19538APPLICANT TO FILL IN INFORMATION WITHIN REDLINES —USE BALL POINT PEN ONLY
\
BO.Building /dH41-n 21A)V" 404'- 0Ulk/�YV6 Gq. SOMI
inding Ad�Cess:
rAPPUCA
P TNI 9538
Owner's Name: , IJ, Ph e:
` At 4M !- " � 5-'jO
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BUILDING-ELECTRICAILPLUMBING-MECHANICAL
�p
( 0
Contraebr's Name: // Lk. No:
9V 14 I A p
CATEGORY
CONTROLp 6 D
rchltect/Engineer: Lk. No:
QTY ELECTRICPERMIT FEE
BUILDING PERMIT INFO -
Addres.:
IX , I� ❑ .
iYj }J
PERMITISSUANCE x, OD
LICENSED DECLARATION
underCONTRACTOR'S
fC .p nc
Thereby.(imnthatlaivisim3oftheesine.adPmf
APPLIANCES -RESIDENTIAL
JOB DESCRIPCION
PANELS
sions9 .,and
ofthe BuelneasandlrrofeseloneCotle,send my
Incense is
Sfon force and
license Ie in full fora and effect.
Clan
j
Data Cont
Date Contractor -
ARCHITECTS DECLARATION
I understand my plansshallbe used as public records.
l.. aUf1A� e
201-1000 AMPS
OVER
OVER 1000 AMP"'
SQ. FC. FLOOR AREA
I E/SQ. FT.
j
s
%
Licensed Professional
OWNER -BUILDER DECLARATION
IherebyafRrmthat lamexemptfromthe Contractoe.Llcena Law forthe
following reason. (Section 7031.5, Business and Professions Code: Any city or
county which requires a permit to construct, altep Improve, demolish, or pair
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MI.SC
TEMP. bR POLE N5T.
Sfile
any structure prior to its Issuance, also requires the applicant for such permit to
a signed statement that he b licensed pursuant to the provisions of the
PO
LELECCRIC
SWITCHFSFIXTURES
3
Contractors License Law (Cha Enter 9 (commencing with Section 7000) of Divi -4
sion3 ofthe Business and Professions Code) or that he is exempt therefrom and
the basis for the alleged exemption. Any violation of Section 7I
appllant fora permit subjects the applicant to a civil penalty ofn
VALUA N
s AT
C
W RESID ALE TR SQ.FT.
five hundred dollars ($500).
❑ I, as owner of the property, or my employees with wages
RES
TYPE CONSTRUCTION
compensation, will d o the work andthestructure isnot intendedsale(Sec.7014, Bushels and Professions Code: The Contractor.
does not apply to an owner of property who build. or improves
whodoee such work himself orthrough his own employees, proviimprovements are not Intended oroffered forage. If, howevep th
Improvement Is sold within oneyearofcompletion, the owner-bullderwill have
TOTAL: r�
OCC. GROIII'
RES. DNTI'$
ea.1n,rden of proving that he did not build or improve for purpose of sae.).
"L as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec, 7094 Business and Profesdom Code:
QTY,fkA4L1MBI*GPERMIT FEE
FLOOD ZONE
APN
ANCE t9
V
The Commoner's Licence law does not apply to an owner of proparty who
bunds or improves thereon, and who contracts for such pto)ects with a
cgR{(actor(eexempt under Snt to the ContradaJ.License Law.
L I am exempt under Sec. B & P C for this reason
ALTER -DRAIN& VENT- WATER (EA)
FEE SUMMARY
BACY FLOW PROTECT. DEVICE
DRAINS FLOOR ROOF, AREA, COND. OD
SANITARY Y_ N_
RECEB'I a
ner Data
•
WORKMAN COMPENSATION DECLARATION
[]I hereby affirmorkem that I have o certificate of consent to py thn are, ora
wnlflab C.Workers'Compensatlon insurance ora certified copy thereo((Sec.
