23960APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Rulldln Pm'eat Identification
Budding Addresa:
�I C 1 1 1 LJT I
- - - PERMIT NO.
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CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION I PERMIT
BUILDING-M.BCTRICAL-PLUMBINGMECHAMCAL
A
2
Con1a o2'N" °' Lie. No:
VArchlted/Eegineer.Lic.
No
CATECABY
CONTROL#
QTY ELECTRIC PERMIT FEE'
• BUILDING PERMIT INFO
�sff�!
Addresa:
PBRMIT ISSUANCE ��
PLUMB
❑ ❑
LICENSED CONTRACTOR'S DECLARATION
Thereby affidnthat l sun leered under provisions of Chapter9(comment,
Sedion7000)of Dlvllon3ofthe Buslnessand PmfnslanaCode, and my
license is hi full force and died.
licensee Class Lk.#
Date Contractor
APPLIANCESRESIDENITAL
I _ PANELS !
'JOB DESCRIPTIONIngwith
1 �� A /
(circ
ARCHITECTS DECLARATION
I understand my plane shall be used ae public records.
'
201-1f100 AMPS
OVER 1000 AMPS -
SQ. FT. FLOOR AREA S/SQ. FT.
SIGNSELECTRICAL
Licensed Profenioml -
OWNER -BUILDER DECLARATION
I hereby a(firmthat I am exempt froContradorl License Law for the
following Mason. (Section 7MI.5, Business and Professions Code: Any city or
c°untywhlch requiresa permit teconatruct, alter, lmpmve, demolish, oreepair
anystrvcture prlorlulteissuares, also requireslheapplicant forsuch permitto
file a signed statement that he Is Licensed pursuant to the provisions of the
Contractors License Uss (Chapter 9 (commencing with Section 7000) of Divi-
don3 ofthe Business and Professions Code) orthat he is exempt therefromand
the hall for the alleged exemption. Any violation of Section 7031.5 by any
appikantfora permit eubjecl the applicant toss dull penalty o(nd morethan
live red dollen ($500).
a owner of the property, or my employees with wagro a the4 sole
c pensadon, willdothe work andthe etmdure loot Intended or offered for
sal (Sec. 7094, Business and Professloru Gde: The Cantradote Liceexe Law
does not apply to an owner alproperty who Wilde n, and
whodoeasuchwarkhimsslfrnthrough Neownemplayees,provWed that such
improvements are n°t Intended orofferedfrnule, If, howevegihebuildingbr
ImprovemeMleoldwithlndmycaro(complMbRtheowner-WBderwW have
tl)„�,vden o(proving that he did nm build orimprove far purpose ofoals.).
�LJJ I, as owner of the property, am exduslvely mntracting with Tissued
contract°n to rorisWd tW Project (Sec.7044, Busmen and Professl°ru Code:
The Coie.pta Llcerue n
Wild. or er Law does n°t apply to an owner of property who
e
car Improvthreon, ad who contracts for such pok ea with a
cretin) nss under Sntt°the Contradote Liconee Law.
of
lJ I am exempt under Bee: B & P C for this reeaon
®' g„t
r A l
n1 � ay
„f• G••�
TION_
SPECIALCIRCUIT/MLSC
III.fp, METER OR POLE INST.
POWER DEVICES .
SWIMMING POOL ELECTRIC SATE
OUTLETSSWITCHESFIXIURES
NEW RESIDENTIAL ELECTS sQ3'T.
STORIES
]YPE CONSTRUCTION
' -
OCC,GROUP
RES.UNITS
.
'
TO
QTY. PLUMBING PERMIT FEE
PERMIT ISSUANCE
ALTER -DRAIN A VENT- WATER (EA)
b7.0OD 7ANE
"N
�IX �WOTECT. DEVICE
FEE SUMMARY
Owner Date
DRAINS FLOOR ROOF, AREA, COND.
