23422APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Protect Identification
Building Address: V V Z w� 1 lj n
`v` KWe: Y4i`-�
PERMIT NO.
23422
c Name: I
"r r. tE er �'1}:^19'gif
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION I PERMIT
BUILDLNG-ELECTRICAL.PLUMBINGMFGHANICAL
A A A
c°ntr nraName: Lie. No:
CATEGORY CONTROL a
Arohltect/En ghee".. Lk. No:
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Add.
❑ 'F[� ❑
IrJ
PERhRTI55UANCE ��
---ElLICENSED
CONTRACTOR'S DECLARATION
Ihereny eefl..rmW Dia t.1 3.ftheRusimvandrmuad! under Chapter9de,and
Ingwith SeMon7000)ofDlvlelon3ofrhe Businessand Pmfessl°nsCode, and my
license b In full force and cited.
LlrenseClass LIc.N
Dale ContractorTO
ARCHITECT`S DECLARATION
I understand my plans @hall be used as public record&
Licensed Professional
OWNER -BUILDER DECLARATION
Ihereby affirmthat l am exempt from the Contractors License Law for the
Anytltyor
followingreu eetudesaprmittomentructand Professions Coxedemolish,
Countywhkh..(Secion 703ttoConstnss alter, Improve, demolish,y city or
anystrudure prior to itsbauance, also requlrestheappllcant forsuch perrtdto
file a signed statement that he is licensed pursuant W the provisions of the
Contractor's License Law (Chapter 9(commencing with Section 7000) of Divi-
ivi-
sion
sion3of the Business and Professions Code) orthat he is exempt therefrom and
the basis for the alleged exemption. Any violation of Section 7031.5 by any
appBant for a permit subject the appllcantto a civil penalty of net more than
five bacuteed dollars ($.500).
owner of the property, or my employees with wages as their sole
to pensation,willdothe work and the structure boot intended or offered for
e (Sec. 7014, Business and Professions Code: The Contractors License law
d cant apply to an owner of property who builds or improves thereon. and
who does such work himself or through hisown employees, provided that such
Improvements are not Intended centered for@ale. If, however, thebuliding or
Improvement issold within oneyearofcompletion,the owner-bullderw111 have
tF�q.�uMen of proving that he did na build or improve for purpose of sale.).
11 L as owner of the property, am exclusively =trading with licensed
contractors to mmtrud the project (Sac. 70K Bush@ sand Professions Code:
The Commttoes License law does net apply to an owner of property who
Wild. or Improve thereon, thern, and who contracts for such plujects with a
licensed pursuant to the Contracture Lioness, Law.
L� I am exempt under Sec. B Is P C for Nb reason
"IN,
APPLIANCESRESIDEN7IAL
)OB DESCRIPTION
^_ •�.a e
Y,`}A1 w\4I -(--
PANELS
200 AMM
201-IOMAMPS
OVER 1000 AMPS
SQ. FT. FLOOR AREA
fnp�`' A V
® 8 A V
p p a� ^
'VY h`,Lf{
$/SQ. FT.
SIGNS ELECTRICAL
SPECIALCIRCUIT/M19C
T2AP.MEFPRORPOLEINSF.
POWER DEVICES
SWPFMING IDOL ELECTRIC
OUTLETS -SWITCHES
VALUA71 N
NEW RESIDENTIAL ELLCTR SQFT.
SFORIES
TYPECONSIRI TION
QTY. PLUMBING PERMIT FEE
PERMIT ISSUANCE
ALTER -DRAW 6: VENT. WATER (EA)
OCC.GROIII@
RFS. UNITS
FLOOD TONE
APN
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
DRAINS FLOOR ROOF, AREA, CONE.
�.Uw;S PER TRAP
SANITARY Y N_
RECEIPT p
Owner Date
WORKMAN COMPENSATION DECLARATION
❑I hereby affirm that I have o lmun to of consent m pyth.ure, ora
3800,matflabo(Worken'Compensatlonlnsurance ora rertifkd ropythemof(Sea
a CJ
Policy Y
Policy
SCHOOL TAX Y N
RECEIPT' a
CAS EA. SYSTEM -1 INCA OUTLEFS
PARKFEE Y N
N
CAS EA. SYSTEM -OVER 4 (EA)
Com any
DING DI'
BUILDING DIVISION FEES
Cert(Sad copy Is herebyi
CertRied ropy b filed withth the tM ticy IrupecHon dlvlelon.
