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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
' Building Project identification
Building Address: ) -'
J11-30
PERMBTNO.
21894
s ams:„ate one:
4d(/0 3—a
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BUILDING -m ECTRICALPLUMBING-MECHAMCAL
APPLICA DON SUM I rAL DA IL
Gj
Contractors Name: _ - No:
W k.
CATEGORY'CONTROL #
BUILDING PERMIT INFO
rcitact/Engione Lt. No:
'14_
'QTY ELECTRIC PERMIT FEE
..
Add.. _5'
❑ ❑ ❑ '
PERMITISSUANCE
LICENSED CONTRACTOR'S DECWRATIO
Ihereby under Businessands.f Cssions odeandn
n3aftheBusinemandProfeselonaCodeandmy
Ingwith in
license is In (ul o d e” G
LlrenseC Llc.p
AI'PLIANCESRESIDENTIAL
08 DESCRIPTION
�. WIhIJOIvs t
110 WItIY 1'YY(/L*W1
-
PONTIS
Date Contractor_—qs
ARCHITECTS DECLARATION
I understand my plans shag be used as public records.
W [
201-1000 AMPS'
OVER1000AMPS
SQ. FC. FLOOR AREA
.$/SQ. FC.
I SIGNS ELECTRICAL
Licensed Professional
CIRCUIT/MLSC
OWNER -BUILDER DECLARATIONSPECIAL
I herebyafflrenthat l am exempt frwn the Contractor. Llmnse Law forth.
- '
TEMP. METER OR POLE INST.
following reason.(Sclon 7031.5, Business and Professions Code: Any city or
cony wh ich mqubes a perrWtw crostmM altep lmpmvq de.lWh, .r re poi r
anystmMmpeortolb Wuamc alsorequireetheappHuntforsuchper tto
file a signed statement that he is licensed Pursuant to the provbiors of the
POWER DEVICES
..
SWIMMING POOL ELECTRIC
OUTLETSSWITCHESFIXTURFS
ContmRor's License Law (Chapter 9(commencing whh Soethm 7000) of Dlvi-
cion 3 of the Business and Profemlom Code) or that he is exempt therefrom a nd
the basis for the alleged exemption. Any violation of Section 7031.5 by any
applicant for a permit subjects the applicant to a civil penalty of not more than
VALUATION
`
NEWRESIDENTIALELECTR_5013.
five hundred dollars ($500).
E]1, as owner of the property, or my employees with wages as their sok
STORIES
TYPE CONSTRUCTION
compensatlon,wW dothework andthe structure la not intended or offered for
.[a &c. 7044, Business and Professions Code: The Contractor's License Law
-
does not apply toes owner of property who Wilde or improves thereon, and
whod.eesuchworkhimmlf orthroogh hieownemplayees, provided thatwch
.00C. GROUP
RES UMTS
Improvements are not ntended oroffered fwsale. I; however thebulldingw
TOTAL:
Improvementbwldwlthln omyearofcompletioMtheowner-bullderwRlhave
th arden of proving that he did not build or improve for purpose of sale.).
LJ ; as mune, of the property, am exclusively contracting with licensed
to construct the project (Sec. 7044, Business and Professions Code:
QTY,. PLUMBING PERMIT FEE
FLOOD TONE
APN
PERMIT ISSUANCE
The Contactor. License Law does not apply to an owner of property who
builds or improves thereon, and who contracts for such p(ojeab with a
actor(s) licensed pursuant to the Contractor's Cleanse Law.
c am_ exempt under Sac B & 6P C for this reason
ALTER -DRAIN &VENT- WATER -
FEE SUMMARY
BAIX FLOW PROTECT. DEVICE
OUTSIDEFEES
DRAINS FLOOR ROOF, AREA, COND.
FIXTURES. PER TRAP-
SANITARY RECEIPT p
ner Date
" WORINIAN COMPENSATION DECLARATION
❑I hereby affirm that I have a certificate of consent to self -Insure, w a
certiflcateof Workers'CompersathisI ....... cartiflcd ropy thereof(Sec.
