23002APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification
Build ing Add ma:
PERMIT NO.
n
t
iO3
G O O
nen a one:
CITY OF CUPERTINO6BUILDING DIVISION
APPLICATION / PERMIT
p
— Q—
Con or'sNa c. No:
Archils / nrer.
� Lie. No:
r
BUfLDINGELECTRICA4I'LIIMBING1dFOHAMCAL
CATEGORY'CONTROL
N
QTY ELECTRIC PERMIT PEE
BUILDING PERMIT INFO
❑ ❑
PERMITISSUANCE
LlIffENSEDCONTR
under provisions of Cha r9(mmmen
Thereby afforri that 7000)o[ iv Bcrosed ue Business
Ingwith inion 7Boo)and off Division BueineseandliolnsioneCode,and my
It.. Is I^7 B and d(Lic7. �Q i �—iL[L
APPLIANCESRESIDENML.
JOB DESC ON
PANQB
Licenx Cls
Cont dor aLT.
Date Contractor
L
2014000AMPS
ARCHITECPS DECLARATION
•�rpl,(J✓{�1
OVER IOW AMPS
SQ. FT. FLOOR AREA
$/SQ. FT.
SIGNSELECTRICAL
::����..uubllca
cense essiorul
SPECULCIRCNT/MLSC
OWNER -BUILDER DECLARATION
I hereby affirmthat I am exempt from the Contractor's License Law forthe
TEMP. METER OR POLE INST.
following reason.{Section 7QI1 S, Buelnen and Pro(enbne Code: Mydty or
cmntywhkhrequimaper ttocoetmc4altep improve,dennllnh,orrepdr
anystm=mpdorlaibbsuanee,alsor gpimtheappBmnttonuchper tto
file a signed statement that he It bceneed pursuant to the provbiors of the
Contractor's License Law (Chapter 9(commencing with Section 7000) of Divi-
sion3 ofthe Businessand ProfessloreCode) orthat he b exernWherefeemand
POWER DEVICES
'
SWIMMING POOL ELECTRIC
VALUATION
the barb for the alleged exemption. Any vfolackvi of Section 70315 by any
stheappgcanttoa tlWl penalty dnU mom than
applicanthudred
OUTLETSSWITCHRIPFINTURES
NEW RESIDENTIAL ELECTR SQFT.
dollars ($5001.
EvEl e 1, as owner
ner of hepr.
I, ss owner of the property, or employees with wage as thele sole
STORIES
TYPECONSIRUCTION
will In
work, and thestmm:The ot
he cl for
so tcI.attort,0K Busdothe
ale I. 701X, Business and Profpetom Code: The Contractors Mceme law
Contractors License Law
does
who .essucapply torn owner dthroug his oWilds ne mpoyees,pvnthercoryand
ownemployee,providedthat such
himsnot
OCC,GROUP
RES. UNITS
ovementsawork n
Intended
edorwghed
improvements earofoo (orsale. If, owmver,er-b iblerhe Ing m have
Improvementlssdd within one ynrofcompidlorythe owner-bugderwlll have
TOTAL:
ilajZurden of proving that he did not build or Improve for purpm of sok.).
u I, as owner of the property, em eulusively contracting with limned
contractors to construct the pmject (Sec. 9074, Business and Profession, Code:
QTY, PLUMBING PERMIT FEE
PERMIT ISSUANCE
FLOOD ZONE
APN
The Contractors License law den net apply to an owner of property who
WUs or Improves thereoand who cuntmets for such projects with a
n,
cgR¢anor(a) hernsed pursuant to the Contractors Llnnse Law.
LII am exempt under Sec B A P C for this reason
ALTER -DRAW k VENT- WATER (E A)
FEE SUMMARY
BACK FLOW PROTECT,
AI
DRNS ND. FLOOR ROOF, AREA, CO
FIXTURES PER .IRAP ��
SANITARY Y N
REC= 0
Avner Dam
WORKMAN COMPENSATION DECLARATION
❑1 hereby affirm that I have a certificate of consent to self-in
self -inure, or a
cert BI rote o(W orken' Compvuatian Iwu none or • certified copy lh ereo(6ec.
