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CnY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BLnMNGFl MCALIR.UMBINGMFLHAMCAL
Lk.No
CATEGORY
CONTROL#
ArthhN Engineer. Lle.No:
QTY ELECTRICPERMIT FEE
BUILDING PERMIT INFO
Addrvs
I'ERMITISAIANCE
❑ ❑ ❑
LICENSED CONTRAROR'S DECLARATION
I hereby stones that l am licensed under provWmu of Chapter 9 (oommene,
Ingwlth5mbn7000)of Divblon3 olthd Buslnee.andlto/es.UonuCnde,and
Boense b la full (ora and skis".
Cls,. Loc#
Date
Date Contractor
ARCHITECT'S DECLARATION
IurdeMandmypbmehaBbeua publiciemrda
Lknnsed professional
OWNEReBUILDER DECLARATION
Iwi.g ufBr thati5seh at7MI-S, (romtheCPmf.irbLlanaeLaw fee AryeJtthe
fa ntywree.equ( lfon7m15,Busineaalld PRpe naemlrhny"tyor
countywhkhPrior toIa pannk tomngruq a s themprwent fors lith grrepmit to
+nyehumue prim to ltsbuance,aborryubes theapp0antfasuch Elmet to
file a signed statement th.n he b Bee sed pursuant to the provbbv d the
Contn"ori Lkerue Law (Chapter 9(co men"ng with Seaton 7000) of Divi-
eon 3 of the Business and Pmfe»Iov Code).1 that he b m
exept therefrom and
the b.eb for the alleged exemption. Any vielulon of Seethes 9015 by any
applicant for a pemlit abjem the appBcsm toes "NI penalty d not more than
Iry hundreddollarz0i; ).
1, as owner of the property, or my employees with wages as the& sole
romper cation, wiB do the work anathe structure Is rot baended or offered for
sale (See. 70K Belles and PMexbns Code: The Cont.d.e. IJanse Law
does not apply to an owner ofproperty who belles or improves the., and
who doessuch work himself athrough his own employees, provided that such
ImpmvemeNaartrwtlntendedordferedfanid. ILhowevu,thebW1dingm
improvemed heed wkhinorbyeerofcompl"bM theowner-bullderwlll Fave
t raenofpmmingthathedld notbuudorlmproveforpurposeorulea.
Lj L as owner ef the property, am excwhely mntraeting with Ise rued
contra"see to mvtnr" the projeet(Sm 7014, Busl and Pmfmbv Code:
The Contneor's Lloeve raw does nes apply to an owner of property who
builds or Imprm es thereon, and who mr0ra"i (a such pAejects with a
omV ort') Bcensed pursuant in the Contneto/s Limine Law,
Lf 1 am exempt under Sec B h P C for two seasonQ1JT11.E
APPLIANCESRESJDENML
OB DESCRIPTION
PANELS
n-1000 AMPS
OVERIODOAMPS.
SQ. FE. FLOOR AREA S/SQ.FT.
ALE D
p ,�
M TE
/ �/ /
VALUA
'
SIGNS FT FG]RIC L
WECMLCIRCUITIM19C
TEMP METISt OR POLE INST.
IYriVER DEVICES
_ SWIMMING POOL ELECTRIC
WDSISSWI7'CFt!-S.FlATURFS
NEW RE5IDEMTAL ELD= SQI7,
STORIES
'
TYPE CONSTRIICHON
TOTAL �Z
QTY. PLUMBING PERMIT FEE
PERMIT ISSUANCE
ALTER -DRAIN &VENT WATER (EA)
OCC.GROIIP
RFS.IJNT15
FLOOD WNE
APN
.
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
RES
DRAINS OR, ROOF, AREA, COND. FLOOR,
PER TRAP
SANITARY Y N—
RECEB'T#Fp(TURFg
Owner Date
WORKMAN COMPENSATION OECTARATION
r-11 hereby .fibro that I hive a orrtlBate of cmrnt w self -Wort, or a
artlBaolWorknn'CanperwtlmlrwrranaasartHled copythemo(0ec.
