19631APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
1.01=01:90iol j
PERMIT NO.
19631
er. teams: Phone:
CATEGORY
CONTROL#
2vw
8 e
CITY OF CUPERTINO-BUILDING DIVISION
G°^t d° Na Y7: tic. No:
EBUILDINGELECTRTCALPLUMBINGMECHAMCAL
.
APPLICATION / PERMIT
A ItM/Engineer. Lk No:
QTY ELECTRIC PERMIT FEE
TYI'ECONSIRUCTION
OCC.GROUP
RES. UMTS
FLCODZONE
Address:
PERMITISSLANCE
LICENSED CONTRACTOR'S DECLARATION
SCHOOL TAX Y_ N
RECEIPT N
PARK FEE Y_ N
RECEIT N
I hereby affirm that l am licensed under provisions of Chapter 9(commenc-
APPUANCESRESIDENfIAL
Ing with Section 7(X0)of Division 3 ofthe Business and PrefcasionsCods, and my
II«nae I. I. full fo dPANELS
TOTAL:
License � i. 6
BUILDING FEE
YT.
Date-��C°ntraRor QJy/aP/4.h/UP
TO 200 ANTS
701.1000 AMT'S
2
O
ARCHITECTS DECLARATION /
Iunderstand my plans shaghe used as public records
OVER1000AMPS
SIGNS ELECTRICAL
ZLicensed
Professional
Z
F4F'u9
�m .c
C r.
3 a L�,
O<
P •-t
�J<5
OWNER -BUILDER DECLARATION
I hercbyafftrm that l am exempt from the Contractor's License Law for the
fallowing reason. (Sevit. 7031.5, Business and Profession. Code: Any dtyor
county which require a permit tumnstrud, alter, im F
prove,demoilsh,orre air
anystmt mpdortoibtswame,aWrequirestheappliantforsuchpermitto
ilk a signed statement that he b licensed pursuant to the provisions of the
Contradorb License Law (Chapter 9 (commencing with Section 7000) of Divi-
slon3ofthe Business and Prosmkxrs Code) orthat heisescmpttherefmmand
the bests for the alleged exemption. Any violation of Section 7031.5 by any
applicant for a pertNt subjects the applicant to a civil penalty of not more than
SPECIAL CIRCUIT/MLSC
TEMP. METER OR POLE INST.
('OWER DEVICES
SWIMMING IDOL ELECTRIC
OUTLETSSWITCHESFlXTURES
NEW RESIDENTIAL ELECTRSQFT,
C'/Q
$ ❑
($$
0.
five hundred dollars
❑I as owner of the
, property, or my employes with wages a. their sole
compensation. wlRaothe work, and medrudumbnet imentied or offered for
sale(Sec.7044,Business and Professions Code: The Con md.e. License Law
does not apply to an owner of propertywho builds orimprove. thereon and
whodoessuchworkhm lforthmughhlsownemployer, pmvidedthatsuch
TOTAL:
137 rV
ISSU�ftATE
FEE 13 hSJ
City Of cgngrtjBm
ISSUEDBY:
improvements are not intended oroffered forsals. If, however,thebuilding or
improvement issold within oneycarofcompletl°n, the owner-bu tlderwlll have
TOTAL:
t rdenof proving that he did not build or improve for purpose ofsale.).
4 as owner of the property, am exclusively contracting with licensed
contractors to mmtmd the project (Sec. 7044, Business and Profmsbts Code:
QTY, PLUMBING PERMIT FEE
PERMIT ISSUANCE
The Contmdor'. License Law time not apply to an owner of property who
or improvm thereon, and who cordrad. for such projects with a
pLTpi-DRAIN & VENT WATER BIM
c78$pador(s) licensed pursuant to the Contractors License Law.
, I am exempt under Sec. B & P C for this reason
BACK FLOW PROTECT. DEVICE
DRAINS FLOOR ROOF, AREA, COND.
Owner Date
WORKMAN COMPENSATION DECLARATION
❑1 hereby af0um that I have certNste of consent to self -Instars, or
MTURES PER TRAP
o ytherea .
MOOL"HIficate bC') rkers'Compensatlonlnsurance oracertified copy thereof(Sec.
3B00,Iab C.)
Paltry Y
GAS EA. SYSTEM -1 INCAOITLETS
Com env L %�t Our Q"'3p
GAS EA. SYSTEM -OVER 4 (EA)
1
�Certiflc co� ledwcre thmohy.
