19885APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
Building Pro'ert Identification -
Building Add mss: -
PERMIT NO. '
n O O C
-
11-342 1
JFVIoJ
ears Phone:
-
A -
- ' 25% 2
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION I PERMITBUILDINGELECTMCAI
Coatrador'a Name:
PLUMBING-MECHAMCAL
CATEGORYCONTROL4
BLECTRIC'PERMIT FEE
BUILDING PERMIT INFOAddress:
*:N�..
', c.r 154 . 1:1
PERMITISSUANCE �LCENSED
CONTRACTOR'S DECLARATION
I hereby affirmthat l am licensed under provisions o(Chapter9(mmmenc-
Ingwllh Sedion7000)of Division3.fthe Businmsand ProfesslonsCode,andiny
II=-Clicenssia in (u8_r deflect. n/
lsse Lk.# Jb
APPLIANCES -RESIDENTIAL
JOB DESCRB']TON '
,` ,'
�l T\vV�
-
PANELSUP
Date Contractor
IQ 2fflAh2S
7014"AMPS
ARCHITECPSD CLARATION
--
OVERICOOAMPS
SQ: Fr. FLOOR AREA
S/SQ.FF.
IundersumdmyplaruSha] be used as public recada
SIGNSELECTRICAL
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirrnthat I am exempt from the Contractor's LI... hw for the
following reason. (Section 70315, Business and Professions Code: Any city or
county which requires a perm a to construct, alter, improve, demolish, or repai r
S['ECIAL CIl2CU[T/MISC
T�P.METBR ORPOLE [NST.'
anyatructure pdorto italssuance, also requlreathe appliontforsuch permit to
file a signed statement that he is licensed pursuant to the provistom of the
Contractors License Uv, (Chapter 9(commencing with Section 7010) of Divi-
si.n3of the Business and Perfessloes Code) or that he is exempt therefrom and
POWER DEVICES
,
SWAShENG POOL ELECTRIC
VALUATION
the basis for the alleged exemption. Any violation of Section 7031S by any
app0cant fora permiteubjectsthe applicant tea civil penalty o(nU more than
OU7'['E7SSW[1'C[-LESHXCURES Zc+
y I' /_ � 4 S -
7
NEWRENDEMAL ELECTR SQ.Fr. -
five hundred dollarshepro
I, net of the property, or employees with wages thele sole
STORIES
TYPE CONSTRUCTION
ss
mm(Sec,7044,wdires.l do he
ri�Pr and thes not intended a r d for
sale(Ser. 704q Business and Profeaslom Code: The Contractors License Law
and Code: The scene Law
TOTAL;
does not apply to an owner of property who builds or improves thereon,and
who does suchwork himself.,through his own employees, provided that such
Improvements are not intended or offered for sale. If, however, the building or
Improvemdntlssddwithinoneyearofcompletiorythe ower-builderwlll have
OCC.GROUP
• ��
RES. UNITS
thq.¢.rden of proving that he did not build or Improve for purpose ofsale.).
L 4 as owner of the property, am exclusively contracting with licensed
contractors to mmlr w, the project (Sec. Business and Professions Code:
QTY, PLUMBING PERMIT FEE
FLOOD ZONE
APN
PERMIT ISSUANCE
The Contractors License Law does cad apply to an owner of property who
builds or Improves thereon, and who contracts,ch for sup\ojects with a
cgR{(ador(s)licensed pursuant to the Contractor's License Law.
LII am exempt under Sec B k P C for thb ressonOUTSIDE
ALTER -DRAIN k VENT - WATER (EA)
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
FEE—S
.. DRAINS FLOOR ROOF, AREA, COND.
SANITARY Y_ N_
RECEPT If
Owner Date
WORKMAN COMPENSATION DECLARATION
hereby affirm that I have a srtificete of consent to self -Insure, ora
If teofWorkers'Compcmationlm mnmoramdifiedmpythereof(Sec.
