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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
BuildinA project Identific_knation
BuildingAddrem: 6
L
PERMITNO.
23339
nere as
N �y� one:
Mr ° l Size 1 -)Pr
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION /PERMIT
BUILDING-ELECTMCAI PLUMBINGMFLHANICAL
2 0 q1/ eZ
L i —'1
c Naa//nqe�� 1 Lm.
CATEGORY
CONTROL N
Architect/Engfmm� Lle No:
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Address:
y� ❑ ❑ ❑
J
PERMITISSUANCE
LmEDCONTR
I hereby aBbmthatlamsiolicensed
that under provisions ofChapterg c
APPIdANCESRE9DENTUL 1 1
]OB DESCRB'IION
�/
PANELS -
-
Ingwith5ection7000)of Dlvielon3oflheBuYneuand Pro(esslonsCode,and my
3ofthe uMp
[I CI %-L Lic. N 4 (J 'I J
license la in full rrcogd aef/ea. Q'` ///•� ' -
�/ 11.�•
Date Contra S
UPT0.200ANIPS_
101-1000 AMPS
ARCHITECTS DECLARATION
I understand my plans shall be used As pubilcroomis
OVERIOOOAMPS
SQ. FF. FLOOR AREA
S/SQ.FT.
SIGNSELECTRICAL
Llmvcy Pmf nai
SPFGIAL CIItCVIT/MLSC
OWNER -BUILDER DECLARATION
I hereby af0rmthat I am exempt from the Contractor's License Law for the
TEMP. MOM OR POLE INST.
following reawn.(Sectlon703]S, Businessand Professions Code: Any city or
county which requbesa permit to covtvct, alter, Improve, demolish, or repair
any structure prior to It Issuance, also requires the applicant for such permit to
file a signed statement that he la licensed pursuant to the provisions of the
POWER DEVICES -
SWIMMING IDOL ELECTRIC
OUTLETSSWIICF{ESEXTURES
Contractor's Limme Law (Chapter 9 (commocing with Section 7D00) of Divi-
simn3o(the Bua mond Profemlov Code)orthathebewmpttherefmmand
the bash for the alleged exemption. Any violation of Section 70315 by any
applicant fora permit subjecIstheapplfcanl to a civil penalty of not nre than
V LUATION 02,
D
five undyed dolbare(S50N.
i, as ower of the property, or my employees with wages As their sole
NEW RESIDENTIAL ELECTR SQRI.
STORIES
TYPECONSTRUCTION
rompeneatlon, will do the work and the structure Isnot Intended or offered for
sale (Sec 7094, Business and Profealov Code: The Contactors Lim. Law
does not apply to an owner of property who builds or Improves thereon, and
whodoes such work himself orthrwgh his own employees, provided that such
OCC. GRDITI'
RES, UNITS
Improvement are not Intended or offered for sale. If, however, the building m
TOTAL
Improvement b wld within ons yearof complYWk the owner-bullderwill have
a-�unlen ofpmving that he did not build mrlmpnove for purpowofukJ.
L_J I, as owner of the property, am exclusively contracting with licensed
momicton to mrutruct the project (Sec. 7044, Buatem and Professions Code:
QTY. PLUMBING PERMIT FEE
FLOOD ZONE
APN
PERMIT ISSUANCE
The Contmdors License law don not apply to an owner of property who
builds or improve, thereon, nod who mrmam far such p(ojecb with a
c aaor(x)licensed pur.uantto the Contractor'. License Law.
LSI am exempt under Sec B k P C for this reawn
ALTQLDRAWAVENT-WATQ9
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
DRAINS FLOOR RODE, AREA, CON I.
SANITARY Y_ N_
REGEIPTI
Owner Date
WORKMAN COMPENSATION DECLARATION
LAS hereby affirm that 1 have a mmnmte of consent to self- nsure, m a
certificate of WorkerVCompevation Insurance or a certified copythenm(($ec.
