ne Workers''Compemationprovbiom of the Labor
NEW RESIDENTIAL PLMIE Swi.
Date Race] tS
.,
- TOTAL:
BUILDING FEE
`S
Code, you moat forthwith complywith such provisions or this permit shall be
deemed revoked. `.
CONSTRUCTION LENDING AGENCY
SEISMIC FEE
Ihemby dffirm that there is a construction lend ing agency for the perform,AL:
ance of the work for which this permit is Issued (Sec. 3097, Civ. C)
Lender. Name-
Lender'sAddress
I certitythatl have read this appl cationand datethattheabove information
Iscorred. I agree to comply with all city and courty ordinances and gate lam
rel tobuildin'mmtmdion,andherebyauthod mpresentativesofthls
city to nterr __c above-mentloned property for Inspection purposes.
e) agree to save, Indemnify an d keep harmless the City of Cupertino
ag nstliablllties,judgment., costs and expenses which may in anyway a¢rue
_
ELECTRIC FEE
PLUMBING FEE. -
,
•
Q'IY:;l'u ;MEC}iA ALx ,,• Tz-'?t1FEE .•,
MECHANICAL FEE' -
PERMITISSUANCE r -
FEES PAID'
_Z;22.. , 62"7
-
ALTERORADDTOMECH.,
Date R2eel}7tii
MR HANDLING UNIT (TO 10,000 CFM)
SUBTOTAL:
'aainst sald.Clty.in cons�y nceoff,,the granNn fthle pennlL
a�— - `e
-
AIR HANDLING UNIT (OVER I0,(00CFM)
CONSTRUCTION TAX
Signature of Applicant//CCoontrador a
EXHAUST HOOD(W/DUCT). .. '
CONSTRUCTION TAX PAID:'
'
1. HA2AR000SM TERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous
+ HEATING UNIT (TO 100,000 BTU)
•Date Receipt
material as defined by the Cupertino Municipal Code, Chapter 9.12, and the
HealthandSafety Code Section 25532(a)7 - r
QYes M No
Willthe applicant orfuturebuilding oanpant use equipment ordevices
HEATING UNIT (OVER 100,000 BTU)
- -
- TOTAL:
VENTILATION FAN(SINGLE RESID)
- ISSUANCE DATE
which eat harardous air contaminants as defined by the Bay Area Air
Quality Management District?
4'Yes❑❑No
hava read the baxardan.materlals requirements underGhapter 6.95 of,
the California Health & Safety Code, Sections 75505,25533 and 25534. 1
understand that lithe building does not currently have atenant,that it is my
'resp^rulbllity to really the occupant of the requirements which must be and
BOILER -COMP OHP OR 100,000 BTU)
BOILER-COMP(OVER100,000 BTU)
NEW RESIDENTIAL MECN. SQ.FT.
prior to issuance of a Certificate of Occupancy.
-
ISSUED BY:J �•
Owner or authorieed agent - Date
r-
• '• TOTAL:
OFFICE COPY.
V,
APPLICANTTO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
'
Building Pro'ectiden atisn-
Buil ngAddress: p •
rel=�Dj
s PF)ih4T NO. -
21669
s one:
C I. e t
- CITY OF CUPERTIN6BUILDING DIVISION
APPLICATION / PERM IT
rAL DAM
r�
BUILDING -ELECTRICAL PLUMBINGMECHANICAL
CATEGORY -
CO OLp
A t gimer:, Lk. Na "
;ELECTRIC PEI%NtIT ' t' '� FEE `�
..BU[GDING:PERMIT,INFO
.
Address
•• PERMITISSUANCE
❑ ❑ .
. LICENSED CONTRACTOR'S DECLARATION
_
APPLIANCES -RESIDE
T hereby afflrmthetlam lceneed under prwlalo of Chapt.,9(commare-
Loan h5in III 7000)of Dlvlsion3ofthe Busineasansd�jPm eloneC.de, and my
Ilce.I is In fu dfect. Y
LlcenseC
_ 1 - •iJOB DESCRIPTION
'
PANELS
Dat ContraRor L.4
ARCHITECT`S ATI ne a
207-1fp0
OVER
SQ. FT. BOOR AREA
S/SQ.FT. .'.
Iuhderetand my plans shall be used as public records. •'
G E ECTRICAL
Licensed PrMesslorul "
OWNER -BUILDER DECLARATION
Thereby alftrtnthatlam exempt(romthe Coneractorb License Law (or<he
following reaeon.(Section 7031.5, Business and Professions Code: Any city or
county which requiresa permit to nummac(, altey Improve, demollsh,orrepair
any structure prior to Its issuance, also requires the applicant for such permit to
file a signed statement that he is licensed pursuant to the provisions of the
Contractor's Liceme Law(Chapter9(commencing with Section 7000) of Divi-
go. 3.fthe Business and Profe�lmm Code).,that he R exempt therefrom and
the basis for the alleged exemption. Any violation of Section 70313 by any
applicant fora permit subjects the applicant to a civil penalty ofnot more than
-
-
-
CIRCLET/MISC
P. METER OR POLE INST.'
'
POWER DEVICES" -
- SWIMMING POOL ELECTRIC.
