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Building Project Identification
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PERMITNO.
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CITY OF CUPERTINO- BUILDING DIVISION
APPLICATION I PERMIT
n
contra raNamef. LIc.N.:
, eCATEGORY
Ikmh d/En neer:
. BMLDINGELECTRICALMUMBING-MECHAMCAL
CONTROLN
PERINIT 1) ;'�FCE
tI(BUILDING PERMIT INFO '
- • -.0
/j //�� pELECTRIC
Address: / 4��� LST' -f o J)Z '>
IPERhRTI55UANCE ^ V (]
jam.,..
IPJ � El.
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter9 (comment,
Ingwith ection I.fullI..a doift,Divisden3eftheeuslnemandProfeseloneCodgandmy
license In In (vH (ecce and e(red.
APPIJANCFS�RESIDENIIA]OB
DESCR+NTION
% G '� O
rANES
Date Clea Lk.N '.
nate Contractor _IQ
ARCHITF.CPS DECLARATION
1 understand my piansshall be used as public records.
200 ANQS��•
1` /
p t ,^^
101-1000AMPS
OVER 1000 AMPSll
SQ.IT.FLOORAREA
f/SQ. FT.
Licensed Professional •
OWNER -BUILDER DECLARATION
I hereby a(fl. that I am exempt from the Contractor's Llretise, Law for the
following reason. (Section 7031.5, Business and Professions Code: Any dtyor
county which requbesa permit tocodumq alter, Improve, demolish, or repair
anystructure prior to Its Issuance, also requires the applicant for such permit to
file a signed statement that he Is licensed pursuant to the provuhm, of the
Contractor'sLicense Law (Chapter 9(commencing with Section 7000) of Divi-
sion3 ofthe Buslnas and Perfemlmes Code) nether he Is exempt therefrom and
the Weis for the alleged exemption. Any violation of Settle. 7¢31,5 by any
applicant
applicant for a permit subjelathe applicant to a civil penalty of not more than
five hundeed dollars ($500).,
I, as owner of the property, or my employees with wages as their sole
SIGNSEL CAL'
SPECIALC NT
TEdCM O EI
POWFRD
"
SWI MMIN REL CTRIC
9 OI17LE7S ES - �a'��
VALUATION
•7` n) Ur
-
- NEW RESTDENTPL ELECTR SQ.FG
SIOIR FS
TYPE CONSTRIIC3'ION
compensation, will do the work and the structure Isnot intended or offered for
sale (Sec. 70K Business and Profession Code: The Contradors License Law
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TOTAL:
QTIS ,N� '- PLUMBING PERMIT;-,,
I PERMIT ISSUANCE 0 `
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ALTER -DRAIN & VENT - WATER (EA)
does not apply to an owner of property, who builds or Improves rhemon, and
who doessuch work himself orthrough hisown employees, provided that such
Improvements are not Intended oroffered for sale. l( however, the build Ing or
i provement b sold within eayearofcompleLion, the owner-builderwill have
thA*rden of proving that he did not bund or lmprovefor purpose of sale.).
IJ m
L as owner of the property, am exclusively r'Q' ng -; I ;s.
mntcatton to mrutmct the project (Sec.70K B.Ar essand Pmindons Code:
The Contractor's License Law dues not apply to an owner of property who
Wilde or Improves (hereon, and who contracts for such pPjeda with a
}}BEffSctor(s) Ilcensed pursuant to the Cmurectn. License Law.
LII em exempt under, See. t j B k P C far thlc.reaon
OCC. GROUP
,
RIS. UNI IS
FhpOu7ANE
nPN ,
FEE•SUMMARY
BACK FLOW PROTECT. DEVICE
OUTSIDE FEES
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\
DRAINS -FLOOR ROOF, ARG, COND,
' I FixNHES'I'CR 7RA, P a'2, V p
SANITARY Y . N_
RECEIPT
a•'^^r Date
WORKMAN COMPENSATION DECLARATION
eseby affirm shat I have a mrtlflcate of consent to self -Insure ora
certi(IcatebfWorkem'Compensatlonlnsuranre ora certlnad ropythercof 6ec.
3800, Lab C.)