3800, lab
I'olkyN
n p ]-^
_
gOOL TAX Y N
RECEFF N
ARK FEE Y N
RECE3IzFM
BUILDING DIVISIONFEES
�SYSI'EM•1INC.40UTf.EfS. .-
p5. .SYSTEM-OVER4 r, Y
Com anv
�CerilO d ropy b ereby (urnlehed.
�ertBie�mpy b filed with the city IvpMlon divialon.
EASE/ DUSTRL WA
LANCHECK FEE
CERTIFICATE OF EXEMPTION FROM WORKERS'
7RAIa
PAID
COMPENSATION INSURANCE
RNs sectWn need not becomplYed lfthe permit Isforov hundred dollars
ITSEWER-SANARY-S10RM EA.ZWFT.
Date RCCeI lM
WATER HEATERW/VENT/ELECTR
ENERGYFEE Y_ N_
(S100)mfy that
thattthe b this permitie Issued,
oftmnner
Ill
WATER SYSTEM/TREATING
net
I shall not employ any person in any manner w u to become subject to the
person A, As to
W Compensation lawn ofGR(amla. Dace
PAID
NEW RESIDENTIAL PLMB. _SQ.FT.
Applicanplies. tDale
NOTICE TO APPLICANT. U, after maWng this Certificate of Eiem)rtlon, you
should become subject to the Workers' Compensation provislons of the Labor
Recei tN
TOTAL:
BUILDING ••E
�^
Code, you must forthwith comply with such provisions or this permit shall be
dmmed revoked.
CONSTRUCTION LENDING AGENCY
SEISMIC FEE
Iherebyafflrm that there Is a mnstructim lending agency for the perform
ante of the work forwhich thio permit Is bsuud (Sec.3097, Clv. CJ
Lenders Name
Leaders Addrees
I mrtllythatl have readthis application and Yate Ihattheabovelnformatlan
Iscumd. l agreeto complywith all city and county, ordinances and Yate laws
TOTAL,
ELECTRIC FEE
PLUMBING FEE
CITY. MECHANICAL PERMIT FEE
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID:
relating tobullding construction, and hereby authorize representatives ofthb
atytoenterupo the above-mentioned property for Inspection purposes..
(We) agree uve, Indemnily an d knp harmieee the City of Cupertino
agabothabil ,Pdg.. mete.ndexpenseswhichmaylnanywayamzue
ALTERORADDTOMECH.
-
Date Retel til
AIR HANDLING UNIT (f010,ODO CFM)
SUBTOTAL:
agalvtsal Ityincane e o the ganUn of this permit
2
AIR HANDLING UNIT (OVER I0,000CFM)
CONSTRUCTION TAX
Sig reof Applicit/Contractor I Dat
EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (TO 100,000 BM
,Date Reeel tN
Will the appilont or future building occupant store or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 933 and the
Health and Safety Code Section 75532007 _
❑ Yea M No
Will the applicant orfuturc building occupant use equipment or devices
HEATING UNIT (OVER 100,000 BTU)
TOT -r-2-
VENTILATION FAN (SINGLE RESID)
ISSUANCE DATE
which emit hazardous air contaminants as deRvd by the Bay Area Air
a v
Bty Magemcnt District?
p �'
T D
BOILER -COMP OHP OR 100,000 BTU
Ym ❑ No
have read the hazardous materials requirement under Chapter6.95 of
the Czlifmaia Health h Safety Cad, Sections 25505, ZM3and 75534. 1
aC.D
F9•B
BOILER-COMP(OVER 100,000 BTU)
NEW RESIDENTIAL MECH. SQ.Ff.
understand that if the
nt wrrently have
note requirmwnts
a 5199
2
the ocgdces
rndestandhat na Ryuil occupant of
nespon hichLthatb mot
Ad which most beset
prior to Issuance of a Certificate of Occupancy.
(! /1 .1v%a7
CITY or (.as�(1 1�-L'n I II
ISSUED BY' �a re&L _
Owner or authorized agent Date
TOTAL:
OFFICE COPY