21807ADbl It -AMT Tn F11 I IN INFORMATION WITHIN REDLINES — USE BALL POINT PEN ONLY
Building Project Identification "
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PERMIT NO.
'807
21807
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CITY OF CUPERTIN6BUILDING DIVISION
APPLICATION / PERMIT
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Contractor's Name: Lk. No:
P9 4jrcml C % WJ2
BUILDING-ELECTRICALPLUMBING-MECHANICAL .
CATEGORY
CONTROL It
Architect/Engineer. Tic. No:
-1q, i tsET.64'I'RiC,PERMIT : , ' '��'FEE
.•
?'•:�`a B IICOING'PERMITilNFp s ,• ,{:;
.
PERMITISSUANCE. I� •d
Address:' '
LICENSED CONTRACTOR'S DECLARATION-
Iherebyaffirm that l am licensed under prmisionsof Chapter 9(commenc
- -
APPLIANCESRESIDENTIAL
JOB DESCRIPTION,
PANELS ' I -
ingwith Section7000)of Dlvbioo3 ofthe Businessand ProfessionsCode,and my
license Is in full force and effect. -
LkenseC m Lknt r'7 y632
C 'PATION •!O �[-Eta,
Dat CHITIE
�( j
( /•Tri ��.1 '
_
OVERDOAMPS
OVER 1000 AMPS �
SQ. FT. FLOOR AREA
$/SQ. FC.
CHITECTSDE public ION
T'S
]understand my plana shall be used as public records.
SIGNS ELECTRICAL
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that am exempt fronthe Contractor's License Law forth.
following reason. (Semon 7031.5;Buslne®and Professions Code: My dty or
countywMch requites.Isuarre,construct, alter, alsoreuiresthe aprovamforsbh,orir
to
anyatmctureprim permit e
Ola a signed statement that he b licensed me.thIg t to the
ttothe provisions
meits batheisaboreq pursuant of the
''�•�
® � AA
u�
`
SPECIAL CE2CUIT/MLS,C r n (�-
_
II-.- �+ / '•
TEMP. METER ORPOLE ]NSC. - 'p - ,'-
POWER DEVICES s \ Lt.i.
-
SWIMMING POOL ELECTRIC
^ V
r'. law (Chapter 9(mmnnncing with Section 7000)o(Dlvl-
Contra, Section
akn3oftheBuslneaeandPro(emlOru Code)orthat hebexemptthere(romand
VALllA ON -
the basis for the alleg d exemption. My violation of Sectbn 7MLS by any.
applicant fora permit subjects the applicant to a civil penalty of not morethan
O�ETSSWI / 0-719
fieunare Iam(&500).
I, as owner of the property, or my employees with wages as their sok
'NEW RE9DENT[AL ELECTR SQ.FT,
S'(OR[p9
TYPE CONSTRUCTION
compensation, will do the work, and the stmcture is not Intended or offered for
,•
sale (Sac. 70K Busnt
lne.. and Profesidma, Code: The COraciOrs License Law
'
does not apply to an owner of property who builds or Improves thereon, and
who daessuchwork himself orthrough his own employees, provided that such
improvements arenot intended oroffered forsile. If, however, thebullding or
improvement issoldwilhm.neyeorofcomplelkn,the owner-bullderwlll have
t ntrden of proving that he did not build or Improve for purpose of saleJ.
u I, as owner of the property, am exclusively contracting with Ikenced
contractors to construct the project (Sec. 70K Business and Profeealons Code:
��t
TOTAL: Jaa 11'&7
77
Q'I'j?'';'t'{•:-1: ;PI:UiViB[NG SBR T;1i��'; •' :'•j; }'EE •t
OCC. GROUT'
-
„
- RES. UNITS -
FLOOD ZONE
APN
PERMIT ISSUANCE -
The Contmctofs License Law does not apply to an owner of property who
or Improves thereon, and who contracts for such ptojects with a
cgll((actor(.)Ikensed pursuant to the Contractor's License Law.
Lf I am exempt under Set,B & P C for this mason
ALTER -DRAIN & VENT WATER (EM,
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''r.PEB'§UMI1'iARY'i
''
BACK FLOW PROTECT. DEVICE
-OUTSIDE FEES
DRAINS FLOOR ROOF, AREE& COND.