380Q Tabb CJ
Pdky I
SCHOOL TAX Y_ N_
RECEFr a
S EA. c -
GASYS'FFifi IN4 ounz5
PARK FEE Y_ N_
M
CAS FA. SYSTEM -OVER 4 (EA)
Co ny
BUILDING DIVISION FEES
DING DI
CmtNed o>pybhertby (urdshed.
CerlMet] ropy b (Ike with the city lespeebe division.
CERTIFICATE OF EXEMMON FROM WORKERS'
COMPENSATION INSURANCE
(Tw"b
sen need nest be cmnplated H permit peJt b (mne ohundred dollars
IS100)grldmy
lBrese atbtne perrnro.anaorine wakrnrwMrhtwpem,Bbbnred,
].ahall nal empby any penin In any unnner o u to become dbje" to the
WorFca" �1,_:p oy-!o Taws of (Thfomb. Date
Appllann
t VICE ro APPLICANT: If,,fler meUlgthb CenHlale of Eaempk,n, you
ehmld become subject b the Worken' Campewtkm provbbv o(the Labor
Code, yw mu"forthwith comply with such provlrbna orthb permN shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
r of the arkfthatthdabammit is lonk(Srn 3gmuyfgrthe perform
sena of the work for which two permit b blued (Sac 3DYW, Clv. C.)
lender's Nsme _
feeder's Marty - e
Iant.Nrt]saw read lhbappHatwnsrd Wtetlunnheabove ln(orrrutim
b mnnt. building mmrrudIM.Bciterseby.eth dlnanmuntt lalelaws
rcJnlogtobu pont mnatm"lon, urd hertoperty orir apreae purge olthb
citytoenkreto tkabedemnify.ned property fainape Cit p fCoxs.
CW-) agree to save,Odg bedeems, ,an dkeep harmlesswh"the Cityo(Cupertlw
ywayacmue
agaWt flab Citylfles, corseq.,mrtof the
eaperues whkhr permit.
ages Wl.ald City In amteequer�a d the gnming d W permlt.
CREASE/INDUS[RL WASTE INTERCEPTOR
PLANCHECK FEE
PAID
Date Recd t#
GRFASETRAP
SEWER SANITARY S10RM EA MOFT
WATERHEATERW/VENT/EL(TR
ENERGYFEE Y N
— —
PAID
Date Retei t#
/EATER SYSTEM/TREATING
NEW RESIDENTIAL IgA18. ��.
TOTAL:
U
.
TOTAL
SEISMIC FE
ELECTRIC FEE.
_
QTY. MECHANICAL PERMIT ITE
PLUMBING PEE
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAIf}
ALTER OR ADDTOMEC[#.
AIR HANDLING (INTI (IV 10,000 CFM)
Date Recel t#
SUBTOTAL:
AIR HANDLING UNIT (OVER la,000cFTn
CONSTRUCTION TAX
Signatua of AppOont/Contn"er Date
HAZARDOUS MATERIALS DISCLOSURE
Will the appllant or future building oceupant swat or ha rd le haaardoes
'rruterla l.1 defined by the Cupertlw MurddpaI Code, Chapter 9.1 7, and the
Health and Safety Code Section 25537(a)7
❑ Yes No
Wllltheappilant SqWmr ildingo Nntuseequipmmr devkes
which emit luardoua air contaminants as defined by the Bay Area Air
Quelky Management Dbtrb7
Yee No
have read tehharvteriab requirements under Chapter 695 of
tha GBfomb Health h Safety Code, Smi..25505, 25533.nd 75531. I
undenlard that IftheboUeRng es b
does neurrently have a tenant, that It my
m,ponvbllltyto nosily the oceupent&the requimmedswhkh nest be mat
potseuarue dacewofom„ n
norm aunh agent Lbne
EXHAUST HOOD (WICOCO
CONSTRUCTION TAX PAID:
HEATING UNIT (TO t 00,000 BTU)
Date Recti 1#
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
VENIIATION FAN (SINGLE RESID)
ISSUANCE DATE
U
[;
') •/'S G 7Q
I !+
'
r rr f (;1113artinn
ISSUED BY
BOILER -COMP OHP OR WOOD BTU)
BORER-CVMP(OVER 100,000 BTU)
KEWRESiDFNTIALMECH. SQFT
TOTAL:
OFFICE COPY