20817APPI 1('ANT Tn Fu I IN INPnRMATION WITHIN RED LINES - USE BALL POINT PEN ONLY ,
Building project Identification
Building Address:
-T r
PERMIT NO. R 17
2 0 8
a� n
J /'Q / CA
1 1
wnera one:
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION 1 PERMIT
V ILJJ
, �L.V�q
cn anor'a Name: L .No:
LM.
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T
BUILDING-ELECTRICALPLUMBWG-ME NiCAL
CATEGORY
CONTROL N -
Architect/Engineer. - ic. Nes -
QTY. ELECTRIC PERMIT FEE
BUILDING PERMIT. INFO: "
Address: - - + ..
El
PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION
Ihereby affirmtlullam lkanacd under provlsivns o(Chapter9 (commm
APPLIANCES -RESIDENTIAL
JOB DESCRIPTION
PANELS
Inenseisectkn foxes of Div(slvn3otthe8uslesaandPm(esaivnsCode,and my
license le In full form and dfect�,a��a++++++ /////���NN
+ P ('�
Llcena Class Lk. N
Date Contractor.
ARCHITECTS DECLARATI N
I understand my plane a hall be used as public records
00 AMPS
OVERVER
O 1000 AMPS
SQ. Ff. FLOOR AREA
S/SQ. FI.
SIGNSEGECTRICAL
Licensed Professional `
SPECIAL CULT/MI
- OWNER -BUILDER DECLARATION
I hereby a(firmthat I am exempt fxamthe Contractor's License Law for the
TEMP ME 1. RPO
SI.-
following reason. (Section 7031.5, Business and Pmfeabns Code: Any city or
county which requlresa permit to construct, alter, improve, demolbh,or repair
'
any structure prior to its Issuance, also requires the applicant for such permit to
file a signed statement that he b licensed pursuant to the provisions of the
POWER DEV]
'
SIyIMAgNG gCTRI -
_
Contradoes License Lasso (Chapter 9(commencing with Section 7000) of Dlvl-
.ion 3 of the Business and Profeialoru Cade) or that he b exempt therefrom and
VALUATION ,•'
the basis for the alleged exemption. Any violation of Section 7031.5 by any
applicant fora permit subjects the applicant to a civil penalty clove mvrethan
OUTLEISSWITC XTURES
NEW RESIDENTIAL EL TR SQ.
five hundred dollars 1,¢500). -
M I, as owner of the property, or my employees with wages as their sole
STORIES -
TYPE CONSTRUCTION'
_
compensation, will do the work and the structure is not intended or offered for
sale (Sec. 70" Business and Professions Code: The Contractors License Law
_. I '
does not apply to an owner of properly who builds or Improves thereon,and
who does suchwork himselforthrough his ownemployees, provided that such
OOC.GROUP
RES. UNITS
Improvements are not Intended or offered for sale. If, however, the building or
TOTAL:
Improvement is sold within one yearofcompldbn, the mvner-builderwill have
t rden of proving that he did and build or improve for purpose of sale.).
LJ L as owner of the property, am exclusively contracting with licensed
contractors to mndruct the project (Sec. 7041, Business and Professions Cade:
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QTY. PLUMBING PERMIT FEE
FLOOD ZONE
AIPN
PEiv(p ISSUANCE .t
y� `
The Contractor's License Law docs not apply to an owner of property who
builds or Improve@ thence, and who contracts fee such pAojects with a
mX}TachaW Bcensed pursuant to the Contractor's License Law.
u I am exempt under Sec. B & P C for Nb reason
ALTER -DRAIN &VENT- WATER (EA)
FEE SUMMARY
BACK FLOW PROTECT. DEVICE Zx
DRAINS. FLOOR ROOF, AREA, COND.
SANITARY RECEIPT N ,
Owner - Data
WORKMAN COMPENSATION DECLARATION
f,{Q/�,I hereby. affirm that I have rcertifimte of consent roself-Insure, ora
r4rtiflmteofWorkene'Compeneatlonlneuranm ora certified mpythereof (Sec.
