21350APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
'
Building Prod Identlflcatlon
eullding Address:
/eV( PF3AIT NO.
�.s4
�/GP3 e.fsTLe�jr 67•
213 5 0
ncra aces: ase:
Te Qag /e as7-figy
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BUILDINC-ELECTRICAL-I'LUMBINC-MFOHAMCAL
9�
antract •Name: Lis. No:
CATEGORY
CONTROL M
Architect/Enginead Llc. No:
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Add.
❑ ❑ _ ❑
PERMITISSUANCH
LICENSED CONTRACTOR'S DECLARATION
whereby W(trmtha(Divislicensed ftheunder Bupressand of Cssions9(m,andm
Ingwlth SeMon7000)af Dlvitlon3ofthe BudnnsandlsrolnslonsCade,and my
license is In fug !orae ddfen.PANELS
License Clam Cei% Llea fi sr�/�G
CE&RE9DENML
JOB DESCRITT[ON �
�L/Jf�V '>M�•/
4e
PANELSAPPLIA
Dat Contractor /Pld/l�
201-1000 AMPS
ARCHITECPS DECLARATION
I understand my plans shag be used as public remML
OVERIMOAMPS
SQ. Fr. FLOOR AREA
f/SQ. Fr.
SIGNS ELECTRICAL
Licenced Professional
SPECIAL CIRCUIT/MISC
OWNER -BUILDER DECLARATION
I hereby afered that l an, exempt learn the Contractor's License Law for the
-
TEMP. METEROR POLE INST.
following reawn.(9ectlon 70313, Butlness and Profembns Code: Any city or
ceuntywhlch requires a permit iommtmct, alter, Improve, demolish,.rrepalr
anystmmampdortoi bwame,aborequimstheapphl nt(orsuchperMtto
file a signed statement that he Is licensed pursuant to the provisions of the
POWER DEVICES
'
SWIMMING POOL EkECTV
Contractor's License Law (Chapter9(commencing with Section 7000) of Divi-
slon 3 of the Business and Pa fembm Code) or that he is exempt therefrom and
VALUATION
the basis for the alleged exemption. Any violation of Section 703" by any
applicant for a permB subjects the applicant to a civil penalty of not eon tb
OUTLETSSWITC
442n
d
five hundred d.11as($M.
F1SQ.Ff• I, as owner of the property, or my employees with wages as their sole
NEW RFSIDEN1
STORIES
TYPE CONSTRUCTION
compensation, will do the work and the structure is not Intended or offered for
as Is IS.. 70K Busbem and Prefemimu Code: The Commove. LIceme law
does not apply to an owner of property who builds or Improves thereon,and
doessuch work himself or through his own employees, provided that such
OCC. GROUP
RFS UNITS
Improvements are not Intended oroffered forsale. If, however, thebulldingor
improvement Owidwithlnomrarofcompletion,theowner-bu0derwilluve
thLJfmIen.( proving that he did notbulldarimprow for purpowofeale).
LJ L as owner of the property, am exclusively contracting with licensed
mntracton to construct the project (Sec. 70/4, Boom= and Promlom feCode:
OTAL;
PLQf6Vfj1GPERMIT FEE
QTY.
PERMIT ISSU
FLOOD ZONE
APN
The Contractor's Llmnm Law don not apply to an owner of property who
hued. or Imprn, avn thereoand who contracts for such proj" with a
�gBt�actor(s) licensed pursuant to the Contractor's License Law.
B & P C for this reon
L•f I ice exempt under Sec as
ALM -DRAIN &VENT- ) 6
FEE SUMMARY
BACK FfAWPROTECT.D CE
-07 OUTSIDEFELES
DRAINS FLOOR ROOF, AREA, COND.
SANITARY Y_ N_
RECEIPT a
Owner Date
WORKMAN I haw COMPENSATION ON DECLARATION
I hereby .(firm that t have • cemfiote of consent to pythowaf or a
ITh o! Warken'Comperwtlon Inurana on certified ropythereof pec.
m,lab C.)'
