22736APPLICANT. TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification
Building
PERMIT NO.
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Wrier. dnle: • site.
'C Up K
CITY OF CUPERTINQBUILDING DIVISION
APPLICATION/ PERMIT
'APFUCA11UN submit iAL DATE
1� _ -
ConlradorsName: I1W Lie. No:
CATEGORY CONTROL
'
°'
BUIL-
DING-ELECTRICA4IPL[IMBING-MECHAMCAL
I
Architect/Engineer Lk. No:
{ag EGBC'7'RICPERIvPC. jtl § i +a V
's' Ei''*:: B41II'DINGIPERMITINFO i,i-rt q t'
Address:
PERMITISSUANCE
❑ ❑ N ❑
LICENSED CONTRACTOR'S DECLARATION
-
IherebyaffirenthatlamBcensedunderprovisiomo(Chapter 9(comment
APTUANCESRESIDENTIAL
TOB DESCICT"HON'
PANELS
ingwlth Sedion7000)of Division3ofthe BusinessandlrofessionsC e,and my,
license lainfall 'okffed. t�9�,a65!
License CWssG •� .p .J 1
'
D(�Si•
Dale' Conhador —UP
TO 200 ANTS
IDI-IOOOAMPS
• ARCHITECT'S DECLARATION
(understand myplarashallbeusei aspublieremrds.
Licensed_ ProfProfessional,
OVERI000AMPSSQ.IT.
FLOOR AREA - �
.,LED ® A. F41.
E/SQ-FT.
_
SIGNSELECTRICAL
i�
SPECIAL CIRCUIT/MISC
' OWNER -BUILDER DECLARATION
I hereby affirm thatIam exempt from the Contractor's License Law for the
ET.�.! r—
following reason. (Section 7031.5, Business and Professions Code: Any city or
cmntywhich mquires a permit W comtmd, altep impmve, de=lIsh,or repair
TEMP, METEROR POLE INST.
0
!!
-
anystrocture priorto its nomance,alsorequireaihe applianlforsuch permit to
file a signed statement that he is licensed pursuant to the provisions of the
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POWER DEVICES - E
'
SWIMINGPOOLELECTRIC
_
Contractor's License Law(Chapter 9(commencing with Section 7000) of Divi-
..too3 of the Business.ed PrefessionsCode) or that he is exempt therefrom and
VALUA
the basis for the alleged exemption. Any violation of Section 7031.5 by any
applicant for a permit subjeds theapplicant toe civil penalty of not more than
Of TLETSSWITCHESHXTURFS
„
_ -
NEW RESIDENTIAL ELECTR SQ.hT.
five hundred dollars ($500. - -
I, as owner of the. property, or my employees with wages as their sale
STORIES -
TYFECONSTRUC'TION
compensation, will do the work and the structure Is not intended or offered for
sale (Sec. 7814 Business and Professions' Code: The Contractors License Law
does not apply W an owner of property who builds or Improves thermr,and
who does such work himself orthrough his own employees, provided that such
Improvements are not intended or offered for sale. If, however, the building or
improvementusoldwltMn oneyearofcompletlorytheowner-buRderwill have
the Wrden of proving that he did not build or improve for purpose of sale.).,�QTy.'.,t?'.`S;;PLUMBING
�; act owner oEthe property, am exdvalvely contracting with Ilcenud
contractors to me rud the project (Sec. 7044, Business and Professions Code:
TOTAL:
PfiRMIT�•�4"'4•;c44,FEE'i',;
OCC. GROUT'
RES. UNITS
pLooD zoNE_.-APN
F PERMIT ISSUANCE I
1
The Contractor's License Law does not apply to an owner of property who
Wilds or Improves thereon, and who contra. for such p4ajecta with a
licensed pursuant to the Contractors License Law.
15, 'm
15I am exempt under Sec. - B & P C for this mason
-
ALTER -DRAIN &VENT- WATER (FA)
`,FEE;STjM1NARY'i;'„?s
-
- BACK FLOW PROTECT. DEVICE
OUTSIDE FEIzq
DRAINS FLOOR ROOF, AREA, COND.
