20676APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
• Building Pro act Identification
Building Addma: �p
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PERMIT NO.
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CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION I PERMIT
�_/ _ � A
D U
Contractors Name: LIc. N.:
Ssi C
BUILDING-ELECTRICAI PLUMBINGMF LAICAL
CATEGORY
CONTROL ND
Architect/Engines& Lt. No:
q zA C
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
a�
Address 2t4�j,, CU 111v—t:Yfi lir si-E:Jo
�C J29 flSL
PFRMTTISSUANCE
LICENSED CONTRACTOR'S DECLARATION
Iherebyeffirmthatlam Bcmmdunderpro inion&of Chapter9(c mc.
IngwithSection 7OOD)of Dlvisim3oftheBudnsmandPmfesalonsCode,and m
license is In full f....d effect.
Llan. Clan LION
APPLIANCFSRESIDENTIAL
JOB DESCRIPTION
/I ,a1/l 260117
y�--��
I PANELS 1�
Date ContractorUP
TO 200 AMPS (
201-IODO AMPS
ARCHITECTS DECLARATION
I understand my plans shall be used as public record&.
Licenand Professional
OWNER -BUILDER DECLARATION
l herebyaffirm that l am exempt frrenthe Conlrado's License Law for the
following reason. 70'f1.5,Bu&Inco and Professions Code: Any city or
county which require&a permit to construct, alter, improve, dernolish,orrepair
JOVERIODOAMPS
SQ. FT. FLOOR AREA
�y!` .a �/�•�/�1f
F�•[
// ,
� V�(i�
$/SQ. Fr.
r7 rvD
i)
SIGNS ELECTRICAL.
$PECIALCIRCU[T/MISC
TEMP METER OR POLE INST.
anystructure prlort.11s Issuance, also requireathesppliant forsuch permit to
file a signed statement that he is licensed pursuant to the provisions of the
Contactors License Law (Chapter 9 (commenting with Section 7000) of Divi.
.ion 3 of the Business and ProfeainmCode) or that he Is exempt therefrom and
the basis for the alleged exemption. Any violation of Section 701.5 by any
ppRant for a permit subjects theappllcant to a civil penalty of not more than
POWER DEVICES
-
o'WIXMNG POOL ELECTRIC 4s�
OUTLETSSWITCHFSFIXTURES 1
///��� VALUATION
2.(�
NEW RESIDENTIAL ELECTR�.FI.
fvehundred dollars (g50m.
cue owner of the propsny, or my employees with wages as their sole
STOW
TYPE CONSCRUCTION
n pensanon,wllldothewor"ndtheslmd mbrmt intended or offered for
ease (Sec.7044, Budne. and Professions Code: The Contractors Llcome Law
don not apply to an owner of property who builds or Improves thereat, and
who does suchworkhim.i(orthraugh Msownempleyses, provided thatwch
OCC.GROUP
RES UMTS
Improvements arenot Intended aroffered forsale. I( however, thebullding or
Improvement bould within oneyearo(compidioNtheowner-buBderwlll have
TOTAL:
thLkurden of proving that hedid not build or improve for purpose of sale.).
as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sae 7064, Buenas and Profesd.ns Code:
the Contractor's License Law does not apply to an owner of property who
builds or Improves thereon, and who contracts for such pkojects with a
15ad.r(a) Licensed Formant to the Cantador's Lt... Law.
I am exempt under Sm. 0 6 P C for this reason
QTY, PLUMBING PERMIT FEE
FLOOD ZONE
APN
PERMIT ISSUANCE 'Z dD
( ALTER -DRAIN k VENT- WATER (EN Cz
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
DRAINS. FLOOR A, ROOF, ARECOND.
SANITARY Y_ N_
RECEIPT X
Owner Date
WORKMAN COMPENSATION DECLARATION
❑I hereby affirm that I have a certificate of consem to salf"narc, o a
certificate of Workero'Comperuatlon lmurance as odu6so copy Chemo!(Sec.
