21098APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
Building Pealed Identification
Beading Address:210
PERMIT NO.
9 8
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weer. a ante: I one:
'�a~'t/e'IZ�TL•ak�iksA�,'
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
.
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C an ctorsName: Lt.. No:
BUR-DINGELECTRICALPLUMBINGMFLHANICAL
CATEGORY CONTQOI., L::�'(�
1 (O
Arch /Engineer. Lie No:
QTY ELECTRICPERMIT FEE
BUILDING PERMIT INFO
Address
♦
- l
PERMIT ISSUANCE
LICE.NSEDCONTRACFOR'SDECLARATION -
IMrebya((brn that lam Bcene.d under pravialone olChapter9(mmmm
APPLIANCES -RESIDENTIAL
]OB DESCRIPTION
Ingwith Sedion7000)of DiWgm3orthe BuNnenand Pm(ni4waCade,and m
bin full (orae anaffect.
d
7�6 Der
Claes # J B
PANELS
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• 1�
_�=�Lic
Data N -1O �jt Contractor
�CHITEC78 DECLARATION
I understand my plans shall be used n public records
Licensed Professional
UP TO 2DOAMPS
AMPS
O1-1000
OAMPS -
SQ. FT. FLOOR AREA
l
sr[
In a}'
S/SQ.FT.
SIGNS ELECTRICAL
SPECIALCIRCUIT/FISC �T
lJ
OWNER -BUILDER DECLARATION
the Corectora License Law for the
I herebyarmthad I am exempt fmmm
(fi
l
TEMP. MEfERORPOLEINST.
following reason.(Sedion 7031.5, Business and Professions Code: Any city or
county which requiresa permit to comtmct, sitter, improve, demolish, or repair
any structure prior to Its Issuance, also requires the applicant for such permit to
fill. a signed statement that he Is licensed pursuant to the pmvbions of the
POWER DEVICES
SWIMMING POOL ELECTRIC
1 GU7LETSSWITCHES-FTXTUREq a,
L
Contractor's Licerde Laav(Chapter 9(comentrubg with Section 7000) of Divi.
sion3 of the Bu diness and Professions Code) orthat he is exempt therefromand
the bash for the alleged exemption. Any violation of Section 7031,5 by any
applicant fora permit subjects the applicant toe civil penalty of not more than
five hundred deltars eiM.
❑ I, as owner of the property, or my employees with wages as their sob
VALU
.�t
NEW RESIDENTIAL ELECTRFT.
�'
STORIES TYPE CONSTRUCTION
compensation, will do the work, and the structure is not Intended or offered for
sale (Sec. 7044, Business and Professions Code: The Contractors License Law
does not apply to an owner of property who builds or improves thereon and
who doessuch work himself or through his own employees, provided that such
.G UNITS
a�
improvements are not intended or offered for sale. If, however, the building or
- TOTAL
Improvement is sold within one yearofcompletion, the owns-builderwBl have
tfuraen of proving Math ala not bund or Improve for purpose of ago.).
QTY. PLUMBING PERMIT
APN
u L as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7014 Business and Professions Cade.
The Contractors License Law does not apply to an owner of property who
builds or Improves thereon, and who contracts for such p(ojem with a
cgp[la0,r(s)Bernard pursuantec to the Contractors License Law.
IJ I am exempt under SB & P C for this reasonOUTSIDE
PERMIT ISSUANCE
_ a
ALTER-DRAIN&VENT-WATER(EA) [�
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
FEES
FIAOK ROOF, AREA, COND.
Fa IVRFsI'ER TRAP t m
SANITARY RFG�'N
Owner DateDRAINS
WORKMAN COMPENSATION DECLARATIONSt7i00L
❑I hereby affirm that I have • certlfiate of consent to a.l(-inwrc, ar a
certificate of W.,ken' Compensation Insurance ora rnrtifled copy thereof (get
3800, Lab C.)