SANITARY Y___' N
RECEIPT N
Owner Dare
WORKMAN COMPENSATION DECLARATION
❑I hereby affirm that I have'a certificate of conxnt to eel( -insure, ora
cedifiateo(Workei Compemationlnauranmaramdi(ledmpythemof(Sec.
3CJ
Policy9
TURES PER TRAP N
TOOL TAX Y N
RECEIPT N
CAS EA.BYBTEM-I INCA OUTLETS
mS
PARK FEE Y -
RECEIPT#
GAS EA. SYSTF=OVER 4_A)
(
Ca
BUILDING DIVISIONFEES
ertified copy 6 herebyte
Certified copy Is hfiled withh the cityInspection dlvlalan.,
ity ,
GREASEANOUSTRL WASTE INTERCEPTOR
PLANCHECKFEE
GREASE TRAP - 'PAID
CERTIFICATE OF EXEMPTION FROM WORKERS'
SEWER -SANITARY -STORM EA. 200FT.
COMPENSATION INSURANCE
(Thissedion need not be completed if the permit Is forom hundred doll..
Date Remi t#
-
WATER HEATER W/VENT/ELFCTR
ENERGY FEE Y N
1. ($1W)or•'-
Iceor 1..) In the performance of the work forwhich thio permltb Issued,
WATER SYSTEM/TREATING -
I shall not employ any person In any manner an as to become subject to the
WorkeraCompensationLaws of Californu.Date -
-
PAID
Applicant ”' -
NEWRMDENTIALPLMB." SQFT.
Date Remi t#
NOTICE APPLICANT: after making this Certificate Exemption, you
-
TOTAL;
co a is of Ladner
to the Worker' Campenaatilns
Cade,shoulyou orchis pe
Cade, you must forthwith comply with each proWbru or this permit shall be
forth rmit s
deemed revoked.
BUILDING FE
-
,
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
Ihereby affirm that there he a construction lending agency for the perform-
.rus of the work for which this permit Is Issued (Sec. 3097, Co. C.)
Icrder.Name ..l:
Lender�Address _
- - TOTAL
ELECTRIC FEE
t
QTY.'",t ,MECHANICAL PER" lt :1' .t''FEEL,
PLUMBING FEE
MECHANICAL
Iminty thatl have read thuappliation and etatethatthe above information
ismrreq: l agree to complywilh all city and county ordinances and state laws'
'
PERMIT ISSUANCE
FEE
FEES PAID:
relating to building construction, and hereby authorize representatives of this
city to enter upon the above-mentioned pmperty for inspection purposes.
(We) agree to save, indemnify an d keep harmless, the City of Cupertino
against liabilities, j dgments, costa.ed expense. which may In anywayaccrue
agalrs Id City InLce(the gantng of ehe mitcoue
`
ALTERORADDTOMECH..
Date Receipt#
_
AIR HANDLING UNIT (TO 10,000 CFM) -
SUBTOTAL:
'AIR HANDLING arm (ovER to,000cr•M) -
CONSTRUCTION TAX
EXHAUSTHOOD(W/DUCT)
t
CONSTRUCTION TAX PAID:
Signswreo(Applimnt/Contractor DAB
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (TO 100,000 BTU)
Will the applicant orfuture building occupant atom or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.12, and the
I lcalth and Safety Code Section 25532(.)7
F1 Yen N NO. -
_76—ate' Reeelf#
HEATING UNIT (OVER 100,000 BTU)
TOTAL•
•
VEN'DLATION FAN (SINGLE RESID)
, ISSUANCE DATE,
Will the applicant or future building occupant use equipment or devices
'which
emit hazardous air contaminants as defined by the Bay Area Air
��i Management District?
_
BOILER -COMP (3H P OR 105,500 BTL
Jlily
Ys No
BOILER-COMP(OVER 100,500 BTU)
shave read the haurdove materials regWrernenu under Chapter 6.95 of
the California Health & Safety Code, Sections 25505, 25533 and 25534. 1
understand that lithe building does not currently have a tenant, that it is my
y r/
NEW RESIDENTIAL MECH. SQ.FT.
responsibility to notify the occupant of the requiremems which most be met
,Csep
1
SEP l
- - -
prior to issuance of a Certificate of Ocmpa ncy.
ISSUED BY
Owner or authorized agent - Data
-
TOTAL:
A' OFFICE COPY