3800. Lab C.)
Po11ryX
TRAP
SCHOOL TAX YN_
RE -OPT X
pq .1t, .40UTTh15
PARK FEE Y N
RECEM' X
G 'PA: SYSTEM -OV ER4(EA)
,
Cam any
BUILDING DIVISION FEES
❑ CertiOad copy Is hereby furnished.
❑certmed copy Isthea with the alylnspedmnalvIsmn.
CERTIFICATE OF EXEMPTION FROM WOR KERS'
COMPENSATION INSURANCE
(Thi§ion need notbecomplete l Ithe permit is forom hundred dollam
CREASE/INDUSTRL WASTE IMFRCEPTT)R'
PLANCHECK FEE
PAID off
Date ReCCI ted
goo
_
G l
SEWER-SANITARY-91015WEA:Ypi•T.
WATER HEATER W/VEV.IyELEc.1.R
ENERGYFEE YN
_
�(s
(5100)or
Irtify fy,th maMth
aat In the perfoanafthework forwrh tide peanit is wed
in,
WATER SYSTEM/TREATING
1 shall not employ any person In any manner so as to become subject to the
Workers' Compensation laws o(011fomIs. Date
PAID
plicae
NOTICR
NOTICETO esubjettothe after makingthisCtion press Exemption, you
becomesurtoit theWywithsachInsatbn provisions nsofthe Labor
Date Recel tri
NEW RESIDENTIAL PLMB. SO.Fr.
TOTAL:
Code,shoul
Code, evoket forthwith comply with each provisions orlhIs pemml shall be
dmmed revoked.
CONSTRUCTION LENDING AGENCY
BUILDING
SEISMIC FEE
I hereby affirm that there is a construction lending agency for the perform-
Lender's e m l,for which this permit is issued (Sec. 3097, Civ. C.)
Lenders Addreae
I certilythat I havereaathbappllathmand datethat Iheabove information
Is coned. Iagme tocomply with all cityand county ordinancesand date laws
TOTAL: (��
ELECTRIC FEE
Q
QTY. I MECHANICAL PERMIT FEE
PLUMBING FEE
MECHANICAL FEE
a�
PERMIT ISSUANCE `yC
FEES PAID:
relating to building construction, and hereby authoram representatives of this,
city to enter upon the abovanentioned property, far Inspection purposes.'
(We) agree to save, Indemnify an d keep harmless the City of Cu FeMnn
against liabilities,judgments, cods a rd expense& which may In any way accrue
ago Wtsald tyin rotn/n�uxryonce of the granting of this permit.
111-)... �c� --W 'l
1 ALTER OR ADD TO MECH. 'ZfYy
Date Receipt#
AIR HANDLING UNIT ITO 10,000 CFM)
SUBTOTAL'
AIR HANDLING UNIT(OVER 1 g000 CEM)
CONSTRUCTION TAX
" i�`a�1
SI tare.! an t m Date
EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAZA MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle haazrdous
material as defined by the Cupertino Municipal Code, Chapter 933 and the
Health and Safety Code Ion 75532(e)7
qYes
ill the applicant o future building occupant use equipment or devices
HEATING UNIT (TO 100,ODO BTU)
Date Revel [#
HEATING UNIT l00,OW BTU)
TOTAL:
a
VENRLATION FAN(SINGLE MID)'�(`�
DATE
which emit haysrdous air contaminants as defined by the Bay Arca Air
Q�jallty Management Distfact?
pAWCE
ir./vUE
BOfLER-COMP DHP OR 100,000 BTU)
Yes 15N.
have read the haze oro materials rerequirements under Cha er6.95 of
$ 1asea0
a a�•``�J'
BOILER-NMP(OVER IW,DOO BTU)
the GlOomla Health k Safety Code, Sections 25505, 25533 and 25534. I
NEW RESIDENTIAL MECH. SQ.Fr.
understand that lithe building does not currently have a tenant, that It is my
reapomtbility to notify the occupant of the requirements which must be met
prior to(�(�{1ss\\s\*** (ncvor. Certiiffeatteed Occupancy.&s ,s •�
1�0tlslo
A.l iM
RRA, �d:9�'l!L'+'U'
ISSUEDBY:�O`P"
Olvnero Data
TOTAL:
Mx OFFICE COPY
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