�Certiflh copy b flied with the city inspection division.
GREASE/WDUSIRL WASTE INTERCEPTOR
CERTIFICATE OF EXEM PFION FROM WORK ER S'
GREASE TRAP
COMPENSATION INSURANCE
(Thissedionneed not bscomple A ifthepermit bforone hundred dollars
SEWER -SANITARY -STORM EA. 700FT.
C✓ Z
Q
W j
aO
(S100) or IcaJ
1 certify that o zhe any personIn a°f the work fors I.which this eestnit is both,
I shall not employ any person in any manner n s I. become subject to the
Workers Compensation Lawn of California. Date
Applicant
NOTICE TO APPLICANT.If, after ma king this Certiflote of Exemption,youshould become subject to the WorkersCompemat Ion provisions of the Labor
Code,you roust forthwith comply with such provisions or this permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirmthat there ls a corutruction lending agency for the perfmcn-TAL:O arses oftheworkfor which this permit b issuy(See. 3097, Civ. C.) ).ender. Name
WATER HEATER W/VENT/ELECTR
WATER SYSTEM/TRFATTNIO
M=-ALPWB..FT.Z
FEE
IL H
LendersAddreas
OW
} 4
H Z
1rertify thatt have read thlsapplica0onand statethetheaboveinformation
Lsmrrect. Iagreeto comply with all city ami county ordinances and state laws
relating to building c°mtrudlon, and hereby authorize representatives of this
city to enter upon the above-menti°ned property for inspection purposes.
(We) agree to save, indemnify an d keep harmless the City of Cu pert Lro
agaLstllabiW judgment --:M
as despenaeswhlch mayin anywayarcoe
agajagt.`id i incone hegranting o(thla Ptmrut
ALTERORADDTOMECH.
ATR HANDLING UNIT (TO 10,000 CFM)
A R HANDLING UNIT (OVER t0,000CFM)
1/ {/1
M
Slgmttrc of ApplC0 Date
HAZARDOUS MATERIALS DISCLOSURE
EXHAUST HOOD (W/DUCT)
BEATING UMT(TO 100,000 BTU)
Will the appUcant or rertino h,
by
material a. Safety by the Cupertino Municipal Code, Chapter 9.17, and the
Municipal Ceti, Chapter and
1 -(EATING UNIT (OVER 100,000 BTU)
Hslthand Safety Code Ion 75537(a)7
LIJ No
VENTILATION FAN (SINGLE RESID)
viccs
Wlllthe applicant or futurebtildinga.defi
which emitharardomalr cont ,vote as deBny by the Bay Area Alr
cdbythr B,y .a AI
BOILER -COMP OIiP DR 100,000870)
Yc. No
4uy Mawgerrcnt Dlstou
BOILER-COMP(OVER 100,000 BTU)
have read the baza s materials mqulrerrcnta undcrChapter 6.95 of
the Calffcrnia Health & Safety Code, Sections 75505, 75533 and 25534. I
NEW RESIDENTIAL MECH. SQ.FT.
understand that if the building does not currently have a tenant, that it is my
responsibility to notify the occupant of the requ Immenls which must be met
prior to osua oce of a Certificate of Occupancy.
Owner or authorized agent Date
1.01=01:90iol j
PERMIT NO.
19631
A A
CATEGORY
CONTROL#
BUILDING PERMIT INFO
JOB DESCRUMON
C�irnne �e
SQ. Fr. FLOOR AR
//SQ. F7.
VALUATION
l (Ooo 0
STORIES
TYI'ECONSIRUCTION
OCC.GROUP
RES. UMTS
FLCODZONE
APN
FEE SUMMARY
SANITARY Y N
RECEIPT 0
SCHOOL TAX Y_ N
RECEIPT N
PARK FEE Y_ N
RECEIT N
BUILDING DIVISION FEES
PLANCHECK FEE
PAID
Date Remi t#
ENERGY FEE Y— N
PAID
Date Remi of
TOTAL:
BUILDING FEE
YT.
SEISMIC FEE
ELECTRIC FEE
PLUMBING FEE
MECHANICAL FEE
FEES PAID:
Date Receiptfl
SUBTOTAL:
CONSTRUCTION TAX
CONSTRUCTION TAX PAID:
Date Reoei tN
TOTAL:
137 rV
ISSU�ftATE
FEE 13 hSJ
City Of cgngrtjBm
ISSUEDBY: