20213APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building project Identification
Building Addreaa:
o s ,Atte
PWLMIT NO.
2 0 213
�1
ane:
, r
one:
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BUILDINGELECTWCALPLUMBING-MFCHANICAL
A
Cono-actbra Nara: _ Lk. No:
CATEGORY
CONTROL#
Archlte Engiucen Lk. Na
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Address
�
LICENSEDCONTRACTOR'S DECLARATIONPERMITISSUANCE
Iherermtamlkemed en.ofmen
Chapter
ingwith Msion3ofth.Budne.and I'mlesslon.Cadenc my
,e
time.is 1. Full and died.
LDlaatenuC LIaM
ARCoHnIhTEctT CARAON
I understand my pshall used u
plans M public records.
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirmihat I am exempt from the Contradar's License Law for the
following reason. (Section 7031.5, Business and Profesabns Code: Any city or/k
countywhich requires&permit roH
consnct, alter, improve, denelish,or repair
anystructure prierto Its issuance, also requlresthe appBant for such permit toodes
file a signed statement that he is licensed pursuant to the provisions of thePowRAEvlqEsA
Contractor's Lkerom Law (Chapter 9(contaminating with Section 7DOO of Divi-
don 3ofthe Buslnnsand Pmedslons Code) orthat he b, exempt thercfmmand
the basis for the alleged exemption. Any violation of Section 7Q3LS by any
applicant fora permit subjects theapplicanl Ina civil penalty of not more than
five hundred dollars ($5001.NEW
L as owner of the property, or my employees with wages as their sok
comperuation, willdothework andthe structure isnot Intended or offered for
sale (Sec 7064, Business and Professions Code: The Contractors License Law
does not apply to an owner of property who builds or improves thereon, and
whodaes such work himself orthrough his own employees, provided that such
m
Improveents are not intended or.ffemd for s ile. If, however, the build Ing car
Improvement bwidwlthinomyearofcompldiomtheawner-bu0derwlll have
OFL4urden of proving that he did notbuudorlmprovelorpurposeof We.).
LI L as owner of the property, am exclusively mmratling with Ilaneed
contractors to construct the project (Sec. 7014, Business and Professions Code:
The Contractors License Law ducat not apply to an owner of property who
Wilds or Improve. thereon, and who contracts far such p\ojecis with a
�qWI+or(d licensed pursuant to the Contractors Lim.. Law.
LJ Ictam exempt under Sec- B A P C for this mason
�
APPHANCISRESIDGNfIAL
JOB DESCRII ON
�
F-3,r�UP
PANELS
TO 200 AMEM
AMPS
VER00
OVER
OV1000 AMPS
SQ. FT. FLOOR AREA
5/SQ. FT.
SIGNSELECTWCAL
i
SPECIA CUIT/M A (A [
TEMP. OR L _0T1'
I al
/ b
SWAIMI s L rYl
CTjEtB q
5 O SWITC FlXTUR ,y /3' y �7 \CSO
//, !7 'l i
VALUATION
O QO� QO
ftESI ENTIAL ELEC x .FT.
SfOW PS
TYPE CONSTRUCTION
TOTAL: 1313
QTY. PLUMBING PERMIT FEE
OCC.GROUP
RES. UNITS
PpRMIT ISSUANCE 11L 66 x-C.J
ALTER -DRAIN AVENT-WATER (EA)
FLOOD ZONE
APN
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
OUTSIDE FEES
DRAINS FLOOR ROOF, AREA, CONED.
FIXTURES PER .TRAP /%
Cl l�
SANITARY Y N
RECEIPT Y
OwnerDate
WORKMAN COMPENSATION DECLARATION
❑1 hereby affirm that I .a o lmumne of consent to pytheure, ora
certlfiabC. Worken'CompewHon Wuranaoracertl(ted copythereo(($ee.
3#Oq Lb C.)
