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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification
Building Address:
PEtk9TNO.
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CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BUfLDING-ELECTRICALPLUMBING-MECHANICAL
A MATE—
A
L � Z� �h
o (/
c.t�ntrat.ra Name: _ p u..No:
_4Jl FfC.�D �h�~�'•\ I�L(�LUL/2s yBLSO L/
CATEGORY
CONTROL If
ARhitet/Engineer. Llc. No:
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
/Ufinn y
Address: /"/ V� 1S77aY C-SVYL
PERMITISSUANCE
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I herebyatfirm that lam Bcrosed under pnevisionsot Chapter9(commem.
ingwith Section7000)ot Dlvislon3ofthe Busine dProfesslonsC°d dmy
license la in fulland effect.
Loco Class U Le X - L -I L rU Li
APPLIANCES-RESIDEMTAL
JOB DESCRIPTION
).T
PANELS
Gate_ Contractor
201-]000 AMT'S
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records
OVER lO30 AMPS
SQ. FT. FLOOR AREA
$/SQ. FT.
SIGNS ELECTRICAL
Licensed Professe..I
OWNER -BUILDER DECLARATION
I hereby of lmi that lame xempt from the Contractors License Law for the
SPECIALCI2CIRT/MISC
TEMP.MEITBORPOLEIN
POWER DEVICES
following resson.(Section 703lmS Business and Professions Code: Any city or
county which requires a permit toconstct, alter, Improve, dernolish,or repair
m
nystrocture priort.Its tsaance,aisorequiresthe applicant for such permit to
file a signed statement that M Is licensed pursuant to the provtsiom of the
Contractor's License Law (Chapter 9(commencing with Section 7000) of Divi-
Sion 3O(the Business and Professions Code).,that he is exempt therefrom and
the basis for the alleged exemption. Any violation of Section 7031.5 by any
appllant fora permit subjects theappllcant to a civil pemlty of not more than
five hundred dollars ($500).
❑ 1, as owner of the property, or my employees with wages as their sole
SWIMMING E.E
VALUATION �•
D
OUTLETS -SWIM FS
NE ESID EL .I L
STO
TYPE CONSTRUCTION
compensation, will do the work and the structure isnot intended or offered for
sale (Sec. 7044, Business and Produes mit Code The Contractor. Lt.. law
does not apply to an owner of property who builds or Improves thereon, and
who does such work himself or through his own employee, provided that such
Improvements are not Intended oroffered for sale. I(howceegthelnuic USor
improvement issold wlthinoneyearofcompldti theowner-buMerwill have
TOTAL:
OCC.GROUP
RFS. UNITS
th*Oden of proving that he did net build or improve for purpose ofsale.).
Lj 4 as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7W4, Business and Professions Code:
QTy, PLUMBING PERMIT FEE
pp(MIT LSSIIANCE
ELOOD 7pN
nPN
The Commdoes License Law doe net apply to an owner of property, who
Wild. or improves thereon, and who contract. for such piojets with a
�`gLtjacuria)licensed pursuant to the Contractor'. License Law.
LJ I am exempt under Sec B h P C for this RasonOUTSIDE
ALTER -DRAIN & VENT. WATFA ffN
B=FEEROTFGT.DENCE
FEE SUMMARY
FEES
Owner DaeRECEIPT
DR, ROOF, AREA, GOND.
FTRAP
SANTEARY Y N
X
WORKMAN COMPENSATION DECLARATION❑I hereby affirm that I have a certificate of consent to self -Insure, or a
SCI IDOL TAX YRECEIPT X
GFM-t INC.40UlLETS
PARK FFE YNGM-OVER4(EA)
Certified ropy is filed with the city Inspection division.
GSTRL WASTE INTERCEPTOR
BUI LDING DI VI SION FEES
PLANCHECK FEE
GREASETRAP
CERTIFICATE OF EXEM PTION FROM WORKERS'
COMPENSATION INSURANCE
(Thlssectionneed not becompleted lithe permit isforomehundred dollars
PAID
Date Rewi t#
SEWER -SANITARY -STORM EA. 200FT,
($100)orlcssJ
Icenete employ an person In tmanner so a, tobeco perrnitbito therd,
1 shall not employ any person In any manner m u to become subject to the
Workers Compensation laws of California. Date
Applicant
NOTICE
NOTIC APPLICANT: If, after
Ipro
WATER HEATER W/VF /ELECTR
ENERGYFEE Y N —
PAID
Date RTA t#
WATER SYSTW/TREATING
NEW RESIDENTIAL IPLMB. SQ,FT.
ca Workers' icoExemption, oftheyou
Compensation provisions of the Labor
sowed YOU
subject to the Workers' suchprovisions
most
deemed o1mdL forthwith comply with such pr.vblom.,toll permit shall be
dMIMd RV°ked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there Is a rom uction lending agency for the perform
ance of the work for which this permit Is fsysedec
(S. 3097, Civ. C.)
