23833APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
-_ . Building project identification '
Building Address:
ai
_ PERMIT NO.
wnera
23833
' on .
' - -Res _ 5
-
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION PER IT
�p
cnn actoe Name: ue.Ne:
//I
'BUILDINGELECTRICA4PLUA16IN MCAL,.
CATEGORY , CONTROL9
BUILDING PERMIT INFO
Architect nee . Llc o:
QTY ELECTRI PE IT - FEE
Address 15-(!' ".
PERMITISSUANCE
LICENSED CONTIIA OR'S DECLARATION�-
I hereby affirm thatI am licensed under provisions of Chapter 9(xturnmc-
ingwith Section7000)of Dwielon3ofth. Buslneseand Professlon.Code,andmy'
license Ia in full force effect..
License ClassIc
' . N
Date " Contractor--rs�•-`��q�—(.LySi��/
ARCHITECTS DECLARATION I 1�
I understand my plana shall be used u public records.
Licensed Professional' -
APPLIANCES L
1 AM
JOB DESCRB'DQN
K s^O W t La•i Nn t H
41t 0•� �J r
d
D I w' �•
1000
SQ. FT. FLOORAREA '- S/SQ.FT.
SIGNS ELECO'a''
OWNEReBUILDER DECLARATION
Iherenixisamthatlam31.5, B,mrsaxempt C Profesorb License Gw fmthe
following hIchrequirm. esa Pel tto Business and Pmfeasve, eo le hny tltyir
nystmcountykbps to.spemdttocoorequia)ter,Improve, demolish, orrepalr
any atmclure prlormits bsuance,aleo requlresthe appliontfmsuchpermitin
Ole a signed statement that he b licensed pursuant to the pmvblmu of the
Contnctres License Law (Cha pter9(comoencing with Section 7000) of Divi-
airthe basis for
Pro(ption. Any orthat lation f exempt eherufmin31,5by y
the alleged
the bean for the alleged exemption. Any violation of Section not m by any
fiveapphundredt for aper it rs($50ecte theapplicant his civil penalty of not mom than
Ove hundred dollen he pr .
„ ❑ I, as owner l the property, or h. employees with wages r them sole
rk an r na intended
role
.`L.. Epi_
n _
',S` /,j
U'✓'�
O U
-EA
SPECLYLCIR
T/MISC -
TEMP. METER ORPOLE INST,
POWER DEVICES
gWN1MING POOL ELECTRIC p
OUTLETSSWITCHESFIXHJRES
T TION'
/ Ji
NEW RESIDENTIAL ELECTA �'�
STORIES
TYPE CONSTRUCTION
(Sm. 0" Businessand siono
sale (Sec. 7064, Business eM Iarafenlom Code: The Contractols License law
ode! Th License Law
does not apply to an owner of property who build. or improves thereon, and
who does such work hlmselforthrough his ownempibyees, provided that such
improvements are not Intended or offered for sale. If, however, the building ce
improvement bsold within oneyearofcompletlon, the owner-budderwlll have
ll(gJ;urden of proving that he did not build or improve for purpose of sale.).
u C as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business and Professions Code:
The Contracm'a License Law does mat apply to ar owner of property who
builds or Improves thereon, and who contracts for such projects with a
cgp((ador(s) licensed pursuant to the Contractor's License Law.
LJ I am exempt under Sec B & P C for this region
OCC. GROUP -
ft6. UNRS
UNITS—
. T
QTY, PLUh1BING PERMIT. FEE.
pp(M)T ISBIIANCE
ALTER -DRAIN & VFM-WATER (EA)
l•7GDDZINE
APN
BACK FLOW pRO.1.ECT. DEVICE
.FEE SUMMARY
Owner Data
DRAINS -FLOOR, ROOF, AREA, COND.,
I'IXTe" PER TRAPSCIdOOL
SANITARY Y_ N
RECE'I N
WORKMAN COMPENSATION DECLARATION
❑I hereby affirm that I have a certificate of consent to self -insure, or a
mrtRicate ofWorkera' Compensation Insurance m a certified copy thereof (Sec.