❑ city
CERTIFICATE OF E)CMPTION FROM WORKERS'
COMPENSATION INSURANCE
(usection need not Se completed If the permit b (Drone hundred dollars
($100)0)orless3
[certify charm any he permute booed,
nce In an thework so as to become
I shall not employ any person in any manner at u to became mbjed to the
W plicae Compenssfion lawn of Grnb
llfo. Date
Applicant
NOTICE co APPLICANT:ttohe, after nuking this Certificate of Exemption, you
Code,shoulbecome Forth to the Workers' such pruadon provbbns of the Labor
Code, you ckeforthwith comply with such proviel°ns orchis permit gall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
Iherebyaffirrn thatthereb a construction lending agency for the perform
anof the work for which this construction,
is Issued (Sec. 3097, CN. Q
Lender's Name
Lender's Address
I certifythatl have read thhapplicatlonard gat ethattheabovemlo @ration
brorrect. Iagree to comply with all city and county ordinances and nate laws
relating to Wilding Construction, and hereby authorlu mere artatteesof this
city to enter upon the abovcmentk aid property for lnspedlon purposes,
(We) agree tosses, Indemnify an d keep harmless the City of Cupertino
agalmtlbbilities,jrdgmenb, ed expenxa which mayinanywayaccrue
.go l�granting of this
as�d City In conseque o permit.
h3IJV q.I—
GREASE/INDUFFRL WASTE INTERCEPTOR
PLANCHECK FEE
PAID
Date Recti t#
GREASE TRAP
SEWER -SANITARY -STORM EA 201FT
WATERHEATERW/VENT/ELGCTR
ENERGYFEE Y N —
PAID '
Date Recei t#
WATER SYS.IEM/TREATING
NEW RESIDENTIAL PLMB.SQ.FT.
TOTAL:
BUILDING FEE
SEISMIC FEE
ELECTRIC FEE
TOTAL:
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
MECHANICAL FEE
PERMIT'ISSUANCE
FEES PAID:
ALTER OR ADD TO MECH.
Date Recei t#
P
AIR HANDLING UNIT (170 IO,OCFM)
SUBTOTAL:
AIR HANDLING UNIT (OVER 10,000 CFM)
CONSTRUCTION TAX
Signatureppllant/Contactor Dace
HAZARDOUS MATERIALS DISC IR'
Will the applicant or future building occupant store or hand ie hanrdous
material as, defined by /he Cupertino Municipal Cotle, Chapter 9.12, and the
I lealth and SafetyCode Section 25532(a)7
qYes M No
illthea. ppiiant or foto re Wilding occupant use equipment or devices
which emit havrdous air conte mimnts as defined by the Bay Area Air
lity Management District?
. have read the hazardous nuterlab requirements under Chapter 6,95 of
Yea ❑ No
the California Health k Safety Code, Sections 75505, 8533 and 75531. I
understand that fthe building does not currently have a tenant, that it b my
Pdporeibility to notify the ompant of the requirements which= at be met
or to Issuance of a Certificate of Occupancy.
IXFiAUST Hoop (YJ/DUCT)
CONSTRUCTION TAX PAID:
HEATING UNIT(TO IOLODO BTU)
Date Recei f#
HEATING UNIT (OVER IOO,ODO BTU)
TOT
VENTILATION FAN(SINGLE RFSID)
ISSUANCE DATE
hI�
u� 11 ry
e'V 9
C��j' 8 �g9�
ISSUED BY: T
BOILER -COMP DIE' OR 100,000 BTU)
BOILER-COMP(OVER IOQ000 BTU)
NEW RESIDENTIAL MECH. SQ.FT.
Owner or authadved agent Data
TOTAL:
OFFICE COPY