Landm'c N.me
Lender'. Add.
I cedilythat l have read thLsappBcatto.. ed state thatthe.tWer lnf.rnutlon
TOTAL:
BUILDING
00
TOTAL:
SEISMIC FEE
ELECTRIC FEE
e
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
MECHANICALFEE
-PAID,
lacorect. Iagree to comply with all city and county ordinances and tate laws
relating to building co"miction, and hereby authotlae Rpresentatives of this
city to enter u Pon the AWvnmentloned property for Impection purposes.
(We) agree to save, Indemnify an it keep harmless the City of Cupertino
aga Ova liabilities, judgments,costsand expenses which may In any way accrue
against said City in consequence of the granting of this permit.
PERMIT ISSUANCE
FEE
ALTERORADDTOMECH.
AIR HANDLING UNIT (TO 10,000 CFM)
Date Receipt#
SUBTOTAL•
s
MR HANDLING UNTE(OVER 10,000 CFM)
CONSTRUCTION TAX
Sig®tum of Applicant/Contractor Date
HAZA R DOUS MATER IALS DISCLOSURE
EXHAUSTHOOD(W/DUCT)
CONSTRUCTION TAXPAID:
HEATING UNIT (TO I W,000 BM)
_
Will the appllca nt orfutum building occupant store or ha od le hazardous
materia l as defined by the Cupertlno Mu Ndp.1 Code, Chapter 9.12 and the
Dale RCCeI t#
Ilealth and Safety Code Section 25532(a)P
❑ Ye Na
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
Will the applicant or ture building Occupant use equipment.,devices
which emit havrdous air contaminants as defined by the Bay Area Air
Qu a lily Management Dist rict7
4 Ye
VENTILATION FAN (SINGLE RESID)
ISS EDATE
��
BOILER -COMP (31 IP OR 100,000 BTU)
QNo
havereaathebva us mater,&di..l SDSbunde,Cbapter.I of
the Calilomu Health h5afety Coda Setons 25505, 25533 and 25534.1
I11', 2 q C'
JV P 1J9U
BOILER-COMP(OVER I00,ON BTU)
NEW RESIDENTIAL MECH. SQ.FFr.
understand that lithe building does not curmntly have a tenant, that it is my
resp.OseihiiIlytorwilifythe q ant of the mqubements which most be met
Pit oissu nu of rt fiats of Occupancy.
city, dcup-t p
rauthoriud .gen D
TSS UED BY..
TOTAL:
OFFICE COPY
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APPROVED
ACCORDANCE WITH THE CITY OI
ERTINO CODES AND ORDINANCES ,...
OATE_�ZZ� D
SIGNED CCmust conform with UBC 25 UBC 2517d4. Trimmer
This set of pans ani rc.thretn U oists shall be doubled whhen the span of header
be kept on the job aexc�tenesda� � ut2 The ends of header p
lawful to make any :Un PoOf alt�e+Iaf{,Ons joists more than 6 shall be
on same without wancpemssfofi lion Joist hangers.
the bui ding Dept, C t&of 1C1 pehipo. be 2 ' x 3 ' J.C. Barry The stamp.ngof ihs m� �p,ggc ll?ns y double dome vented.
iHALL NOT be he a .' e 4,, [� ApBroved (#42,57)
ipproval of the w,ia30 n, provisions -�
>nv C o d n,n r •3aT? ..+ Address and Phone
Joe Slakosky �\
21549 Edward Way 1441 lu)1990
Cupertino, CA 95014 JUN 2�,
408 973-1196
BLDG. INSPECTION DEPARTMERT1
CITY- OF, CUPERTINQ
DIFFENDERFER BUILDERS, INC,
• 1484 MISTAYA CT.
SUNNYVALE, CA 94087
copy