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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Pru'ed Identification
Building Addmsa:
PERMIT NO.
76
nO
amc: r onc:DAIL
e. -L
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION I PERMIT
X�
J
con or'e Name: LB. No:
".,04
BUTLDINC-ELECTR]CAL-PLUMBINGMECHANICAL
CATEGORY
CONTROL X
Arehhed/Engineer. Lire Na
*,. n"F� .y
;QTY ux '7., ELECTRIC PERMIT 4,, _
;,'» I BUILDINC PERMITINFO t ' t%i'i,
t
Addrvitj�2
❑ ❑ ❑
PERMITISSUANCE
LICENSED CONTRACTOR' ECLARATION
I hereby affirm that l am licensed under provisions of Chapter 9(commmc-
ingwltht ufti n7000)of fA ffaxs. 3o(the BudnmandPro(emlonsCode,and my
license Is in full =re of d(ecL
License Cbm ICX
APPLIANCESRESIDENTIAL
n JOB DFSCREVIION
PANELS
Date/n .- /� U / ContractoUPTO
r
200 AMPS
901-1000 AMPS
ARCHITECT`S DECIARATION
I understand my plans ehaBbe used as public records,
OVER 10DO AMPS
SQ. FT. FLOOR AREA
5/9Q.FT.
SIGNS ELECTRICAL
Ll ... d Professional -
SPEGIALCIRCUIT/MLSC
OWNER -BUILDER DECLARATION
I herebyaf(Irm that I am exempt from the Contractor's License Law for the
TEMP METEROR POLE INST.
following region. (Section 7011.5, Business and Professions Cade: Any city or
county which requireaa permit to construct, alter, Improve, demolish, or repair
any structure prior to its bsuance, a leo requires the applicant for such permit to
file a signed statement that he is licensed pursuant to the provislors of the
Contractor'. License IA. lChapter9(commencing with Section 7000) of DWI-
eon3ofthe Buslnmand Pr f.W.Code7orthathebexemptthemfromarad
POWER DEVICES
SWIMMING POOL ELECTRIC
VALUATION
the bas! for the alleged exemption. My violation of Section 70315 by any
apph., fora permit subjects the applicant to a civil penalty of no more than
OUTLETSSWTTCHM FIXTURES
five hundred dollars (5500).
❑ I, as owner of the property, or my employees with wages as their sole
NEW RESIDENTIAL ELECTR SQXT.
STORIES
TYTECONEIRUL71ON
compensation, will do the work and the structure brat Intended or offered for
ale (Sec 7044, Bualnea and Professions Code: The Contracim'. Lt.. Law
don not apply to an owner of property who builds or improves thereon, and
who doeasuchwork hUns 1forthrough his own employees, provided that such
OCC.GROUP
RES UNITS
improvements are not intended or offered for sale, If, however, the building or
TOTAL:
Improvement issold within omyearofcompletlon,the owner-builderwill have
ttLura as of the the dm rmt WBa or Improve roc purpou or
m [, as owner of the property, am exclusively contracting nd Pro with licensed Code:
conmcmrs tomnstroRthe project (Sea 7044, Business and Professions Code:
, sy-,+.-rr1 rvPLU 1, .X"'--
a µ^,,,r _ PLUMBING PERIYMIT?'...'-.'/ h . d: ,,=.FEEi'n
p1.00D TONE
MN
PERMIT ISSUANCE
The Contractor's License Lw don out apply to an ..at of property who
buBds or improves thence, and who contracts for mch ptojeab with a
cgB(IactorW licensed pursuant to the Contractor's Llan. Law.
7 am exempt under Sea B & P C for this reamn
ALTER -DRAIN & VENT • WATER MA)
FEE ...
BACKFLOW PROTECT. DEVICE
DRAINS FLOOR A, ROOF, ARECOND.
SANITARY RFLERTN
OwnerDate
WORKMANCOMPENSATIONDECLARAnON
❑I hereby affirm that I have • certificate of consent to self -Insure, or A
cimifiate of WmIxeri Compensationlnsuranceor A certified copy thereof (Sec.