'Policy ab C.)
FIXTURES, PER TRAP
SCHOOL TAX Y_ N
RECEIPT p
GAS EA. SYSTEM -1 INCA OUTLETS
PARKFEE Y_ N_
RECEIVE If
Poon
on
Cam a y -
GAS EA. SYSTEM-0OVER (EA)
BUILUINC DIVISION FOES
[� edified copy is hereby furnished.
copy b filed with the city Inspection division.
GREASE/INDUSCRL WASTE INTERCEPTOR
PLANCHECK FEE
20 Z
GREASETRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
PAID
COMPENSATION INSURANCE
(Chis section need not be completed lithe permit b forone hundred dollars
SEWER -SANITARY -STORM EA 200FC
Date Recei t>f
WATER HEATER W/VENT/ELECTR
ENERGYFEE, Y N
($100)orlessJ
Iartl/ythat in the performance of the wakforwhkh this permit le blued,
WATER SYSTEM/TREATING
I shall not employ any person in any manner ce as to become subject to the
Workere'Compens.lon Laws of California. Date
PAID
NEW RESIDENTIAL PLMB. 9Q.FT.
Applicant
Date Recel t4t
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you
should become subject to the Workvs' Compensation provisions of the Labor
TOTAL:
G
� Q
Cade, you must forthwith comply with such provisions orthls permit shall he
deemed revoked.
CONSTRUCTION LENDING AGENCYSEISMIC
FEE
I hereby affirm that there Is a construction lending agency for the perform-
onceof the work far which the permit Jammed (Sec. 3097, Civ. CJ
Lenders NamePLUMBING
Lender's Address
1 certify that I have read this appllation and state that the above Information
is correct.I agree to comply with all city and county ordinances and state laws
70TAL: D✓m
ELECTRIC FEE
S'UO
FEE
QTY. MECHA CALPERMIT FEE
MECHANICAL FEB
PERMIT ISSUANCE
FEES PAID:
relating to building construction, and hereby authorize representatives of this
city to enter upon the above-mentioned property for inspection purposes.
(W a to save, indemnify an d keep harmless the Cityof Cupertino
agai Il itfes,}adgmeme coatsand expenses which may In any wayaceme
ALTER OR ADD TO MECH,
Dale R2Ce1Pt#
AIR HANDLING UNIT ROIO,WOCFM)
SUBTOTAL:
seg st i In consent. of the granting of this permit.
AIR HANDLINGIINI"I'rovER 10,000 CFM)
CONSTRUCTION TAX
SiAlz a pplicant/Contractor Date
EXHAUSTHOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
I cappliaor building occupant store or handle hazardous
material as tle0ned by the Cupertlm Municipal Code, Chapter 9.12 and the
Health and Safety Code�+. -S�ection 25532(a)7
F1 Yes u No
Will the applicant or hours building occupant use equipment or devices
which emit herardous air contaminants as defined by the Bay Area Air
Quality Management DbIrict7
QYes, �Nn
HEATING UNIT (TO 100,O BTU)
100,E)DO
Date Reeei t#
HEATING UNIT (OVER 100,00) BTU)
TOTAL:
VENTILATION FAN (SINGLE REBID)
ISSUfW 7� kTE
FEB 2'r TySJ
3 BOILER -COMP OHP OR 100,000 BTU)
BOILER -COMP (OVER 100,000 BTU)
of
havenia Teeth&
materials requirementsunderand
,
Tet and25534. [
25534.
the Californiaat If the
rentlyh have
Code, not currently
building
understand thatlfthe building does not corrently have atenanL that it Is
responsibility to notify the occupant of the requirements which must be met
p}�� .{
City of rrirert(oo
NEW R[SIDENTIAL METH. `nTOTAL,
prior to issuance of a Certificate of Occupancy.
ISSUED BY:� Y!
Owner or authorised agent Date
- -
OFFICE COPY