22695APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification
B�o`n4arez D�,v�SoN At,F r C'� , C4-.
PELMITNO.
22695
Mr9ante: One: _
17lO/'7A 76,&OT /`j �j
5 SSS —
h OF CUPERTINQBUILDINC DIVISION
APPLICATION 1 PERMIT
A n
Contractors Name: Lip. No:
BUILDINGELECTPJCALPLUMBING-MECHAMCAL
CATEGORY
CONTROL 0
Aschltm/Eng! neer. � Llc. No:
QTY ELECTRICPERMIT FEE
BUILDING PERMIT INFO
I= PLUMB mk�
Address:
PERMITISSUANCEM
Ml
O ❑
LICENSED CONTRACTOR'S DECLARATION
Iherebyafflrm that l am licensed under provisions of Chapler9(mmmenc
ingwith Sitio ,7000)of DiWsion3ofthe Buslnessand ProfesslonsCode,and my
license is In full force and effect.
APPLIANCES RESIDENIAL
JOB DESCRIVIION
PANELS-
LuaracClass Lic.N
Date Contractor
UP TO 200 A142S-
201-1000 AMPS
ARCHITECPSDECLARATION
I understand my plans shall be used m public records.
Licensed Professional
OVER 1000 AMPS
SQ. FT. FLOORAREA
/�$/SQ. Ff.
SIGNS ELECTRICAL
SPECIALCIRCUIT/MI
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
,
following reason: (Section 70315, Business and Professions Code: Any city, orTEMpMETLTi
cmntywhichmqubesapermittomnstmd,alteglmprove,demoilah,orrepair
ORIOLE
^ p�
anystruature prlortoltslsarares, alsorequires theappbcant forsuch permit to
ale a signed statement that he is licensed pursuant to the provisions of the
Contractor's License Law (Chap t..9(comenw.cing with Section 7000) of Divi-
shin of the Busimmitnd ProfesomaCede) mthat he W exempt therefeamand
of Section not L5 re any
the basis far the alleged exemption. Any tviolationcivil
app fora permit subjects the applicant to a civil peealty d rat more than
POWER DEVICES
C .ice•
SWIMMING POOL ELECIRI /
OIITLETSBWITCHESR%TURFS - '�
VAA�LUATION
l a.E e C�
1. �7
NEWRESIDENTIALELECTR SQ.FT.
III dmd dollars ($5001.
s owner of the property, or my employees with wages as their so
ea1, le
STDIIES
TYPE CON'LTRUCT'ION
mmpenstion, wJl dothe work and the structure Ism Intended or offered for
'
.In (Sec. 7044, Business and Professions Code: The Contractors License law
TOTAL: 1�
does not apply to an owner of property who builds or improves therms,and
who does such work himself orthrough hes own employees, provided that such
Improvements are not intended oroffered for sale. I(however,thebuildingor
OCC, CROUP
RFS. UNITS
improvement W sold within oneyearofcompletlon, the owner -builder will have
h,C*rden of proving that he did not build or improve for purpose ofsaW.).
LJ L as owner of the property, am exclusively contracting with licensed
contractors to mnstmt the project (Sm 7004, Business and Prefeagema Code:
QTY. PLUMBING PERMIT FEE
PERMIT ISSUANCE
FLOOD ZONE
APN
The Contractor's License Law does not apply to an owner of property who
Wilds or Improves thereon, and who contracts for such piojets with a
c,,99j1 0 r(s) licensed pursuant to the Contratora License Law.
LII OT exempt undyr See. B & PP C�for thisreason
oon
ALTER -DRAIN & VENT - WATER (EA)
FEE SUMMARY
gACK FLOW PROTECT. DEVICE
FEES
DRAINS FIAOK ROOF, AREA, COND.
SANITARY Y_ N_
RECEIPTN
Owner /)tII�.`d/ �S:z—i—v'�ate Y// L / Y /
k�'EIRKMAN COSI#{'NSATION DECLAR�fION
❑1 hereby affirm that I have a cenificste of consent to se,lf-losure, or a
certificate ofWorkers' Compensation Insurance ora cxtNed ropy thereof (Sec.
3800, fab C.)