3800, Lab C.)
Pdiry
FpTTRES PER. TRAP
SCHOOL TAX Y N
RECEzT A
GAS EA.SYSIEM-1 WC40UTLETS
PARK FEE Y_ N_
RFXF31'I X
X
Com
�Certlfied ropy ere�by (umished.
�CoMfled ropy! riled with the dry Inspection divitlon.
CAS EA. SYSTEM -OVER d MA)
BUILDING DIVISION FEES
REASE/INDUMn WASTE INTERCEPTOR
•�
PLANCHECK FEE
G }?Ufa �'
CERTIFICATE OF EXEMPTION FROM WORKERS
PAID
COMPENSATION INSURANCE
Trhlssection need not Is, completed lithe permit lnforone hundred dollar"-
(5100)orlm.7
I certify that lythe performance of the work for which this permit Is issued,
I shall not employ any penton N any manner m as to become aubject to the
Workers'Compenatlon Lawaof Calll
om. Date
SEWEIk.SANITARYSIORMEA.900FT:--,
Date Recei t#
i WA IffAl'FR W/VENT/ELECTR • .,
ENERGY FEE Y N —
PAID
WATEI�y /TREATI
Applicant
NOTICE TO APPLICANT. If, after making this Certificate of Exemption, you
should become subject tothe Werkers'Compersxtlon provbiom of the Labor
- _'
TIM RESIDENTIAL PLMB. SOFT.
Date Recei t#
TOTAL:
BUILDING FEE
Code, you must forthwith comply with such provisions Orthis permit shall he
deemM remoked.
CONSTRUCTION LENDING AGENCY
SEISMIC FEE
TOTAL:
ELECTRIC FEE
I hereby offlan that there is aconstmctice lendingagenry forthe perform-
race of the work (arwhich this peanut bsu
Issued (Sec 3097, CIv.C.)
Lerder. Name
Iendcr's Addrem
I omi/ythatl love read thisappliceHonand gatethat/heabovemlornutlon
bcorrect. l agreeto complywith all city and county ordinances and state laws
PLUMBING FEEIcy
.-.. ,
917Y.- "':'-Ii1CCHdNICAG'PER.MIT"' f api?FEE
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID:
relating to building construction, and hereby Authorize representatives of this
cityto enter upon the above-mentioned property for inspection purposes.
Me) agree to ave, bndemNly an d keep harmless the City of Cupertino
ago' bWtlea,judgments, roars and expense. which may In any way accrue
Aga' aid CI i n.que of the granting of this permit.
B
ALTER OR ADD TO MECH.
Date Recei t#
AIR HANDLING UNIT CTO 10,000 CFM)
SUBTOTAL:
AIR HANDLING UNIT(OVER 10,000 CFM)
CONSTRUCTION TAX
to of pp do r Data
EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DI SCLOSURE
HEATING UNIT (TO 100,000 BTU)
'Date Recei t#
Will the applicant orfuture building occupant store or hand Is hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.R, and the
Health and Safety Cade Section 75539(x)7
❑ Yn No
WIII the Applicant or lure building occupant use equipment or devices
HEATING UNIT (OVER 100,000 BTU �
TOTAL.
VENTILATION (SINGLE RESID)
ISSUANCE DATE
which emit hazardous dr contaminant. as defined by the Bay Area Air
Quality Management District?
❑❑ No
i3 t{ a1
BOILER -COMP OHP OR 1 W,OW BTU
BOILER-COMP(OVER 100,0008N)
4Y.
have read the haar3nn. materiab requlrcments under Chapter 6.95 of
a.A
the Ulifmia Health & Safety Code, Sections 95505, 75533 and 95534. 1
understand that lithe building don not currently have a tenant, that it b my
respombbWty to notify the occupant of the regWarrams which moat be met
Q - )
Cl
NEW RESIDENTIAL MECH. SQTT.
prior to issuance of a Certificate of Oavpa ney.
1 {
i f
ISSUED BY'
Owner or authorized agent Data
TOTAL:
OFFICE COPY