24210APPLICANT TO FILL IN INFORMATION WITHIN REDLINES —USE BALL POINT PEN ONLY
Building Protect IdantlflxatlonPEI(bETN¢
Budding Add ress:
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4 210
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CITY OF CUPERTINO-BUILDING DIVISION
L�
Co tracusesN me: iSo:
APPLICATION / PERMIT
b
BUILDING -ELECTRICAL PLUMBINGMFGHANICAL
CATEGORY CONTROL p
BUILDING EERMIl'INFO
Architect En neer.
T
tQrY;. .:`'ELECTRIC,P.ERMIT t" :FFP ..
Add—/r'?&/,0 / Ll;i
❑ ❑ El
PERMRISSUANCE
CONTRACTOR'S DECLARATI
�S
Ihercbyalfirm that l am licensed under provisions of Chapt mnun£nc
ingwith Sectioo7000)of DlWslon3 ofthe Businessand ProfesslansCade,and m
APPLIANCESRESIDENTLAL
JOB Dr9CRIPI ION
limve Is In full force and died.
LlcensClapsp_`Llc p
PANELS
-
Date Contractor
•MI'\��"\�l
201-1000 AM
ARCHITE ECLAION
I undemtand my plans shall be used as publlfrerords.
OVERIODDAAMPMSP
PS
SQ. FT. FLOOR AREA
$/SQ. FT.
SIGNSELFGTRICAL R B
Licensed Professional
h R
lr
s
.: C..
SPLCIALCIRCUIT/MISC
OWNER -BUILDER DECLARATION
I hereby affirm that l am exempt from the Contractor's License Law for the
fallowing reaaon. (Sedian 70315, Bi dressand Professions Code: Any dty or
county which requires a permit to construct alter, improve, demolish, or repair
any structure prior to Its Issuance, also requires the applicant for such permit to
file a signed statement that he b licensed pursuant to the provisions of the
Contractor's License Law (Chapter 9(commencing with Section 7000) of Divi-
sion3 of the Business and Professions Cade) orthat he b exempt therefrom and
D
jI II,
/�
TEMP. METER ORPOLE INST. ,� L % ��,
POWER DEVICES
D 19
SWIMMING POOL ELECTRIC ' -
---- -VALUK ION
the basis for the alleged exemption. Any vlolathm of Section 7eH.S by any
appllontforaper tmbj btheappRcanitoadWlpemkyofnotmomtlun
OU7LETSSWITCHFSH%TURES
NEW RESIDENTIAL ELECTR SQ.FT,
five hundred dollars, MOD).
E] I, as owner of the property, or my employees with wages as their sole
STORIESTYPE
CONSTRUCTION
rompensatfon, wfil do the work. and the structure is not Intended or offered for
sale (Sec. 7044, Buabresa and Professions Code: The Contractor's Lirerue Law
does not apply to an owner of property who Wilda or improves thereon,and
who doesauch work himself or through hisown employees, provided that such
OCC.GROUIa
RFS. UNITS
Improvements are not Intended oroffered forsals. I( however, thebulldingor
bnprovementbaoldwlthlnom)Tarofcomple IoNthe ownerbu0derwill have
TOTAL:
'�,
tl(Zurden of proving that he did not build or improve for purpose ofsale.).
m
U ( as owner of the property, am exclusively ntncting with licensed
contractors to mntruct the Project (Sec. 70K Business end Profession Code:
Q7y;1'•„.PI.UMBING.PERMIT-'FEE
PERMIT ISSUANCE
F7.00D7ANE
APN
,is Contractor's License Law does not apply to an owner of property whoALTER-DRAIN
builds or improves thereon, and who contracts for such pw is with a
mlllfadm(s)licenced pursuant to the Convadols License Law.
LII am exempt under Sec. B 6s, P C far this reason_jQTSI
A VENT - WATER (EA) -
FEE'SUMMARY
BACK FLOW PROTECT. DEVICE
DE FITS
DRAINS FLOOR ROOF, AREA, COND.
PER TRAP
SANITARY Y_ N_
RECEBT R
Owner Dale
WOR IeN COMPENSATION DECLARATION
❑I hereby affirm ve that I haa certificate of convent to self-Insure,FIXNRFS
or
certificate of Workers'Compenatlon Laurance or a cenBled copythemof(See.
