23023APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification
Building Address:
I oc.rV18 00%jW 1�.
PERMIT NO.
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G
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mrs ..:rho��� ine:
1"ese"G
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION I PERMIT
BUILDINGELECTRICALPLUMBINGMECH NICAL
T—1
Contractor. Name: Lic. No:
CATEGORY
CONTROL M
ArehltM/Engineer. Lie. Na
QTY ELECTRICPERMIT FEE
BUILDING PERMIT INFO
Adtlrem:
I
SL ❑• E:1LICENSED
PERMITISSUANCE
CONTRACTOR'S DECLARATION
I hereby affirm that lam licensed under provisions of Chapter 9 fixernmeno
Ingwah Sertion 7000)O(Divisim3oftheB"mmandprofeml.n.Code,and my
Iicena 1b In full force and
Class It.# -
Dale Contractor
ARCHITECTS DECLARATION
I understand my plan shag be used as public records.
Licensed Pmfemionl
OWNER -BUILDER DECLARATION
I hereby filmes that I am exempt from the Contractor's License Lew for the
following reason(5ecilon 70715, Business and Profembns Code: Any city or
counlywhichrvNu aper temntruct,alter,Improve,de=lbh,orrepalr
any.tmc mpr rialm Issuance,aboreqube.theappBantfmachpem tto
file a signed statement that he Is Bmnsed pursuant to the provision of the
Contractor's License Law (Chapter 9 (commencing with Section 7000) of Divi-
sion3 ofthe Business and ProfessionsCode) arthat he is exempt therefromand
the basis for the alleged exemption. Any violation of Section 70715 by any
for a permit subjects the applicant to a civil Pena By of not more than
flue ndrcd doll an (5500).
s owner, of the property, .,my employees with wages ae their sola
mpensatlon, will do the work and the mrucWre Is not Intended or offered for
Ie (Sec. 7000, Business and Profession Cade: The Contractor. License Law
doe. not apply to an no, of property who Wilde or improves thereon.and
who does.uch work himself orthraugh hisown emplayeea, provided that such
Improvements are not Intended oroffered forsale. ILh..,P thebulldingor
improvement issoldwithlnoneyearofc xmpldlon,the owner-bullderwRl have
tl)RJZurden of proving that he did nor build or improve for purpose of Yale.).
U L as owner of the property, am exclusively contracting with licensed
contractors to construct the project (See. 70K Business and Profembn Code:
The Contractor'. License Law does not apply to an owner of property who
or Improves thermn, and who contracts for such pRojeds with a
rya(Tactor(.) licensed pursuant to the Contractor's License Law.
ec
I t I am exempt under SB k P C for this reason
APPLIANCES -RESIDENTIAL
JOB DESCRIPTION
SPA
PANELSLlc
201-10DOAMPS
OVER 1000 AMPS
SQ. FT. FLOOR AREA
$/SQ. FT.
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC
TEMP METER OR POLE INST.
POWER DEVICES
SWIMMING IDOL ELECTRIC
OUTLETS -SWITCHES -FIXTURES
VALUATION
,
NEW RESIDENTIAL ELECTR SQJTr.
STORIES
TYPECONSTRUCTION
TOT
QTY, PLUMBING PERMIT FEE
PERMIT ISSUANCE
OCC.GROIIP
RFS UNITS
FLOOD TONE
APN
ALTER DRAIN hVENT-WATER MAI
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
OUTSIDE FEES
DRAINSFLCOR ROOF,AREA, COND.
FIXTURES. PER TRAP
SANITARY Y_ N_
RECEIPT 0
Owner Date
WORKMAN COMPENSATION DECLARATION ❑
1 hereby affirm that 1 have a certificate of consent to seB.Inarc, or a
certificate of .rkem• Compensation lnumem ora certlffed copy thenmf(Sec.
3800, feb C.)
Policy N
SCHOOL 7A% Y_ N_
RECEIPTN
GAS FA. SYSTFM.I INC4 OUTLETS
PARK FEE Y_ N_
RECEIPT N
GAS F.A.SYSTEM-OVER4(EA)
Com n
a Y
BUILDING DIVISION FEES
Certified copy hereby furnished.
❑ Certified copy Is filed with the city inspection division.
CERTIFICATE OFE%EMPTION FROM WORKERS'
COMPENSATION INSURANCE
Rhle.ecilon read not be completed 1Nhe permit Is (Drone hundred dollars
(SI00)orins.I
I mrtifythat in the performance of the wok for which this permit Is Issued,
1 shall not employ any person In any manner an as to become subkct to the
Workerea Compensation laws of California. Date
Applicant
NOTICETO APPLICANT:cttoe, after making persationhis ro is Exemption, you
Code, become abjectto the Workers' Compensationprovhianofthe Labor
Code, you must forthwith comply with such provision or this pertNt shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
I herebydOrm that there is amntrolendingagency forthe perform,
once of the work far which this permit Is Issued (Sec 3097, Civ. C.)
Lender's Name
Larder's Address
I udlfythat I have read thisapplicationand statethat theahoveieformatlon
IscormR. l agmto complywilhall cityand county ordinances and Mate laws
relating to building commotion, and hereby authenio a representatives of this
city to enter upon the above-mentioned property for inspection purposes.
(We) agree to save, Indemnify an d keep harmiem the City of Cupertino
against liabilities, judgments, Cons and expenses which may In any wayaocroe
ga Inst said City In aon.rquence gra ding of this permit.
X ,� e / n 1 It /23 �
CREASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE
PAID
Date RCcel t#
GREASE TRAP
SEWER.SANITARYSTORM PA. 200FT.
WATER HEATER W/VEM/ELGCTA
ENERGY FEE Y N
PAID
Date Recei t#
WATER SYSTEM/TREATING
NEW RESIDENMAL PLMB. SOFT.
TOTAL:
BUILDING FEE
SEISMIC FEE
TOTAL:
EEction
ELECTRIC F
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
MECHANICAL FEE '
PERMIT ISSUANCE
FEES PAID:
Dale RCCCI [#
ALTFRORADD'TOMECH.
AIR HANDLING [IMT CTO 10,000 CFM)
SUBTOTAL:
AIRFiANDLINCUNIT (OVER 10,000CFM)
CONSTRUCTION TAX
?SnafitU ApA IIcannI/Can or Dace
HAZAR US MATERIALS DISCLOSURE
Will the applicant orfulum building occupant store or handle havardoux
material as defined by the Cupertino MunicipalCode, Chapter 9.11, and the
t❑ Ynd Safety Code Section 25531(a)I
Willtheeppllonlor futurebuildingoavpanlumequipmentordevim
which emit haaardous air contamHunle as defined by the Bay Arca Air
Quality Management District?
Yn n❑ No
have read the heTardous materials requirementsunderChapler6.95 of
the G!Efemi. Health A SafetyCode, Section 25W5, 25533 and 2553N. 1
understand that tithe building does not mrrently have ate n..tthatitIsmy
responsibility to notify the occupant of the mquirem nts which must be met
prior to Issuance of a Certifinte of Ompanry.
EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
Date Recei t#
HEATING UNIT (TO 100,ODO BTU)
HEATING UNIT (OVER IMfice BTR)
TOTAL. 10
VENTILATION FAN (SINGLE RESID)
ISSUANCE DATE
,
ry.a
IfAID
fl19N 25 199 '
1'
Cd7Y ur CU uvU
ISSUEDBY:
BO COMP OFT' OR IW,000 BTR)
BOILER.COMP(OVER l ,000BTU)
NLWRESIDENIIALMECH.SQ.FT
Owner or authorlaed agent Data
TOTAL:
OFFICE COPY