3093 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONL
BU I LDING PROJECT I DENTIFICATI ONMBER
CPU
SOILOING APPLICATION & PERMIT /Q^ i
AO RE 5
BUILDING -ELECTRICAL-PLUMBING-MECHANICAL •-
ociessia.'S
PLAN CHECK VALIDATIOI,
NAME / OTY. ELECTRIC PERMIT FEE
ALG ' Aly EKlCJ / PHONE
CONTRACTORS
ME ✓ C•!�Q q OUTLETS-SWITCHES-RECEP 5.00/1.00
V CS%Q 0 �C.No. _ `C' LIGHTING FIXTURES 5.00/1.00
`CONTRACTOR'S
mRE s ` APPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 5.00 DATE OF APPLICATION
ARCHITECT
ORSIGNS 6.00 PLAN CHECK FEE P.O.ND.
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ADDRESS END. 5.00 CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP. METER OR POLE INS. 15.00 /aj�?
AMOTORS SEE FEE SCH.
ADDDRESSDRESS
SERVICE CHANGE 10.00 t,� p
w o o LICENSED CONTRACTORS DECLARATION 9a'//(�3
a z U I hereby affirm that 1 am licensed under provisions of Chapter 9 AID ISSUANCE DATE
y a H (commencing with Section 7000)of Division 3 of the Busi ss and BLDG. ELECT. PLG. MECH.
F w a Professions Code,�nd}ny icense is in full fore0' d cfh ❑ ❑ ❑
i Ovi - License Class_(,-L(_-Lic.Number-
License G- JAN . 1983
w r w Date Contractor
a x BUILDING PERMIT
¢ ¢ w a
OWNER-BUILDER DECLARA" I
°AU MISC.- /a+ peecc g RD INFORMATION
E
; LL H 1 hereby allirm that I um exempt from the Contractor's License Cit 01"68 WLI VALUATION $/FT,
F ac O v, Law for the following reason.(Sec.7031.5,B lsimessand Professions PERMIT ISSUANCE 6.00
1w � f Code:Any cityor county which requires a permit to Construct,alter,
¢ ¢ ¢ O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO, ELEC.
t0 requires the applicant for such permit to file a signed statement that TOTAL �� PERMIT TO
$ he is licensed pursuant to the provisions of the Contractors License
H z i
Law(Chapter 9(commeneingwieh Section 7000)of Division 3 ofthe �C-/'��J �Lei'7/Gy(✓
4 c Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
IS I-c� the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant to n civil penalty
of not more than five hundred dollars(S5001.1: ALTER-DRAIN& VENT-WATER (EA.) 4.00
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:1'he Contractor's License Law does not apply to an owner of
properly who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTALACREAGE
Inumse• meets are otintffirongthde ownemred forssle.If,
however,Th impeding GAS-EA.SYSTEM-11NC.40UTLETS 4.00
meets are eme intended w thin on year o If mplevee the building
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
builder will have the ale). of proving that he did sol build or int- RES IND CON PS Ome,
prove fors owner of sale.). INDUSTRIAL WASTE INTER.
❑ L as owner of the prot,Rc, hmine exclusively c 7044Cl ing with 20.00 O ❑ ❑ 1:1 El
licensed contractors Code: re the project(Sec. 7044,Business LAWN SPR IN KLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions propThe who
Contractor's License Law does not appy'
to t,owner of property who builds tr improves rased pt and who LAWN SPRINKLERS OVER 5 (EA.( 1.00
con hunts for such projects with a eontractorls)licensed pursuant to
the C'ontractor's License law. I SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec.-.BARE.for this WATER HEATER W/VENT 4.00
reason
Date Owner WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO,
WORN ERS'COMPENSATION DECLARATION WATER TREATING EQUIP, 4.00
1 hereby affirm that I have a Certificate of consent wself-insure, ZONING ENG.SITE N0.
or a certificate of Workers'Compensation Insurance,Or a cereif
copy thereof ISec.3800 Lab.C.I
Policy No. Company
O ❑ Certified Copy'is berehyfu t c FIRE SPRINK ENERGY T-24
Z Z 6/Certified co is Ied II the ly inspection divisiat.
O Applicant MISC.- REFER TO ORD. Y❑ N❑ Y ❑ N[
~ wPERMIT ISSUANCE 6.00
CIiRTI C OP BXEAIP'I'ION I'RO,\ 'ORRfiRS' FLOOD ZONE AL.U.C.
LU � Upf ATION INSURANCE PLG.CONTR. _LIC NO. PLGCL .