3800, Lab
Policy N
SCHOOL FAX Y N_
RECEIPT N
GAS EA.SYSTEM-1 WC.4 OUTLETS
PARK FEE Y_ N
RECEIPT N
GAS EA. SYSTEM -OVER 4 (EA)
Com any
BUILDING DIVISION FEES
�Cedified copy is hereby furnished.
� Cedltled copy b filed with the city Inspection clMsion,
CARCASE/WDUSIRL WASTE INTERCEPTOR
PLANCHECK FEE
GREASETRAP
CERTIFICATE OF EXEMPTION FROM WORKERS"
PAID
SEWER-SAN17ARY-STORM EA pOFR.
COMPENSATION INSURANCE
Rhlssection need not be completed tithe permit b (orors Hundred dollen
($100)orfyth
[certify emploat is y bo the
any pershe esinan thework for to becch this ome
I shall not employ any perwn m any manner at n to become abject to the
Worker, Compenutbn fawn o(GB(ornk. Data
Date Re ei til
WATER HEATER W/VENT/ELECTR
ENERGY FEE Y N
PAID
WATER SYSTEM/TREATING
Applicant
NOTICEco APPLICANTesubjettothe, after enticing this Ction Preis Exemption, you
should becomesubjectto the Labor
Date Recei til
NEW RESIDENTIAL PLMB. SQFT.
TOTAL:
Code, you meet forthwith comply with each provlslore or this pedNt shall be
ply with such provisionsorpeions rmit hall
BUILDING FEE
deemed revoked.
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby.firm that there 6. ma
ruuction lending agency for the Perform
ance of the work for which this permit is Issued (See. 3097, Civ. Q
lander'. Name
Lender.Addm"
I cedlfythat I have read thbapplicatiunand stanethat theabove Information
bmnect, I agree to cmnplywlth all city and county ordinances and state laws
T ��
ELECTRIC FEE
PLUMBING FEE
�^
QTY. MECHANICAL PERMIT JEE
MECHANICAL FEE
PERMITISSUANCE
FEES PAID:
relating tobuilding construction, and hereby authorize representatives of this
city to enterupon the abavcmentloned property for Inspection purposes.
(We)a ve, Indemnify an d keep harmless the City of Cupertino
ALTER OR ADD TO MECH.
Date Re[p
C01 P
AIR HANDLING UNIT (TO 10,0XCFM)
SUBTOTAL:
egai 1t menet, ran ees which may In anywayacvue
egrenting of this permit.G /
/� �I
AIR HANDLING UNIT (OVER IOW
,OCFn4) -
CONSTRUCTION TAX
Signature of Applicant/Contmctor Dan.
EXHAUST HOOD fW/DUCT]
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (TO 100,000 BTU)
Date RCCeI [>Y
Will the applicant orfuture building occupant store or handle harardous
rtaterial as defined by the Cupedine, Municipal Code, Chapter9.IZ and the
HEATING UNIT (OVER IMM BM
TOTAL:
Health and Safety Code Section 25532(a)2
❑ Yea No
VENTILATION FAX (SINGLE RESID)
ISSUANCE DATE
Will the applicant or lure building occupant use equipment or devices
which emit hazardous air contaminants as defined by the Bay Area Air
ality Management DlstricO
BOILER -COMP OHPOR 100,000 BTU)
Vo, Q No
have read the hazardous materials requirements under Chapter 6.95 of
p 'pA
K �/
BOILER-COMP(OVER 100,000 BTU)
the California Health 4 Safety Code, Sectiore 25505, 25533 and 25534. I
NEW RESIDENTIAL MECH. SQ,FT.
understand that if the build Ing does not currently have a tenant, that It is my
responsibility to notify the occupant of the requirements which must be met
prior to Issuance of a Certificate of Occupancy.
NOV �� ����
cw
Cilr, 1} ICL 1'dk1i��\
ISSUED OYV_C�T�ImL1�
Owner or authorized agent Date
TOTAL:
OFFICE COPY