SANITARY Y_ N
RECEIPT it
WORKMAN COMPENSATION DECLARATION
pI hereby affirm that I have a mrOficaM of consent to self -insure, or a
redifimte of Worken'Compensationlruuranm or. ttdified mpy thereof (Sec.
3800, Lab C.)
Policy a
HXTURF_S PER TRAP
GAS EA. SYSTEM.1 INCA OUTLETS
SCHOOL TAX Y N
RECEIPT #
PARK FEE Y - N
RBCEEPT #—
Com any
Certified copy l herebyth the city
Certified ropy b Ned with the city inspection division.
GAS EA. SYSTEM-OVER4(ILA)
CREASE/INDUSTRL WASTE INTERCEPTOR
BUILDINGDI VISION FEES
PLANCHECK FEE
GREASETRAP
CERTIFICATE OF EXEMPTION FROMWORKERS' -
COMPENSATION INSURANCE
(Thlssectionneed not becompleted ifthepermit lforom hundred dollars
($100).,I...) lodtifythin issued,
cant that employ
I any arson I an tmanner fo as to become
I shall not employ any person In any manner w n to become subject to the
W m
`C°pns
eatlon Lowe of California.alifornia. Date
Applicant
NOIICETO APPLICANT: If,site, ma king this Certificate of Exemption, you
should become subject to the Workers'Compensatlon provlioru ofthe Labor
Code, you must forthwith comply with such provisions or this permit hall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there l a construction tend Ing agency for the perform-
ane, of the work for which this permit l Issued (Sec. 3097, Civ. C.)
Ieoder'e Name
Lender's Addren
I adifythat] have readthlapplicatlonand atatethattheabovein(ormMion
lcormd.Iagree to comply with all cityand countyrodinanree and state laws
relating to building construction and hereby authorize representatives of thl
ctry to enter upon the above-mentioned properly for impaction purprets.
(We) agree to save, IndemNfy an d keep harmless the City of Cupertino
against llablitles,judgments, consand expenses which may In anywayaccrue
against said City in comaquene. of the granting of this permit.
PAID
Date Recei t#
BEWE&SAMTARY-STORM EA. 20OFT.
WATER HEATER W/VENT/ELECTR
ENERGYFEE Y N—
—
PAJD
Date Re i t#
WATER SYSTBM/TREATING
NEWRESIDENTIALPLMB, SQ,FT.
-
TOTAL:
BUI TNG E
TOTAL:
SEISMIC FEE
ELECTRIC FEE 1711ni-
IL
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
PERMIT ISSUANCE -
ALTERORADDTOMFCH.
AIR HANDLING UNIT (TO 10,000 CFM)
MECHANICAL FEE '
FEES PAID: '
Date 'Receipt# ,
SUBTOTAL:
AIR HA LADLING UNIT (OVER 10,030 CFM_)
EXHAUST HOOD(W/DUCT) -
CONSTRUCTION TAX
CONSTRUCTION TAX PAID:
13'gZ
gnawro of Applicant/Contractor Date
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (TO 10,000 BIIJ)
Will the applicant orfut,m building occupant store or hand le hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.17, and the
Health and Safety Cada Section 25532(a)7
❑ Yea No
Will the applicant orluture building occupant use equipment or devices
which emit haeardous air contaminants as defined by the Bay Area Air
Quality Management DlsMdT
❑No4harereadthehazardousmatedalrequiremenlunderChapter6.95ofp�Q�
the Ghforma Health k Safety Code, Sections 75505, 25533 and 25534. 1
that if the building does not currently have a tenant, that It Is mySQ.FT.
responsibility to notify the ompart of the requirements which must be mat
prior to issuance of a Certificate of Occupancy.
Date Recei t#
HEATING UNIT (OVER 1W,000 BTU)
TOT
VENTILATIONM(SINCLERESID)
D) -
ISSUANCE DATE
TP9understand
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hip,
.Yea
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ISSUEDB I ,_,}- Ii\b
Ownerorauthodzed agent Data
- TOTAL:
OFFICE COPY