21375APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification - - - -
Build ug Address:
PERMIT NO.
A035'S- - O£ 4p)2,'? -/j I—V O .
213,75
ncr ams: one:
CITY OF CUPERTINOLBUILDING DIVISION
APPLICATION / PERMIT'
BUILDING -ELECTRICAL PLUMBINCMECHAMCAL
=AATE
Coetndors Name:� �• Llic.lNe:
P6,e �K—C • I %SSG
CATEGORY
CONTROLN
Architect/Engineer. Lie. No:
QTY ELECTRICPERMIT FEE
BUILDING PERMIT INFO
Add..
❑ y ❑ ❑
PERMIT ISSUANCE tQ
LICENSED CONTRACTOR'S DECLARATION
Ilithb ion7O that lam Bcensedunder iroand mfeW ofChapter
Bran. 1. 1. fun7000)o(DlWelon3 ofthe Busiwuand ProfeWonsCode,and my
license b in full form and affect.
License CV LION/ 7 y %F
APPIlANCESRE5IDENTIAL
JOB DESCRIPHON
PANELS
Dale�CantnctorUP
ARCNITECTSDECLARATION
TO 2DO AMPS
201-IODO AMPS
OVEOVER 1000 DOAM AM['S
SQ. FC. FLOOR AREA
$M.Fr.
shall be
!understand my platy Bhew
SIGNS ELECTRICAL
Licensed Professional
SP[CIALCIRCNT/MISC
' OWNER -BUILDER DECLARATION
I herebyaffim that I am exempt fmmthe Conlractm's Limwe Law /or the
gyp. METERORPOLEINSf.
following reason. (Section 7031.5, Business and Professions Code: Any city or
countywhichrupbl apermbtowmtmd,alter,impmw,dem lish,orrepdr
anyelmdure prlartolb tswance,atsomqulmlheapp0unt for such pemnit to
file a signed statement that he is licensed pursuant to the prewbiow of the
Contractors License Law (Chapter 9(commencing with Section 7DOO) of Divi-
elon3 ofthe Businessand ProlenwloCed0carthe bets exemrefr
ptthedmnd a
the basis for the alleged exemption. Any violation of Section 70315 by any
applicant for a permit subjedsthe applicant to a Civil penalty of not more than
POWER DEVICES
SWIMMING POOL ELECTRIC
UTLE7SSWITCHES-FIXTURES /ra
VALUATION,
NEW RESIDENTIAL EIEC7R
SQ.FT.
five F11, ashundred
ownerdollars he pro
as owner of the property, or my employee, with wages their dole
STORIES
TYPE CONSTRUCTION
compenI,
work and the s not Intendedor for
ation,.70K
Jj
ask (Sc BusBothe coffered
dale (Sec. 7064, BuaNn, an, Profeaslow Code: The Contnctola License law
Code; actoe
y
\ �. ?� / TOTAL: r
INmbuild
PLUMB'TERM' FEE
does notapply to an owner of property who Wilda or improves thereon, and
who dote duchwork Mmself orthruugh Ns own employees, provided that such
Improvementsamnotintendedorofferedforsale. ILhowevepthebuildingor
improvement ts sold wuhin oneyearefcompldiom the owner -W Bderwlll have
t rden of proving thathe did norimprovelorpurpossofsale.).
L1, as owner of the property, am exclusively contracting with 1lceneed
rontndord to Cowiruct the project (Sec 7614, Budneee and ProfessionsCode:
The Contractor's License law don not apply to an owner m property who
builds t r improves tpursua and who mn<nds for such p(ofem with a
�Bf+mor(eexempt under Sec to the Con/ndori License PLaw.
I_I I am exempt under Sec. B & P C for this rea,on
OCC.GROUP
RES UNITS
QTy. I
P IT ISSUANCE A
B
AL-DRAINI& -WATER'
_ •„
FLOOD 7ANE
APN
FEE SUMMARY
BACK 7.D C
DRAT r RROOAREA, COND.
SANITARY Y_ N_
RECE11`' N
.
