23992APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification
B.9ding Address:
`3
PERMIT NO.
23992_
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ne . antis: — — one:
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION /PERMIT
•' �%���
ate`
cm:rad N, Lie. No:
CATEGORY
BULDING-ELECnUCAL PLUMBING MECHAMCAL
ArrhaM/Engimer. Lle. No:
QTY ELECTRICPERMIT FEE
BUILDING PER ITINFO
Add.
❑ ❑
PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION
l herebyaffirm that l sm licensed under provisions of Chapter 9 immanent,
ingwith Se ..7000)of Divislon3ofthe Busfnauand ProfeulonaCode,and my
license is In fuI forte and affect.
APPLIANCES -RESIDENTIAL
LOB DESCRIPTION
PANES
License Class Lica
P
• I v Ys
Date Contractor
To 200 AM
201-IODO AMPS
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records _
Licensed Profensional
OVER1000AMPS
SQ. Fr. FLOOR AREA
Y�� Ld
Ill��aa ( V
$/SQ.pr.
Son
SIGNS ELECTRICAL
SPECIALCB4CUT/MLSC
I OWNER -BUILDER DECLARATION
I hereby affirm am exempt aexempt from the Contractor's License Law for the
U
TEMP. MET'FR ORPOLE!NST.
following rcnon.(SeNon 7031.5, Business and Professions Code: Any city or
county which requires, a permit to construct alter, Improve, demolish, or repair
anystmeWre prior to Itluuance,also requires the a ppgcant I .... ch permit to
file a signed statement that het licensed pursuant to the provisions of the
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETSSWITCI IF_SFI%TURFS
Contractor's License Law (Chapter 9(mmeencing with Section 7000) of Dlvi-
go. 3of the Business and Professlma t
Code) orthat he exempt therefromand
the basis for the alleged exemption. Any violation of Section 70315 by any
appb.et fora permit subjects ts the applicant to a civil penalty of rat mor,than
VALUAT/IO�N
Ls(/
l�l �1
fI dred doll..($500),
as owner of the property, or my employees with wages as their sole
m atf�will do the work and the structure t not Intended or offered for
ale 7 BuainnsandI'mfeasiona Code: The Cmumadm'e Lt.. law
NEW RESIDENTIAL ELECTR SQ.FT. /
STORIES TYPE CONSTRUCTION
,� / `9 r
does cast ply torn owner of wthrou ty who hhism, em orimproves
whodoesuchovidedreogand
uch
amwork tInten ed oroogh Msowne. If,ho however, gor
buildithatng
Improvement amnotwitht cote rofodforule. the mrsvepiheerwili have
improvement tsoldwithin
C
p
j UNITS
r J
TER
Is did not of sahave
t rdenofproving that he did not build or improve for purpose o(n1eJ.
rimthae for purpose
u L as owner of the property, am exclusively mntracimi; with licensed
contredoes to mreee tmuct the project (S 7044, Business and Profeasbna Code:
QTY, PLUMBING PERMIT
FIAODZA /t y,
\i�
PERMI7155UANCE
The Contractor's Lleenae Law dm not apply to an owner of property who
builds or Improves thereon, and who contracts for such plojecis with a
ec denial, Ienaed pursuant to the Contractor's License Law.
151am exempt under SB & P C for thin reason
AL•f•FR-DRAIN &VENT -WATER (EA)
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
DRAINS FLOOR ROOF, AREA, COND.
SANITARY Y_ N_
RECEIPT B
Owner- Date
WOR"AN COMPENSATION DECLARATION
ofhereby affirm that 1 have a certificate of consent to seI-tore, or a
metificate of Workers'Compenaalion Insurance macertifled mpythermfl5ec.
3800, Lab Cd
Policy#
FD(TPER TRAP'
�S
SCHOOLTAX Y N
RECEIPT N
GAS EA. SYSTEM -1 INCA OunA
PARK FEE Y N
RECEIPT x
Com n4,
GAS EA. SYSTEM-OOVER )
BUILDING DIVISION FEES
Certified copythereby famished.
Cnrtlled copy 1. filed with tet city inspection division.
GREASE/INDUSIRLW INTERCEPTOR
PLANCHECK FSE
' T l U aZ Q
GREASE TRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
PA f� I
COMPENSATION INSURANCE
(This section need not he completed U the permit t for one hundred dollar
SEWER -R -SANT Y -'STORM EA' 200FT'
ate Rece t#
(StoB)wleua
1certly that the performance ofthe wmk permit toed,
WATER TER W/VENT/ELECTR
ENERGY FEE Y
O
WATER SYSTEM/.TREATING
an as to become c
I shall not employ any person In any manner n n to berome mbfM to the
o
Worken'Compenutlon laws of Gllfomla. Date
PAID �' I
NEWRESIDENTIALPLMB. _SOFT.
Applicant
Date Recel t#
NOTICETO APPLICANT: I, after making this Certificate of Exemption, you
should become subpd to the Work<n' Compewtlon provisions of the Labor
TOTA
BUILDING
SEISMIC FEE
Code, you must forthwith comply with such provisions or this permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
lherebyeffirm that there is a construction lending agency for the perform
once of the work forwhich this permit t Issued (Sec. 3097, Civ. Q
Lender. Name
Lender's Address
I mdlfythatl have readtht applimtlonand stale Fate Information
at correct. I agree to comply with all city and county ordinances and state laws
Torpl:
ELECTRIC FEE
PLUMBING FEE
QTY. MECHANICAL PERMIT FEE
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID:
relating to building construction, and hereby authorise representatives of this
city to enter upon the abovo-menliuned property for Wpeetion purposes.
(We) a o ave, indenudty an d keep harmless the City of Cupertino
again abNl fu ment m#e pensee nay In any wayacauc
ag t Id con a the nth g t noir.
Date Reeei t#
ALTERORADDTOMECH.
AIR HANDWNC 11MT(f010, )
SUBTOTAL:
AIRHANDLINGUNT(OV IB,ODOCFM)
CONSTRUCTION TAX
Sig v o(Applicant/Cont Date
EXHAUST HOOD (W n
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle havrefous
Date Recei t#
HEATING UNIT 100,100 BTL])
material as defined by the Cupertino Municipal Code, Chapter 9.1 2, and the
Health and Safety Code Section 25532(.)7
E" No
W,
Willtheapplicantar tore Wilding«mpant ussequlpment ordevices
HFATWCU (OVER 100,000 BTU)
TOTAL:
VENTILATION FAN( SINGLE RESID)
ISSUANCE DATE
which emit haurdOus air comaMnant as defined by the Bay Area Air
Quailty managenrom D'utrict]
❑ Y. ❑ No
BOILER -COMP DHPOR 100,00) BTU
BOILER-C'OMP(OVER 100,000 BM
I have mad the hu.Qua materials requirementunder Chapter6.95 of
the California Health & Safety Code, Sections 25505, 75533 and 25534. l
understand thatn doesnot that It troy
requiyhave
P7 A
NEW RESIDENTIAL MECH. SQFI•
tBythebuilding
occupant a s which
reser to issuance of aCtheottteof oftherequlrementawhich must be met
prior to issuance oI a Cer1l/kale o/0ceupanry.
)SSUEDBY; �V
Owner or authorized agent Date
TOTAL:
_•rI//Tru
OFFICE COPY