Policy p
SCHOOL TAX Y_ N_
RECEIPT 0
GAS EA. SYSTEM -I INCA OUTLETS
PARK FEE Y N
#
RECEGAS
EA. SYSTEM -OVER 4 (EA) �
Cam any
DING DI
BUILDING DIVISION FEE
Cenlfiedapybhercby famished.
Certified ropy ts filed with the city Imp_,.. division.
CERTIFICATE OF IB(EM"ION FROM WOR KCRS'
COMPENSATION INSURANCE
RM1isuctbn need Ccut OMcompleted NI SURApermit V(Drone hundred dollare
(S1fXBoify thatI performance tmannerhe work for s towhibohla pesmitis4wed,
lani(y mplo any phe erson
I ork nm employ any person In any runner at u to Mcome subject toted
Applicant s'Compensaslan Laws of California. Date
Applicant
NOTICE TOre subject to
after making thin Compensation
Certificate of Es of the Labor
shouldou mus a forth tothe Workers' Compervisinprovisionsdthe Lab be
Code, you neat forthwith empty with each provisions or this permit shall M
deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lemdingagenry, for the perform
anawork for whkhthh permit tsLassed (Sec. 3097,Civ. CJ
I<nder'.era Nof the Name
Lender&Address
1 cenifythat I have read Ihoapplintlonand Hateth0thaanfor
bove imation
is correct. I agree to comply with all city and countyordinances and pate laws
Mating to Wilding construction, and hereby authorize representatives of this
city to enter upon the aWvo-m,ntioned property for Inspection purposes.
(We) agree to save, indemnify an d keep harmless the City of Cu Even Ino
against liabilities, N dgment%ands. and expenses which may in any wayaccrue
against Bald City In consequence of the granting of this Permit.
CREASE/INDIISIRh WASTE INTERCEPTOR
PLANCHECK FEE
PAID
Date Reeef t0
P
GREISETRAP
SEWER-SANITARYEA 2001T
WATER HEATER W/VENT/ELECTR
ENERGYFEE Y N —
PAID
Date Recel tk
WATER SYSTEM/TREATING
NEW RESIDENTIAL PLMB. SQ.FT.
TOTAL:
BUILDING
SEISMIC FEE
a
TOTAL:
L
ELECTRIC FEE-
<<jp
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
i.Qca
MECHANICAL FEE
,,
PERMIT ISSUANCE (2 -CO
FEES PAID:
ALTERORADDTOMFCH.
AIR HANDLING UNIT QO I0,ODO CFM)
Date ReeeiptN
SUBTOTAL'
AIR HANDWNG UNIT (OVER IO,OODCFM)
CONSTRUCTION TAX
Slgnatu to of Applicant/Contractor Date
HAZARDOUS MATERIALS UI SCLOSU RE
Will the applicant or future building occu pant store or hand le hazardous
material as defined by The Cupertl no Municipal Code, Chapter 9.1 7, and the
Health and Safety Cod Ion 25532(a)7
❑ Y. No
Wllltheapplicant or tuns building occupant use equipment or devices
which emit hazardous air contaminants as defined by the Bay Arca Air
Quality Management Di r t?
4 Yea 76[I1Yb
have read thehazar cissa materials requirements under Chapter 6.95 of
the Ca1tZraia Health k Safety Code, Senlons 25505, 25533 and 25534. 1
Au�d�lut 11 the Wllding does not currentlhave atenan4 that ltlsmy
o not i(ythe accvpan[ofthe requirements which mu the met cefaCertificm.Occup"uy.
N�OfoLmd
EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HEATING UNIT (TO 100,0DO BTU)
Date RCCCI IN
HEATING UNIT (OVER 100,00D BTU)
TOTAL:
asy��as�x
�-M
f VENTILATION FAN (SINGLE RESID) 2 C -v
ISSUANCE DATE
ISSUED BY: VCaTYnllf\V"'•#'�^CL\
BOILER -COMP QHPOR 100,0!X1 BTU) '
BOILER-COMP(OVER 100,000 BTU)
NEW RESIDFNTIALMECH.SQ.Fr
agent Mul
TOTAL: �' \
' .x{�
OFFICE COPY