FDT`URES PER TRAP
SCIdOOL TA% Y_ N _
RECEIPT
GAS EA. SYSTEM -1 INCA OUTLETS
PARK FEE Y_
policy M
RECEIPT If
CAS G. SYSTEM -OVER 4 (FA)
CHC n4,
BUILDING DIVISION FEES. '
Ketifiedmpyesherebyfirnished.
Certified copy ex (Jed with the city Inspection division.
CREASE/INDUSTRL WASTE INTERCEPTOR
PLANCF-IECK FEE
GREASE TRAP
CERTIFICATE OF F.%EM PTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not W Completed B the permitSURA W (Drone hundred dollars
PAID
Date Recei t# �a�
SEWER -SANITARY -STORM EA. 200FT.
($l W)or less.)
Icertlfy that in the performance ofthe work forwhich this permit is Issued,
WATER
WATER HEATER W/VCM/ELFGTR
ENERGY FEE Y N
I shall not employ an/ person In any manner so m to become subject to the
Workers' Compensation laws of California. Date
WATERSYSTEM/IRFATING
PAID Q
Applicant
NOTICE TOAPPLICAtothe orkfter makingfhbcat[on pro is Exemption, you
Code,shoulyou
Code, you must forthwith comply with such provWlora or this permit shall be
forttmthe Workers Compemamnp orchis ermit the s Labbe
deemed revoked.
Date Recei t# f
NEW RESIDENTIAL PLMB. SQ.IT.
TO-I'AL: "t 1
BUILDING ISE a
SEISMIC FEE 'O
CONSTRUCTION LENDING AGENCY
I hercbyafarm that there W a mmtrution lending agency for the perform
ance of the work for which this permit Is Issued (Sec. 3097, Civ. CJ
TOTAL:
_
ELECTRIC FEE
lender's Name
Lender's Address
melfythA l have read this applieitionand atatethat theabove lnformatlon
hemmed. l agree to comply with all city and county ordinances and state laws
QTY. MECHANICAL PERMIT FEEMECHANICAL
PERMIT ISSUANCE
PLUMBING FEE
FEE'I
FEESPAID:
relating to building constrution, and hereby authotae representatives of this
city to enter upon the above-mentioned prcety for inspection purposes.
(We) agree to save, Indemnify an d keep harmless the City of Cupertino
ALTFRORADDTOMECH.
Date Recei t#
P
SUBTOTAL: t)
against liabilities,judgments, cotsand expenses which may In anywayaccrue
ago' t uid Gty In co uc.myf the granting of this permit
ry of
AIR HANDLING UNIT (TO 10,000 CFM)
AIR HANDLING UNTT(OVER 10,000 CFM)
CONSTRUCTION TAX
Signature of Applicant/Contractor ate/'
EXHAUST HOOD(W/DICT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSUR
HEATING UNIT TO 100,000 BTU)
Will the applicant or future building owupant store or handle hacardous
material as defined by the Cupertino Municipal Code, Chapter 9.1 2, and the
RCCCI l#
HEATING UNIT (OVER 100,000 BTU)'
—Date
TOTAL:B
Health and Safety Code Section 25532(a)?
r-1 Yea M No
Will the applicant orfutombuilding occupant use equipment ordevices
which emit Kara rdous air contarm ants as defined by the Bay Area Air
VEN"IILATION FAN (SINGLE RESID)
ISS ATE
rPY6T
BOILER -COMP OFI' OR 100,IXp BTU)
Quality Management District?
4Ys gNn
havervvd Cha pier of
a ousmmer,5l
SEP 16 199
BOILER-COMP(OVQt t00,ON B7UI
lh.Ith i.0 25505tsunder
the CalilornW health &Safety Code, Sections 25505, 25533 and 2553d. I
4. I
NEW RESIDENTIAL-MECJgL SQ.Fr
understand that lithe building does not currently have a tenant, that it is my
responsibility to sexily the occupant of the requirements which must be met
j�
Ca4�w 4 ^ U!��a.,,��
ot
prior to Issuance of a Certificate of OCNpancy.
a V
yy
Ow...... uthorlud agent Date
TOTAL:
ISSUED BY:
OFFICE COPY