Owner Date
WORKMAN COMPENSATION DECLARATIONPER
hereby affirm that I have a certificate of consent to self -Insure, or a
rtifluteof Workers'Compewahmlw mnmaramAlfiedmpythemof(Sec.
3800, Lab CJ q,Q
I'ollcyN PC / /0�.r�'
TRNr p ,
8
SCI{OOL TAX Y N
RECDIxf N
d
G-IdNC.4OUTLLTS ••
PARK FEE Y_ N_
RECED'fN
G'S -EA. S' d J
Com env ��c) vaI'
BUILDING DIVISION FEES
ertified Copy It hereby famished.
Certified ropy is filed with the city pen division.
CREASE/INLWA ri'M'ERCEPTOR
PLANCHECKFEE
GREASE ` 1''
' CERTIFICATE OF EXEMPTION FROM WORKERS'
PAID
COMPENSATION INSURANCE
(CAlasecllon need rot be completed if thepermB b for ane hundred dollars
SEWER-SANRARY SIO EA 70oFI
Date Remi t#
WATER HEATER W/VENT/17.FLTR
ENERGY FEE Y N
($100) or lees.)
I certify that In the performance of thework forwhlch this permit is issued,
WATER SYSTEM/TREATING
I shall not employ any person In any manner an as to become subject to the
Workers' Compensation Laws of California. Date
PAID
Applicant
NOTICE TO APPLICANT: If, after enticing this Certificate of Exemption, you
should become subject to the Workers' Compensation provtsiorst of the Labor
Code, you =at forthwith comply with such provlslow or this permit shill be
deemed revoked.BUILDING
Date Recel t#
NEW RESIDENTIAL PLMB. SOFT.
TOTAL:
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that there It a construction lending agency forthe perform-
ance of the work (or whkh thio permit ts issued (Sec. 3097, Civ. C.)
can ier's Name
TOTAL:
ELECTRICFEE
(60
PLUMBING FEE
Lenders Addme
I Certify that] have mdthtsapplkation and statethattheabove information
bcomeet.I agree to comply with all city and county ordinances and state laws
QTY. MECHANICAL PERMIT FEE
MECHANICAL FEE
PERMITIssDANCE
FEES PAID:
relating tobullding construction, and hereby authoslu representatives of thio
city to enter upon the above-menlloned property for inspection purposes.
agree to save, Indemnify an d k<e harmless the City of Cu pertlno
ALTERORADDTOMECH.
Dat('. Receipt#
- SUBTOTAL:
Banat labillticjuigments,co ande o wh nanywayaccme
agalw said City In Cone a o!t gm it
AIR HANDLING UNIT CFO 10,000 CFM)
AIR HANDLING UNIT (OVER Ie0D0CIM)
CONSTRUCTION TAX
stare of Applicant/ onlraco to
EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
• HA7ARDOUSMATERI SDISCLOSURE
HEATING UNIT (TO 10),000 BTU)
- Date Revel t#
Wlllthe applicant or future building pant store or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.17, and the
Health and SafmyC a ion 29537(d)i
Q Yrs No
HEATING UNIT (OVER 105,000 BTU)
TOTAL:
VENTILATION FAN (SINGLE RESID)
ISSUANCE DATE
Will lheappllnnt re building occupant use equipment ordevices
whkh droll havrdou air contaminants as defined by the Bay Area Air
BOMEELCOMP OMB'OR 1D0,000 BTU)
Qui llty Management Dl 7
Yean
l
/�1
BOILER -COMP 100,000 BTIJ)
T a a
have mad the olio materials requlmrrcnts under Chapter 6.95 of
the Callfornla Health & Safety Code, Sections 75505, 75533 and 75534. 1
ad rs rad thatffthe building don nm currently have a tenant, that It u my
C�1�
1990
_
NEW RESIDENTIAL MEC}{: SQgf
rePonilitylo nmlfythe ant catch quire is which rrwsl be rout
MJ1
prion Issuance maCert fk sof Oc
_
—act!
raulhorlad agent Date
ISSUED BY: `
TOTAL:
OFFICE COPY