TAX Y N
RECEPT #
GAS EA. SYSTEM -1 INCAOUTLETS 2a�
PARK FEE Y N
RECENT p
Policy
m any
GAS F.A. SY9TEM-OVER4(EA)
- BUILDING DIVISI ON FEES
Certified copy is hereby tumie
rt fled copy b filed with the city inspection d
city ivision.
ci
GREASE/WDUSRLWAS1EINTERCEPTOR
PLANCHECKFEE
GREASE TRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
PAID
SEWER -SANITARY -STORM EA ZOOFT
COMPENSATION INSURANCE
Qhis section need not be compleed if the permit b feeone hundred dollen
($100)mIcan)
I certify that In the performance of the week fmvvIdch this permit Is issued,
DRIB RCCC{ 1#
WATTR HEATER W/VENT/ELECTR
ENERGY FEE Y_ N_
WATER SYSTEM/TREATING
I shall not employ any person In any manner so as to become subject to the
Worken'CompenseBonlewsof CAIfomia. Data
Applicant
NOTICE TO APPLICANT: If, after making this Certi iate of Exemption, you
should become subject to the Workers'Compereation provisions of the Labor
Code, you must forthwith comply with such provisions or this permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
PAID
Date Recei t#
NEW RESIDENTIAL PLMB. SQ.FT.
TOTAL:
BUI
SEISMIC PEE
TOTAL:
ELECTRIC FEE e
Ihereleyaflim that there be construction lendingagenry(canine perform
ante of the work for which this permit Is blued (Sm 3097, Civ. CJ
Lender's Name
tenders Aaaren
PLUMBING FEE
Q TY. MECHANICAL PERMIT FE
MECHANICAL FEE
nand dcouate tenttrants, andtion
Iced. I agree to e mad comply is withall
la carred.Iagree to comply withellcity end manly ordlnanrns and trate lawn
^'7
/y
PERMIT ISSUANCE -
FEES PAID:
TER OR ADD TO MECH. q LV
rebting to building construction, and hereby authorize representatives of thio
city to enter upon the above-mentioned property for hapedbn purposes.
m
(We)agree to save, indemnify an d keep harmless the City of Cu part no
liabilities, Odgmen, massed expenses which may In any way as
againstmassedmu
Date Recef t#
AIR HA UNIT (TO 10,000CFM)
SUBTOTAL:
AIR HANDLING UNIT (OVER l0,000CIM)
TAX
against as City In equence of granting of thl pennl _CONSTRUCTION
1Date
na r pliant/Contractor
"ARTERIALS
LD(HAUST HOOD(W/DICT)
CONSTRUCTION TAX PAID:
HAZARDOUS 'yDISCLOSURE
Will the applicant or future inflicting occupant store or handle hazardous
Date Recel t#
HEATING UNIT (TO 100,000 BTU)
material as defined by the Cupertino Municipal Cods, Chapter 9.1 7, and the
Health and Safety Cade Smion LSSJ2(a)t
❑ Yes
Will the applicanteefuture bullding occupant ..equipment or devices
HEATING UNIT (OVER 100,000 BTU)
TOTAL
VENTILATION FAN (SINGLE RESID)
I DANCE DATE
which vent ham rdous air contaminants as defined by the Bay Area Air
Quality Management District?.
4JYes ❑❑ No
havereadtheberdousmaterialsrequirementsunderChipler6.95of
the Calm
lf.mis Health & Safety Code, Sed lane 75505, 75533 and 25534. 1
understand that if the building dm not currently have a tenant that it Is my
responsibility to notify the occvpa nt of the requirements which moat be met
t'
AfAr J
BOILER -CAMP pfm OR l00,IXq BTIn
BOILER-COMP(OVER 100,000 BTU)
NEW REST DEI -MAL ME(H. SQ.FT.
prior to leen nee of a Certificate of Occupancy.
SSUEDO
Owner or aulhorimd agent Date
TOTAL:
OFFICE COPY