3800, Lab C.)
-
SQi00L TAX Y_ N_
RECEIPT p
GAS EA. SYSTEIA4 INCA OUTLETS
PARK FEE Y N -
RECEIPT#
Polley #
C om any
GAEA. SYSTEM -OVER 4 (EA)
S
- BUILDINGDIVISIONFEES
�CertBled copy is hereby furnished.
❑Certified copy is filed with the city inspection division.
GREASE/INDUSIRL WASTE INTERCEPTOR
PLANCHECKFEE
GREASE TRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
PAID
SEWER -SANITARY -STORM EA 20011"
'COMPENSATION INSURANCE
(Chis section need not be completed lithe permit bfor.. hundred dollars
($11ID)wlone)WATER
I woolly that In the performance of thework forwhlch this permit is leaved,
Date Recei [#
BEATER W/VENT/FJ.ECTR -
ENERGYFEE Y_ N_
WATER SYSTEM/TREATING
I shall not employ any person In any manner so as to become subject to the
Workers'Compensation Laws of California. Date
Applicant
PAID
Date Recei t#
NEW RESIDENTIAL PLMB. SQ.FT.
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you
should becomeeubject to the Workers' Compensation provisions fth. Labor
Cade, you mu at forthwith comply with such provisions .,this permitshall beG
deemed revoked.
CONSTRUCTION LENDING AGENCY
TOTAL:
,E
- U
SEISMIC FEE
TOTAL:
ELECTRIC FEE
I hereby affirm that there is a cerstruction lending agency for the perform
sane of the work for which this permit is blued (Sec. WW, Civ. C.)
Lenders Name
Lender. Address
PLUMBING FEE
4TY: MECHANICAL PERMIT FEE-
MECHANICAL FEE -
I rertlfythatl havereacithlsappBcatlonand statethattheabove Information
Is correct. Iagwa to cwnplywlth all dty.ed county.minance.and.[ate laws
PERMIT ISSUANCE
FEES PAID:
ALTER OR ADDTO MECH.'
relating tobuilding on strucrion, and hereby authorize repreeentatives 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
against liabilities, judgments, mks and expenses which may In anywayaccrue
Dale - ReCeija[#
AIR HANDLING (IMT (3010,000 CFM)
SUBTOTAL:
AIR ]iANDWNG UNIT (OVER 10,000 CFM)
CONSTRUCTION TAX
against mid City In consequence of the granting of this permit.
'
Sigruture of Applicant/Contractor Data
EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or hand le hazardous
HEATING UNIT (TO 100,000 BTU)
Date- Recei t#
material as defined by the Cupertino Municipal Code, Chapter 9.12, and the
Health and Safety Code BMion 25532(1)7
❑. Yet No -
Will the applicant or(Slurs building occupant use equipment or devices
HEATING UNIT (OVER 100,000 BLU)
- -TOTAL:
Q•
VENTILATION FAN (SINGLE RESID)
Y I$5(l�ply'�DATE
which emit ham mines ab contaminants act defined by the Bay Area Air
Quality Manugement District?
4Yrs ❑ No
havereadlhehazardousmaleria requlremenbunderCMaper6:95o(
(]
Y�
BOILER -COMP DHP OR 100,000 BTU)
BOILER-COMP(OVF]i1W,000 BTU)
the Callf.mla Health & Safety Code, Sections 25505, 25533 and 25534. 1
s understand that if the building does not currently have a tenant, that it is my
responsibility to notify the occupant of the requirements which must be met
d �Tf�`�I ,
NEWRFSIDENIIALMECH.' SQXT
prior to issuance of a Certificate of Occupancy.
Y{V W f_•_
(-
ISSUED BY: V
Owner or authorced agent Data
TOTAL:
OFFICE COPY —
I. — - -.-- - - — — IL