Z) z CI'his section need not be completed if the permit is for one TOTAL Y E] N❑ Y E] N E]hundred dollars IS 100)or Icss.)
U O_ I certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F- mit is issued, I shall not employ any person in any manner so as to
O W become subject to the Workers'Compensation Laws of California.
a Datc Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
} to NOTICE TO APPLICANT: If,after making this Certificate of Ex-
t 2 emption,you should become subject to the Workeri Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
C.) such Provisions or this permit Shall be deemed revoked. AIR HANDLING UNIT(TO 10OWGRMJ 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 100(30GFM.) 5.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the Performance of the work for which this permit is issued(Sec. MICROFILM
3097,0,C.). I HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name H EATING UNIT(OVER100,000 B.T.U.)7.50
Lender's Address ELECTRIC . 7,
I certify that l have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information is mulct.I agree to comply with all city and county PLUMBING
ordinances and state laws relining m building l city and
co and BOILER-COMPI3 H.P.or 100,0008.T.U.) 4.00
hereby authorise representatives of this city to enter upon the BOILER-COMP (Over,100,000 BTU)SEE FEE SCH. MECHANICAL
above mentioned property for inspection purposes,
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertinoagainst liabiliti ,judgments, costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
may in any way ocerue a ''est Said City in consequence of the
giontm", fis a lit. MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
Signa
pl can ontraemr Dale
OFFICE COPY
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO �-~-"- BUILUWG- UmuFRICAL PERMITNO.
BUILDING DIVISION APPLICA'T'ION/PERMIT PLUMBING-MECHANICAL r'}'q 7ry(�
BUILDING PROJECT IDENTIFICATION L 44 J J
BUILDINC"isSS:',' SANITARY NO. APPI.ICATIONSUBMTITALDATE
(019,6 I-PMrc .� 2
UNIT# LOT#
OWNERS AME: I PHO : ,/1 , 'S NAMF,: �.1 O:,
�• �fho�ECON
1 G/d6/ /"/" 8— i NIC
CONTROLM
ANC " 1'/1?NGNELK LIC NO. A DRE�s:
5 .d.e l✓ 6((y �eBGI 14"m • let (eG � ID
CONTACT: PHONE. BUILDING PERMIT INFO
r QTY. ELECTRIC PERM FI?E B� ELECT PLUMB let
�t// Z'+ / t2SE PERMIT ISSUANCL�
LIt'0SE15 CONTRA R'S DECLARATION APPLIANCES-R II) AL JOB DESCRIPTION
py2 Thereby affirm that lam licensed under provisionsofChapmr9(commencing with
O Semiom e00 d e f Divis on J,Rhe Business and Professions Code,and my license is in PANEL foil tome
andeffec[. _ Y
,z License Class Lick PT(
T S ,
m< Data Cmineve r DAMPS
ZOM ARC]IITFCTS DECLARATION SQ,FT.FLOOR AREA $/SQ.IT.
z 0 o,, I understand my plans shall be used as public recortls. 1000 AMPS �OO '
P4th1 i SIGNS ELECTAICIL
<yy�a Licensed Professional
�yf2< OWNER-BUILDER DECLARATION P IA IR
OyF 1 hereby uffinn titan 1 am exempt from the Contractor's License Law for the
31z-vJ following reason.(Section]031.5,Business and Professions Cede:Any city or county O LE INST.
which mquiresn penniuo conxtrvm,alter,improve,demolisM1,or repair any xvuaure
��Y priorm its issuance,also eyuires[he applicant forsuch permit[,File axigneJ statement :R UEV ES
Iha[he is licensed pursuanuo the provisions of the Comment License Law(Ch.'
dKe 9(commencing with Section 7000)of Division 3 of the Business and Professions Code) SWIMlrqbPOOL ELECTRIC VALUATION
m,,,m or that he is exempt herefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-FIXTURES Z..g�(oOt3
QSection 1031.5 by any applicant for a permit subjects the applicant no a civil penalty of V ��GG�✓✓//
not more than five hundred dollars($500). NEW RESIDENTIAL ELECfR _sQ.El
❑ 1.mownerofthepmperty,ormyemployeeswithwagesastheirsolecompensation, STORIES TYPE CONSTRUCTION
a will Aolhewons and :The mureisctim s License ace dos not apply t an Business
and Professions Code:The Contractors License Law does not apply to an owner iof
s
ownproPermwhe builds viimpraveslhemogandwhodoessucmadind imselfonhrougb his DEC.GROUP RES.UNITS
employees,providedmprovchimprovld wit in ne earc edcil[fercd[,reale.If,
however,theavet a orimprovement]ssoldwithinoneyear conciliation,thrower- L
builder will have the harden of provin6 that he did not build or improve for purpose of
ala).
