28347Me6Z
u00
WU[
FZ _t
Amy
.Fye
:Z -C
LL
LO
u.y
_u -O¢
oe
-SCC
asMsn
Fz�
Cf-�
0
c3°—e
9
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO I BAINc- ELECTRICAL
PLUMB NG CT IDENTMC
BUILDING DIVISION APPLICATION/PERMIT
BUILDING PR0J6C1'IDBNT6lCATION':••-.
PERMIT NO.
2 Q Q /I 7
G o J (•�
BUILDING ADDRESS: _ J ,,
o2a5 C0L1-ren- SIA." Cat- UNIT# LOT#
SANITARY NU.
APPLICATIONSUBMITTALDATI
g -as- 43
O .RS NAMEPHONE
VpVrwJ®:53—�
COpCfOR'S NAME
LIC NO:
'Sy.%�
NiC
CONTROLIs
'ARCHITECT GINEER: LIC NO:
AgDORE :� per`
/J�4-.^-
l,a.
CONTACT: PHONE:
) W --sec ipn�'�F rig .-
(?TY. i �`I, ELECTRIC PERMIT S -x' 1. FEEv.
-'a-I-, BUILDING PERNUT INFO - -
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE
El ❑ ® ❑
LICENSED CONTRACTOR'S DECLARATION
1 hereby eftnm than I an licensed underpmvisiom MChepter9lcommencing with
APPLIANCES - RESIDENTIAL
JOB DESCRIPTION
PANELS
Section 7") of Division 3 of the Business and Professions Code, and my litems is in
full force and effect.
License Class Lic.#
UPT02MAMM
I
Dam Contractor
ARCHITECTS DECLARATION -
1 understand my plans shall be, used as public records.
201 - I" AMPS
SQ. FT. FLOOWAREA
J15Q. FT.
OVER IOW AMPS
SIGNS ELECTRICAL
,
Licensed Professional
OWNER -BUILDER DECLARATION
SPECIAL CIRCUITMISC.
1 hereby efirm that 1 am exempt from the Consncmrs Licase Law her the
TEMP. METER OR MOLE INST.
fallowing reason. (Section T03L5. Business and Professions Code: My city orcounty
which reforms a permit m camtrvd, alcor, improve, damolisi, ar repair any stmeture
prion.itaisamem.almouniisatheapplicant forsuchpemtitmftleaaignedsulement
POWER DEVICES
that he is licensed pursuant to she provisions of the Contractor's License Law (Chapter
9(cammencing with Samoa 7000) ofDivision 3 of Ne Business and Profession. Code)
SWIMMING POOL ELECTRIC
VALUATION
or Bur he is exempt therefrom and the basis for she alleged exemptive. Any violation of
Section 7031.5 by any applicant fora permit subjects the applicant to a civil Penalty of
U� OQC7 k C7 C:i
1
OUTLETS-SWOCHFS- FIXTURES
not more than five hundred dollars ($501J).
ElI,nownerofthepma M.mmyemploymswithwagesmtheirsolemmpnunion.
HE WRESIDENTIALELECTR _SQ,Fr.
STORIES
TYPE CONSTRUCDOb
will dothe work, anddm swerve isnot intendedoroffemd fortune (Sec. 70,16, Business
and Professions Code: The Contractor License Law does not apply to an owner of
property who builds or improves Nemo, and who does such work bimulfmthmugh his
own employess.pnwided Nmsuch improvementaam not imendedoroffemdformle. If,
OCC. GROUP
RES. UNITS
TOTAL:
however, she building mimprovement is sold within one year of comple umflie owner-
builder will have Ne burden of proving Nat he did not build m improve for purpose of
i'ak, ,sin :rsn.s 'T�}SJ s ff
3 #a PLUMBDVG PERMIT-+' .s5^^' PEE
-.h. tE t+w.: ^,s.-.s.•w ., wxwnc.v: �a Y.. x' ::IP'4 ..vii
see.)...
❑ l,asownerafthe Pm ny.mnexclusivel conwctin thlicensedconoactonto
Y Bwi
conswm Ne project (Sec. 7036, Business and Professions Code:) The Contractors
License Law does not applytoan ownerofwhobuilds or improves themon, and
FLOOD ZONE
APN
PERMIT ISSUANCE ']
2 t tJ (7
whocontracts fmsuch projects with accommorfs) licensed gumantrothe Contranor's
License law.
ALTER -DRARI & VENT - WATER (EA)
ts,. y; r,.F _
ptr .xa'm�F'.-al :FEE SUMMARY,ea%Y'It
❑ 1 an exempt under Sm. , B & P C for this reason
BACK FLOW PROTECT. DEVICE
ITfSID TMs
SANITARY Y N
RECEIPT#
Owner Dne
DRAINS- FLOOR, ROOF, AREA. CONE.