3 W, Lab CJ
FIX'NRES PER TRA['
SCHOOL TAX Y N
RECEIPT M
GAS EA. SYSTEM -1 INC.40VILECS
-
PARK FEE Y N
Policy# -
RECEB'r#
GAS EA. SYSI)7d-OVER4(EA) '
Com any -
BUILDING DIVISION FEES
�Cemfied copy is herebyth the cid.
'j—}Certified copy ls Ned with the city inspection division.
GREASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECKFEE
GRE-ASETRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
PAID"
SEWER-SANIfARV-STORM EA.200F1'.
COMPENSATION INSURANCE
(Fhissection need not be completed if the permit is forms, hundred dollars
-
($1 I comily that pesubjecrmit is timed,
Ill nor that o any Foram,he t an tmanterhe work forwto becoto me
I ork not employ any person in any manner so m to become subjM to the
Workers! Compensation Laws of CaO(orma. Date
Date Recei t#
"Z
WATER HEATER W/VENT/ELECTR
ENERGYFEE •Y N
PAID '
- WATER SYSTEM/,TREATING
Applicant
,Applicant '.
NOTICETO a subject to the after making celssationlcate.f Exemption, you
' should coma eubFd m she Workers Compemovial n provbions
Date Recei t#
NEW RESIDENTIAL PLMB.SQ.Fr. '
-
TOTAL:
o
ode,youly,wit permit shall
dromedumlard. hwithcomplywithauchprovlsbns.rthlspermitshellbe
deemed revoked.
BUILDING
1ST
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
Ihereby affirm
orkfthat whicthem lsecomtmction lend eded(Sengagency Civ. .) perform,
Lead erthe work forwhlch this permit is lssued (Sec. 3097, Civ. C.)'
d.ender'a Name
Lender§Address - -
Icertifythat l have read this application and statethat the above information
lsmrrect.I agreew comply with all city and county ordinances and state laws
,TOTAL:
ELECTRIC FEE
'l{�
'PLUMBING FEE
QTY. MECHANICAL PERMIT FEE
MECHANICAL FEE'
PERMIT ISSUANCE
FEES PAID: ..
relating to building mmtruchon, and hereby authorize representatives of this
city to enter upon the above-mentioned property for inspection purposes.
(We) agree to save, indemnify an d keep harmless the City of Cupertino
agalndt liabilities, judgments,costsand expenses which may In anyway accrue
against Bald City In consequence of she granting of this permit
a
ALTERORADDTOMECH.
Date ReCe1Pt#
AIR HANDLING UMT CFO 10,OW CFM)
SUBTOTAL:
AIR HANDLING UNIT (OVER IO,ODDCFM)
CONSTRUCTION TAX
Signature of Applicant/Centrad., Date-
FXHAUSTHOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
14FATING UNIT (TO 100,000 BTU)
Will the applicant crfuture building occupant store or handle hazardous
material as defined by the C 'kine Municipal Code,Chapter9.14,andthe
Health and Safety Cmxae Ion 25537(a)7
❑ Yee No
Date Recei t#
HEATING UNIT 100,000 BTU) -
r
TO
'
81s
L
VEMHLATION FAN (SINGLE RESID)
ISSUANCE DA'Z'E. ,
Will theipplicant or fumes building mmpantuse equipment or devices
which emit hazardous airco minanteas defined by the Bay Area Air
Quality Mawgement Dts 7
n Yea No
BOILER -COMP LIHP OR 100,000 BTU)
' `shave readtheb a ommaterlalsrequimm ntsunder Chapter6.956f
rl
BOILER-COMP(OVER 100,000 BTU)
--
ueCalifrnia Hlathe lthbuilding does nemns25yhave33and tenant, that itlsmy
Health kSafetyildin Code, otcurrently have a Land, 534. that1
understand that
- pp�`9W^
ll'jHR I t(7'aJ,
NEW RESlDEN71AL MECH. SQ.FT.
responsibility to edify the occupant of the requirements wits must amet
a�
pri ssuance rtl cafe o! - scary. ?O
Owner., authorized agent to
1
l
ISSUED BY:
OTAL:
OFFICE COPY