Poli p Cl (DO J
Com any tYAwy' /��—EA.
�certinadh 6lidi�y (�irn
.r,}cenuied copy Is filed with the city inspection division.
.. CERTIFICATE OF EXEMPTION FROM WORKERS'
y F.IX.FURE& PER TRAP CLSCHOOL
(
TAX Y' N_
- RECEBT N -
GAS F.A. SYSTEM -1 NCA OUTLETS
PARK FEE Y N
GAS SYSTEM -OVER 4IRA)
•ISION FEES
BUIDING DIVISION
GREASE/INDUSIRL WASTE INTERCEPTOR
PLANCHECK FEE
PAID
GREASE TRAP+
SEWER -SANITARY -STORM EA. 200FT.
• " COMPENSATION INSURANCE
(This section need net be completed if the permit sfor one hundred dollars
($100)or lea.)WATER
„ Imnl(ythat in the' performance ofthewwk forwhich this permit is Issued,
Date' Recei t#
'
EN
HEATERW/VT/ELECTR
ENERGY FEE Y_ N_
WATER SYS"lEtrt/TT3FATTNG ,
I shall not employ any person in any manner so as to become subject to the
Workers' Compensation laws of California. Date.
- -
PAID, -
NEW RESIDENTIAL ELMS. _SOFT.
' t
Applicant
Date Recei t#
NOTICE TO APPLICANT. If, after making this Certificate of Exemption, you
should become subject to the Workers' Compensation provisions ofthe Labor
- TOTAL:
+
L G FEE
Code, you mmv at forthwith comply with such provisions mthls permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
SEISMIC FEE - +
TOTAL:ELECTRIC
FEE
I herebyaffirmthatthere isamnatructlon leadiagagency forthe perform-
ance of the work for which this permit Is Issued (Sec. 3097, Civ. C.)
Lendd. Name
Land.e.Address
IcertBythatl have read thisapplientionand statethattheabove information
scormet.I agreeto complywlth all city and county ordinances and state laws
PLUMBING FEE .c,CYa
QTY. MECHANICAL PERMIT FEE
-
MECHANICAL FEE
-
PERMIT ISSUANCE
FEES PAID:'
relating to building constructlon,and herebyauthortm repreantativesofthi.
city toenterupon the above�mendoned property for Wpertlon purposes.
(We) agree to ave, IndemNfy an d keep harmless the City of Cupertino
against BabI itle dgments,"sand expenses which may In anywayaccree
,
Date Recei t#
ALTER OR ADD TO MECH. ..
AIR HANDLING UNIT (TO 10,000 CFM)
- SUBTOTAL: .
.galId In consequenceo the granting of this permit.
as
AIR HANDLING UNIT (OVER IEWOCPM) -
-
CONSTRUCTION TAX ,.
S'wh pp cont TtiV
D(HAUST HOOD(W/DUCT) -
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or lotion, building occupant atom or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9,17, and the
Health and Safety Code Section 25532(a)7
- Yes, LJ No
Will the applicant orftairebullding occupant use equipment or devices
Date Recei t#
HEATING UNIT (TO 100,000 RTU)
HEATINGUMT,(DVER 100,000 BTU)
TOTAL:
VENELATION PAN(SINGLE MID)
-
rjgkWCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
Quality ManagementDistrict? - .
❑ Yes nn No
.]have read the Aaza[Zmaterials requirements under Chapter 6.95 of
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aU i. n
BOILER -COMP GHP OR 100,0008TU)
BOILER-COMIP(OVER 106,000BTU)
the California Health & Safety Code, Sections 25505, M533 and 25534. 1 -
understand that ifthebuildingdoes not cormatlyhave six nanI, that it 1. my
responsibilitytonotifythe cavpantold, requirements which must be and
prior/ 4suadcem cateof0avpancy.-
ps.E p
,. p�Ea@ CBQLr3.'�s•�
NEW RFMDFIMAL MECH. - SQ.FT
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taut ze k—�-'�DItte T1
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ISSUED BY: �IW'Vl�s-^'
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TOTAL:
OFFICE COPY