P.Bcy# i W" A07JAV.3
FB(TURPS PER TRAP
SCHOOL TAX Y_ N_
RECEIPT M
� GAS EA. SYSTEM -1 INC.40UILETS
PARK FEE Y_ N_
RECEIPT•
GAS EA.SYSTEdAVERd(FA)
C.m — D/ G
BUILDING DIVISION FEES
edified copy is filed with the city InpcaTlon division.
1 ICertlfied copy is herebydwithfurnished.tcity
CREASE/INDUSIRL WASTE INTERCEPTOR
PLANCHECK FEE
GREASETRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
PAID
SEWER -SANITARY -STORM EA 200Fr
COMPENSATION INSURANCE
Clhissectbn need not ed completed If the permit is farone hundred dollars
Date Recei Nf
WATER HEATER W/VENT/ELFGT'R
ENERGYFEE Y ` N—
PAID
(Sl m)arf[cethat y tis lothe performance of for tAla permit lsbaed,
I
I shag not employ any person In any manner w as to become subject to the
Califomla. Date
WATER SYSTEM/TREATINGWorken'Compensatlonlawsof
Applicant
NOTICETO APPLICANT: If, after making this Certificate of Exemption, you
Date Recei til
NEWRESIDENTIAL PLMB. SQFr.
TOTAL:
should become subject to the Worken' Compenatfon provisions of the Labor
Code, you .9 forthwith comply with such provisions mthis permit ahall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
G
()
SEISMIC FEE
T hereby affirrnthat thereis a construction lending agency for the per/ord,
re of the work for which this permit is baued (Sec. 3097, Civ. C.)
Lxnder'.Name
Lender's Addmss
1 cemify that P have read thisapplintbn and state that the above Information
Is mret.I agree to comply with all city and county ordinances and slate lawn
TOTAL
ELECTRIC FEE
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID:'
relating tobugding construction, and hereby authorize representatives of this
city to enter upon the above-mendomd property for Inspection purpose..
(We) agree to save, Indemhify an d keep harmless the City of Cupertbo
ALTIRORADDTOMECH.
Date Recei Nr'.
SUBTOTAL:
agaW Ia rWties,judgmemsc.Bs a rade ass which may in any wayecerue
•gal t old C In cense u F(the o"his I..,.
w > _ _0 .1
AIR HANDLING UNIT (TO 10,000 ChM)
AIRHANDUNG UNU(OVERlQODOCFM)
CONSTRUCTION TAX
Sig ature of Applicant/Contra/nor Date
EXHIAUST HOOD(W/DUCT
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (TO 100,000 BTU)
Will the a ppllont orfutum building occupant store or hand le h=rdous
mede aterialasde0nedbytheC all Munidpal Code, Chapter 9.12 and the
Healthand SafetyCton 25532(a)2
❑ Vee No
Date ,Recei tN
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
VENTILATION FAN (SINGLE RFSID)
ISSUANCE DATE
WIIIIheapplica or(uW. building oavp.,t use equipment or devices
whkhemit hon us air contaminants as defined by the Bay Area Air
QEsilty Management Dist
Ycs o
PAIS
BOILER -COMP DHiP OR 100,000 BTU)
BOILER-COMP(OVEd 100,000 BN)
- -
vie read the hm cue material, requlrementsunder Chapter6.95of
the California Hnith Safety Code, Stolon 25505,25533 and 25534, I
uederitand that tithe building does not currently have. tenant, that it is my
FED 41991
FED
NEW RESIDENTIAL MEIN. SQFr.
r Ib WtytonoUlytheompant olth .imaxmtswhichmuatba
t /avaanLlofla Ceetl(k7 cv
$/
3/l /er//— P- $(—I/
Int I
VI
ISSUEDBY: _
Obneror.whorlred agent Date
TOTAL:
OFFICE COPY