WORKMAN COMPENSATION RATION �/�
❑ Thereby affwthetlheveacenific to 6Tcom mself-insure, res m,¢)����of
Workers Insurvrceare ce 'sed co f(Sec.3g C)which
covers all employee's under this permit.
Policy #
SCHOOL TAX YN
RECEIPT#
FIXTURES -PER TRAP
/0 a
PARK FEE Y N
RECEIPT' n
GAS - EA. SYSTEM -1 INCA OUTLETS
BUILDING DIVISION FEES
Company
GAS - EA. SYSTEM -OVER 4 (EA)
PLANCHECK FEE
❑ Certified copy is h by f rs
❑ Cmofiecl o yi file ec yinspe ds a.
QOM
GREASFJWDUSMI_ WASTE INTERCEPTOR
GRADING FEE
CTRTIFl OF EXEMPTIn WORKERS'
GREASE TRAP
SOILS FEE
CO SATION T URANCE
SEWER - SANITARY - STORM EA. 200FT.
ENERGY FEE
(Iltisaemlonamdnotbe o plemdif Nepemitisforonehun&Mdollm(SIW)
at less.)
WATER HEATER W/VENT/ELECTR
I certify that in the performance oflis work far which this permit is issued, I shall
not employ any person in mv manner so as to become subject to the Workers
PAID
WATER SYSTEMDUI TING
Compensation Lawsof Celifomfa Dam
Dam Receipt#
Applicant
NEW RESIDENTIAL PLMB. SQ. FT.
TOTAL:
NOTICE TO APPLICANT: If. after making this Ceniftcam of Exemption, you should
become subject to the Worker's Compensation Provisions of the labor Cade, you mon
forthwith comply with such provisions or this permit shall be deemed revoked.
BUILDING FEE
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
1 hereby affirm the them is a construction lending agency for the performance of
the work fm permit this peut is issued (Sm. 3097, Civ. C.)
TOTAL:/C)-?,Qp
ELECTRIC FEE
Lenders Name
.. a.'" - 4:'•'• i.'I>,"''->d1. .'#•rr
QTY. ' a; MECHANICAL PERMIT i„ ,,r `;FEE, i; -
11 1
PLUMBING FEE
D-
Lenders Address
I certify that 1 have mad Nls application and state Nat Ne above information k
cared I agree to comply with all city and county ordinances and state laws relating to
PERMIT ISSUANCE
MECHANICAL FEE
building convection, and hereby authories reprosentim,xi of this citym enter upon the
above-mentioned property for inspection purposes.
ALTER OR ADD TO MECH.
CONSTRUCTION TAX
(We) agme m save, indemnify and keep h undesa Ne City of Cupertino against
liabilities, judgments, toss and expenses which may in any way, scene agaantmdCary
AIR HANDLING UNIT (TO to'" CFM)
in consequence of the gaming of this permit.
AIR HANDLING UNIT (OVER 10.000 CFMI
Signature of ApplicantlCamracmr Dam
EXHAUST HOOD(W/DUCT)
u �
/a
PAI—25—' a— IZp
—
HEATING UNIT(TO I W," BTU)
HAZARDOUS MATERIALS DISCLOSURE
Date Rmnps #
HEATING UNIT (OVER 100.01)) BTU)
TOTAL: V%.V
Will the applicant or future building occupant some or handle harmdous materiel
a defined by the Cupertino Municipal Crain. Chapter 9.12, and the Health and Safety
VENTILATION PAN (SINGLE RESID)
Code, SemiJ2(a)?
❑ Ya ❑ No
Will Neapplicantor(umre building oecupentusc equipmenlnrdeviaswhich emit
BOILER- COMP(3HP OR fle" BTU)
" ISSUANCE DATE
BOILER - COMP (OVER 100.000 BTU)
haurdaus air commonanu as defined by the Bay Area Air Quality Management
District?
a ID yet ❑ No -
!qi 2 "p C
-UG tP 1 key V)
u
NEW RESIDENTIALMECH. SQ. FT.
I have read the hmardins materials refulremems under Chapter 6.95 of the
California Health & Safety Code. Sections 25505, 25533 and 25534. 1 understand Nn
,
if the building does not currently have a tenaps, that it is my responsibility to notify the
occupant of the requirements which must be met prior to issuance of a Certificam of
j
Occupancy.
\/
�l�AA .p
ISSUED BY: wG z2/_z A1KC
Owneror.mumaed agent Data
TOTAL:
OFFICE