SANITARY Y N
RECFlPC N
Owner" Date
WORKMAN COMPENSATION DECLARATION -
❑I hereby affirm that I have a certificate of consent to self -Insure, Ora
mdifiwteofWorkeri CompensaHonlmumncemamdifkdcopythereof(Sec.
3.licy # C.y,
Poliq•p YC49a6.t_3
MITIRpgjEkTRAP
SUIgpOL TAX Y_ N_ -
RECEIPT N
GAS-F.A.SYSTEM-1INCAOUTLETS',.
-
PARK FEE Y N
RECEIPT It
GAS -EA. SYB777rt-DVERS(FA) '
Com anv f_ V LIC �—
BUILDINGDIVISION FEES
�CertlRed copy tsberebyth the city
ertifed copy is filed hereby fu the city Inspection division.
GREASEANDUSTRL WASTE INTERCEPTOR
PLANCHECKFEE
.,
GREASE TRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
PAID ,
SEWER -SANITARY -STORM EA. 200FC.
COMPENSATION INSURANCE
(Chis section nod nabecompleted Bthe permit bforone hundred dollars
Date Recei iii
_ WATER HEATER W/VENT/ELLCTR -
ENERGY FEE Y '. N
'— _—
($100)orles..)
I certify that in the performance of the work forwhich this permit is issued,
WATER SYSTEM/TREATING
I shall not employ any person In any manner an as to become subject to the
Workers Compensation Laws of California. Date
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PAID' 'Applic
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NEW RESIDENTIAL PLMB. �'�'
NOTIant
NOTICETO APPLICANT: It CertRl-,a Exemption,
Date 'Recef til
after making this of you
sheuldbecomesubjecttotheWmkers''Comperuatlon provisimvsotthe Labor
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-
" TOTAL:
BUILDING •E
Code, you =at forthwith comply with such provisions or this permit shall W
deemed revoked.
CONSTRUCTION LENDING AGENCY
SEISMIC FEE -
Iherebyaffirmthalthere is a construction landing agency for the perform-
ante of the work for which this permit blasted (Sec.3097, CIv.C.)
Lender's Name
Lena.raaaareaa - •
I cadlfythatI have read thisappBotionand atatethatthe above Information
is correct. I agmato complywith all city and counlyordinances and state law.
TOTAL:
�QT,1`.ini ME`�HANICl�L:'PBRINIT i , -„`FEE-"V
ELECTRIC FEE
Z. /
PLUMBING FEE
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID:
relating to building construction, and heieby authorize representatives of this
citytoenterupontheabove-mentioned property for inspection purposes.
(We) agree to save, indemnify an d keep harmless the City Of Cupertino
IlablliBea,jadgnr•nts,costsand Ichmaylnanywayacerue
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ALTER OR AUDIO MECH.
Date Reeel tH'
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AIR HANDLING UNIT (TO 10,M) CFM)
SUBTOTAL'
.Ranco said Clty in con ice oft anHns t nnit.
MR HANDLING uNrr (overs l8,000clM)
CONSTRUCTION TAX
Si a mApplIcal/Contractor Date
bxHAUSTHOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUSMATERI LSDISCLOSURE
Wllltheappllcant or future building omapantstore or handle hazardous'
material as defined by the Cupertino Municipal Code, Chapter 9.1Z and the
Health and Safety Code Section 25532(.)7
❑ Yea M No
HEATING UNIT (TO 100,000 BTU)'
Dale Reeei Iii
HEATING UNIT (OVER 100,000 BTU)-
TOTAL:
a-2.9619
VENJ1LA71ON FAN (SINGLE RESID)
-
.
IS).QeATE
Will the applicant or future building occupant use equipment or devices
which emit hazaniousair rontamkantsas defined by the Bay Area Air
IftyManagementDistrkt2
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BOILER -COMP 0HP OR 100,M BT -
Yes F1 No
Yes
jYY read the hazar7ious materials requirements underChapter6.95 of
BOILER -COMP 100,000 BTU)
the California Health& SafetyCode, Sections 25505,25533 and 25534. 1
understand that if the building does not currently have a tenant that it is my
NEW RESIDENTIAL MECH,' SQ.FC.
responsibility to notify the occupant of the requirements which must bemet�
prior to Issuance of a Certificate ofO.panry( .
x
ISSUED BY. V
Ownerorauthodzed agent Date
F G TOTAL;
OFFICECOPY