❑ Las owner,Tobe Property,am exclusivelye,mradingwithlicensedconvam,rstn QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
construct the project(Sec.9044,Business and Professions Code)The Contractors
License Law does not apply manownerofproperty whobuilds orimprovesthereon.and PERMIT ISSUANCE
whoc,ntracts forsuchp ides with a comraeter(x)bcensed pursuant o the Contractor'a
License Law. ALTER-DRAIN&VENT-WATER(FA) FEESUMMARY
❑ 1 an.exempt under Sec. ,B&P C for this reason BACK PLOW PROTECT.DEVICE OUTSIDE FEES
SANITARY Y N
Owner Date RECEIPTO
DRAINS-FLOOR,ROOF,AREA,GOND.
•
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
❑ Ihercby affirm that lhuveucertifiwte of consenuo selfSec.38,or Lab C.)c which DGURES-PER TRAP RECEIPTq
Morkers'Comarnation Insurance or a cvnified copy thereof(Sac.JeOq Lab CJ which PARK FEE Y N
m all employee's under this panni[ GAS EA.SYSTEM-
mail INC.4 OUTLETS RECEIPT
Pit f, If BUILDING DIVISI FEES
NjCO y GAS EA.SYSTEM-OVER 4 EA) PLANCHECK FEE
Certified copy is hereby furnished.
ided copy is filed withmo,ity inspection division. GR S US'fRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GRE MSPPP, SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed Hire permit is forone hundred d,llars($100) SEX NNRY-STORM EA.200F7. ENERGY FEE .�
or less)
Imenify thein the Performance nf the work for which this pennin is iseued,Ishall WA TER W/VENEELECTR /�
,[employ any person in any manner so as to become object to the Workers' PAID lry
Compenmtim Lawsof Cnlifomie. Dam WATER SYS EAT G Daft, Receipt#
O Z Applicant
Z 0 NOTICE TO APPLICANL If,aftermAing this Certificate of Exemption,yoush,old NEW SI .NTIAL B. SQ.PT. TOTAL:
FV) become subject m the Workers Compensation provisions of the Labor Code,you must
.! forthwith comply with such provisions or this permit shall he deemed rcv,ked. BUILD FEE I�
pW, CONSTRUCTION LENDING AGENCY SEINC P '
H Q 1 hereby affirm thin there is a construction lending agency for file performance of
ICJ-' the work for which this permit is issued(See.301 Civ.C.) ELECTRIC FTSE
V. Lenders Name PLUMBING FEEt' Lender's Address QTY, MECHANICAL PERMIT FEE
W I certify What I have read this application and state that[he above information I.
>sP. coned.Iogree tocomply with all city and county ordinances and state laws relatingto PERMIT ISSUANCE. �� MECHANICAL .E
�^ bo building construction,and hereby au[horizerepresentativesofnhiscity teener upon the CONSTRUCTI TAX
U Z above-mentioned property for inspection purposes.armALTERORADDTOMECIL
(We)agree to save,indemnify and keep beardless the City of Cupertino against
IndilitiesJudgmems,costs and expenses which may in any way accrue against said City AIR HANDLING UNIT(TO 10,000 CFM)
wii in onsequence gmalin is pe it. p3
77 AIR HANDLING UNIT(OVER 10,000 CFM)
Applicam/Comram,r Date EXHAUST HOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Receipt#
Will the upplicaator future building occupuntsmro or handle huzsrdous mamrial HEATING UNIT(OVER IOD,BW BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Scetl 255J2( 'l
a)
0Yea 11 No IOVENTILATN FAN(SINGLE RESID)
Willfleapplieamorfumrebuildingoccupanluseeyuipmenwrdeviceswhich emBOILER-COMP(311P OR 10y"BTU) ISSU NCE ATE
it
i arief? air contaminants es defied by the Bay Arca Air QueM�Mllnagement BOILER-COMP(OVER 100,(10)BTU) ley,
OisvicC f n p B V
❑Yes ❑No NEW RESIDENTIAL MECH.—SQ.FT. U' P9
1 have read the hazardous materials requirements under Chapter 6.95 of the FEB 1 9
tithe uil Health&Safety Code,Sections it
and 25534.1understand What •j^,
ifthebuildinge re not currently haveatellWhato is my responsibility tonotify the 1
ceramic,upan of the requiremema which man be met prior to ismm�w of a Certificare of C1 `
txeavaney. ' "V
Oemormamhodzaaagem - DateISSUED BY:
OFFICE
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