SCIiUOL TA% RECE�1' N
GAS EA. SYSTEM-] INCA y
I`'• V Pj
PARK FEE Y N'
�"
RECER'TN
GAS. GAS -G. SYSTEM-OVER4(FA) -,
s
C.
Com any -'
BUILDING DIVISION FEES
�Cmiified copy b heed with the shed.a'
^❑Cerlifiedcopyb(Ilcd with the city inspection divlslon:_ -
GREASE/INDUSIRL WASTE INTERCEPTOR
PLANCHECIC FEE
Ibl�r_o3
GRFASETRAP ,
CERTIFICATE OF E%EMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need nut becompleted If the permit Is (oroa hundred dollars
PAID
Date Rewi t#
P
SEW[R-SANITARY-STORM PA.400Ff.
WATER HEATER W/VENT/ELECTR
ENERGY FEE Y N
(f100) tify that
(certify that in the performance ofthe work forwNch this permit is lamed;
WATER SYSTEM/TREATING
I shall not employ any person In any manner w as to become subjed to the
Workers'Cmepresation Lawe of CeHfomie. Date
PAID
Applicant I
OTICE TO APPLICANT. If, after raking this Certificate of Exemption, you
ueuld bemmc subject to the Workers' Compensation provisions of the Labor
Cde, you at forthwith comply with such provns ldeor this permit shall W
doned revoked.
NEW RESIDENTIAL PLMB, SQ.FT.
Date Real [#
TOTAL:
BUILDING FEE
SEISMIC FEE
1, • CONSTRUCTION LENDING AGENCY
I oreby affirm that there Is a rodt
radlon lending agency for the perform-
once ithe work for which this permit is Lssued(Sec. 3097, Cl, C.)
Le.dcrNa "
/
- TOTAL: p•�%
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ELECTRIC FEE
me ..
Leruldp.Aldeess - -
. I certify int I have read this application and stale that the above Information
is correct.I agreto comply with all city and county ordinances and sate laws
relating to bulldeg construction, and hereby authorize representatives ofthls
city to enter upon he abovo-mentioned property for inspection purposes.
. (We) age o we emnlfy an d keep, harmless the City of Cu pert Ino
agairethabl I ,' grdArs,msaandeapenseswhichmyinanywayamme
age Wt ul C 1 conssqunre o(the granting of this pe iL
be
,..
QTY.' ;MECHANICAL•PERMIT I ::''PE '¢,
PERMIT ISSUANCE Q
PLUMBING FEE
MECHANICAL FEE '
FEE$PAI
Q S -S -77-C
ALTER OR ADD TO MEC
Date Receipt#
AIRHANDLINGUMT
SUB TOTAL•
AIR HANDLING UNIT VER Io,000CrM)
CONSTRUCTION TAX
. signator of Ap cat/Contnttar � ate
F1UTAIJS'I HOOD (W/DUCT) � , S
CONSTRUCTION' TAX PAID:
ALJRDOUS MATERIALSS)ISCMSURE
WRltheapp ance fuwm butompant-store or handle hazardous
-materials,defined by the Cupertino Municipal Cede, Chapter 9.l; and the
Ith and Sa(dy Code Section 2U31(a)7
Yes
HEATING UNIT (TO 100,000 BTU)
.Date Reeei t#
_
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
7'
VENT7 GTION FAN (SINGLE RESID)
ISSUANCE�(j .
YY�g7
p'21990
Y ,
!n.tj ofIrJ"MY^PF^I'1•nV
Wilithe a PplIcant or future building occupant use equlpmont or devices
which emit h.eardoua dr contaminants as defined bythe Bay Area Air
Qua t Mena cat DbtrlNo- l f
• •,
< ^.)Rha• oua matenA riquiremcnh underChapter 6.95 o1
mmta k Safety Code, Sections 25505, 25534.1
and erstand that lithe building does at mrrentl a�Vc. wrost1hot it is my
raponsibHl tonotifytheacmpantorrhere remenew ethernet
pdort ameada Certificanofecmpa
BOILER -COMP OHP OR 100,000 BTI)
HOMER-COMP(OVER100,000 BTU)
NEW RESIDENTIAL MECH. SQ.FT
ISSUED BY:� 0'n(/�t!
Owner or authorized agent - at
70TAL:
OFFICE COPY