3800,I�b C.) aa��
SCI100L TAX Y— N
RECEIPT N
GAS EA.SYSTEMI INCA OUTLETS
PARK FEE Y N
Endi M WII_�JI d.9
RECEIPT
GAS. EA. SYSTFAf-OVER4(Fil)
Com anon C7�]—/.J 1 GFZ�i1Z.
�Cen�d ropyishercby Pornlahed. -
64CenRied copy b filed with the city Inspection division.
BUILDING DIVISION FEES
GREASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE
GREASETRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thissedlon need net be complctN lithe permit is(orans hundred dollars
PAID
Date • Recei t#
SEWER -SANITARY -STORM EA. 200FT.
(gleAorf
Iaxrtlfy that In the performance ofthe work for which this permit is issued,
WorkersI shall not employ any pesson In any manner n m to become subject to the
ls-wg�C�11(omia. Data
WATER HEATER W/VENT/ELECTR
ENERGY FEE Y N —
PAID
WATER SYSTEM/TREATING "'
Appllu'Compereadon
Applicant ai �/'
NOT7CETOMPLIC�:U/i ernaking this Cenifinle of &emptlan, you
should become subject to the Warkers''Compewtion provision ofthe Labor
Code, you at forthwith comply with such provblons orthb permit shall be
deemed revoked:
Date Recei t#
- NEWRFSIDEMIALPLMB. _SQL
E ,�
TOTAL:
BUILDING
-
- TOTAL:
DD
SEISMIC FEE
ELECTRIC
ELECTRIC FEE
E
CONSTRUCTION LENDING AGENCY
IhercbyafOrm that there Is m
a construction lending agency for the perform
ance o(the work for which this pperPdt b issued (Sec. 3097, Civ. C.)
Lenders Name A -11A '
Lender's Address f
I certilythat l have read this application and statethattheabovelnlomation
iscorrect.I agresto comply with all city and county ordinances and data lawn
Q'fY. MECHANICAL PERMIT. FEE
EE
do
MECHANICAL FEE
-
PERMIT ISSUANCE
FEESPAID:
relating to building construction, and hereby authorise representatives of this
city to enter upon the above-mentloncd property for Inspection Purposes.
(We) agree to save, Indemnify an d keep harmless the City of Cupertino
ALTFRORADDTOMECH.,
'
Date ReCCI t#
against liabilities,judgments, met and expenses which may In any wayaccrue
against said City In consequence of the granting of this permit.
AIR HANDLING UNIT CIO Ig000 GFM)
SUBTOTAL:
Q'
AIR HANDLING UNIT (OVER 10,000CFM)
CONSTRUCTION TAX
Sigrumneof Applicant/Cantrador Date
EXHAUST HOOD (W/DUCT)
CONSTRUCTION TAX PAID:
HAZA R DOLS MATERIALS DISCLOSURE
HFATING UNIT CTO 100,000 OTU)
Will the applicant or future building occupant store or hand le hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.1 2, and the
Heahhand SafetyCode Ion 25532(a)P
❑ Yes No
Date RCCCI t#
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
VENTILATION PAN (SINGLE REBID)
ISSUANCE DATE .
p
A BJ
Will the applicartuKture builiingoecvpant use equipment or devices
which emit hazardous air contaminants as defined by the Bay Area Air
Q�iallty Management Dial d7
Yee No
BOILFR-COMP OW' OR 100,000 BTU)
BOILER -COMP (OVER IW,000 BTU)
-
4 have read lheh sea materials requirements under Cha'pler 6.95 of
the Callfomia Health 6 Safety Code, Sections 25505, 25533 and 25534.1
understand that lithe building does not mrmntly have a tenant, that it b my
OCT 7igg' 1,
1s7s7L
NEW RESIDENTIAL MECH. SQ.FT.
rnponlbsi nc of a Ceheocte of of panty. lmments which'mustbemrt
prior to issuance ofa Certificate ofoccupancy. q
ear1Y
V1 Ui' (iUr-Chl!ly�/
PIS
ISSUED BY
� �
nerora ".1 alisht - Data
/
--
TOTAL:
OFFICE COPY