� ,3B00, Lab C,,y6
- Policy N /LI.GA4J C I Z�J 7iiB C�
Com env j IS C2
[Certified copy b hereby filed the cid. -
�CertiOed copy b Ned with the city inspection division. _
7AX Y _ N
RECEIPT '
GAS EA. SYSTEM -1 INC.4 OUTLETS
PARK FEE RECEE'I #
GAS EA. SYSTEM -OVER 4 (EA)
GREASE/WDUSTRL WASTE INTERCEPTOR
BUILDINGDIR ON FEES
•E
GREASE TRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thbaection need not be completed lithe permit is forom hundred dollars
' -WATER
I ¢rtify that in the perfomunce'of the work for which this permit is issued,
I shall not employ any person In any manner so as to become subject to the
Workers'Compensrtton Lees of California.. Data
Applicant
NOTICE TO APPLICANT: If, after making thisCertlflcateof Exemption, you
GV/rel
4PAID'
Re t#(61W)orless.)
SEWER-SANTFARY-STORM EA, 2WIT.
HEATER W/VENT/D-ECTR.
Y N
PAID ,
Date Recei t#
WATER SYSTEM /TREATING
NEW RESIDENTIAL PLMB._SQFC.
should become subject to the WorkersComperaation provisions, of the Labor
Code, you moat forthwith comply withauch provisions orthb permit shall be
deemed revoked.
TOTAL
BUI DIN baa
y
NOTAL:
CONSTRUCTION LENDING AGENCY
Iherebyaffirm that there b a comtmaion lending agency for the perform:
ante of the work for which this permit b heated (Sec. 3097, Civ. C.)
Lender'. Name
Lenders Address'
I certlfythatl have readthbapphotionand statethattheabove information
SEISMIC FEE
ELECTRIC FEE
QTY, MECHANICAL PERMIT FEE
PLUMBING FEE
MECHANICAL FEE �a
bcumd. l agreeto comply with all city and county ordinances and state laws
relating to building construction; and hereby authorize representatives of fhb
city to enter upon the above-mentioned property for Wpedion purposes.
(We) agree to save, indemnify an d keep harmless the City of Cupertino
against liabilities,udgmenb, costsand expenses which nay In anywayaccrue
said City in cosequenne of the granting of this permit.
PERMITISSUANCE ag;-f FFE$pAjD:
ALTER OR ADDTO MECH.
AIR HANDLING UNIT (TO 10,000 CFM)
Date' Receipt#
SUBTOTAL
AIR HANDLING UNIT (OVER 10,WoCFM) '
CONSTRUCTION TAX
Signature of Appgcant/Contractor Date
HAZARDOUS MATERIALS DISCLOSURE
EXHAUS'THOOD M/DUCT)
CONSTRUCTION TAX PAID:
HEATING UNIT (TO 100,000 BTU)
Will theappErant orfuture building occupant store or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.12 and the
I e❑alf Y.d Safety Code SeNioHEATINGon 25532(a)t
Date Recei t#
HEATING UNIT (OVER ]00,000 RTU) •,
TOTAL:
VENTILATION FAN (SINGLE RESID)
ISSTWE DATE
n ! SSJJ
P �
^fy
dV
p
Es1N Uf GUt'Cn
81 a
Will theapplicant or building occupant usesqulperent ordevices
whicticMt haeardmaidr containment... defined by the Bay Area Air.
Quality Management District? -.
4Yes. ❑ No
haveroad the hazardouamaterials requirements under Chapter6.95of
the Cabfemla Health & Safety Code, Sections 25505,75533 and 2MIL I
and enta nd that if the building does not currently have a tenant, that It is my
responsibility to nofBylhe occupant of the requirements which must be met
prion vancedaCertiFlca of Occupancy. -
Z
BOILER -COMP OHP OR100,0MBTU) .
BORER-COMP(OVER 100,000 BTU)
NEW RESIDENTIAL MECH.— -'SCLIT
� -
Ow eror uthorued agenTiotelISS[JED
OFFICE COPY