- VALUATION ) _.
y '
OUTLEISSWITCI-IFS.FIXI'URIS
five hundred dollars ($500).,
❑ 1, as owner of the property, or my employees with wages as their sole
-
- NEW RESIDENTIAL ELECTR SQ FR
STORIES
TYPE CONSTRUCTION
compensation, will do the work and thertructure is not Intended or offered for
-
sale (Sec. 7094, Business and Professions Code: The ContractorsLi= Law
-
does net apply toenowner o(property who builds or imp..thereoM and
whod.eesuchworkh4ivseif.,through hiiownemployen,provlda thatsuch
OCCGROi1P
RES. UNITS
Improvements are not intended oroffered forsale. If, however, the Wilding.,
improvementissoldwlthin.neyearofcompfetiov,the owner-bullderwill have
tty9�urdenofproving that Mdid net build orlmprove for purpose ofcale)
u 4 as Owner of Me ro
p perryt am. 7044, exclusively contracting with licensed
mreWcttheproject (Sec. Business and Code:
- TOTAL:
�jj•; ., , '. PGUMB�N�+,PERMIT I tS;iFEE"�'
PERMIT ISSUANCE
-
-
FLOOD ZANE
t
• APN
The Contractor's
The Contractors License Lew does not apply to , f owner oI property who
app] of
Wilds or .)#rouse thereon, and who contracts ice each #..)acts with e
UffIrtor(sexempt under Sntrothe Contactors License Law.
I_J I am exempt under Sec. B k P C for this reason
ALM -DRAIN A VENT- WATER (EN
C T' -
BAIX FLOW PROTECT. DEVICE
t ,•=FEE:SUMMARY.
DRAINS FLOOR ROOF, AREA, COND.'
FIXTURES- PER TRAP
SANfTABY Y_ N_�
RECEIPT It -
Owner Date
WORKMAN COMPENSATION DECLARATION
❑I hereby affirm that I have a certlBrah of consent to salt -Insure, or 's
SCHOOL TAX Y N_
certilrateofWorkem m eruatlon Insurance or a eartified copy thereof (See.
3800, GbC /. �' D^a
I'ollry# (,(
RECEIPT If
GAS -EA. SYSTEM -1 INCA OUTLETS
PARK FEEY ' N'
' RECEIPT#
Cam an
LY
Certlfled copy is herebyturnlehed.
❑Gerund copy E filedhere with the city 1 i o
AS EA. SYSTEM-OVER4(FA) '.
-
BUILDING DIVISION FEES
EASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE
-
GREASETRAP
CERTIHGATE OF EXEMPTION FROM WORKERS'
' COMPENSATION INSURANCE
('Ihlssectlon need not he completed Ithe permit ci (.cone hundred dollars
($1 fess.)
I.OtI
. out that in the per(omunce.f she work forwhich this permit laissued,
I shallall not employ any Pon. In any manner se, as to become subject to the.
Workers'Compensation Lam of California. Date
Applicant ....
NOTICE TO APPLICANT. If, after making this Cartlficete of Exnmption,you
should become subject to the Workea' Compensatlan pro,01I1. the Labor
Code, you must forthwith comply with such provisions orthis permit shall be
deemed revoked. --
PAID
Date Recei t#
SEWER -SANITARY -STORM EA. 200F7'.
WATER HEATER W/VRNT/ELECTR
ENERGYFEE Y- N
PAID
Date- Recel t#
-
-
'
WATER SYSTES7/TREATING
— NEWRESIDENTIALPLMB. SQFT.
TOTAL:
BUiLDIN FEE
- ", `
-
SEISMIC FEE
ELECTRIC FEE
CONSTRUCTION LENDING AGENCY
Iherebyaffirmthat them lsamnstmction lending agency for the perform
Lemof the work for which this permit is issued(Sec. 3097, Civ. C.) TOTAL:
nders Name -
Lender's Addreea -
I certify that have read this application and state thatthe above information
ro
b rmct.l agree to comply with all city and county ordinances and date
- - ..
QTY, i:i 14BC}IANICAG PERivIIT i :' ,•".FEE
PLUMBING FEE"
MECHANICAL FEE -
�ryr�
PERMTTISSIANCE W
FEES PAID:
.
co"t and hereby authomm representatives of this
hea - ntiana proprty for Inspection purposes.
I de fy an d ep harmless the City Of Cupertino
ALTER OR ADD TO MECH.DateReCel
t#ave,
Pudg
AIR HANDLING UNIT (TO ]0,000CFM)'
SUBTOTAL:
nt sandex nsesw chmayinanyway ce
"CiWi.
c n of the nHo hispemdt.
AIR HANDLING UNIT (OVER fgOW CIM)
CONSTRUCTION TAX.
FxTAusr Hoop ov/DUC'D
CONSTRUCTION TAX PAID:
Signature of Applicant/Contractor Date
HAZARDOUSMATERI ,S 9U
Will the applicant or futu pante dle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.lZ and the
HEATING UNIT(TO 100,000 BTU)' 18�
.Date ReCel t#'
.HEATING UNIT (OVER 100,000 BTU) t
TOT L:
health and SafetyCoder �Section 25532(a)?
❑ Yes u No Occupant the applicant orfuture building opant useequlpment or devices
VENTILATION PAN (SINGLE REBID)
--
ISSU E'
which thazardous air contaminants as defined by the Bay Area Air
alit .agement District? .
-
rtrt
19,91
BOILER -COMP QHP OR 100,000 BTU) •^^
BOILER-COMP(OVER1fA,000 BTU)
Bread the hoz ou materials requlremente under Chapter 6.95 of
Is
the forma Health Sit Code, Sedlons25505,ve a tenant,
y have a tewnL that It E my.
u land that if th it g doespant
'
NEW RESIDENTIAL MECH. SQ.FT -
0 e coq,
res sly/yJlliitty�w1 tort th panto he requlr nb which must e t
an
Owner or authorized agent Date
ISSUEDBY ""`r"`�
' TOTAL: ti
OFFICE COPY