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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY R.C., %
Building Pm'ed Idera flcaUon
Building Address:
PFR.WT NO.
34A 4 �S 441'
21816
nera ane: one:
6 %f/
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION 1 PERMIT
BUILDINGELECTRICAGPLUMBINGMECHAMCAL
A
A A FE
ra's Name:
onndo LIc. N.
(:OL/S!P'�F7G/s�
CATEGORY
CONTROL If
Arch lte Engineer. IG fit-D46jAA &•Q Lk. No:
QTY ELECTRIC PERMIT FEE
BUILDING PER INFO
Address g(„� ,,3 r Sr
PERhITISSUANCE
l._J ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter 9 (comment,
lrgwIt11...h t fun7000)of d effect. o(the Buainevand Pro(esaioneCode, and my
license bit full t and effect
Llcens?rr,sCis Lk. a %% J
DateO 1 Contrador z4 S`)��L4�T7Si�UP
APPLIANCES-RESMENTIAL
PANELS
TO 2DO ANTS
JOB DESCRIPTION
,
201.1000AMPS
ARCHITECPS DECLARATION
I understand my plans shall be used as public records.
OVER 1000 AMPS
SQ. Fr. FLOOR AREA
S/SQ. Fr.
SIGNS ELECTRI IL
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby afBrrn that I am exempt from the Contractor's License law for the
SPFCIALCI2CUIT/MLSC
TEMP.MEfER OR IDLE INST.
following mason. (Section 7031.5, Business and Professions Code: Any city or
ceuntywhich requires a permit tocoretroct, alter, Improve, demolish,or repair
anystrudure priorto its Issuance, also requfreathe applicant for such permit to
file a signed statement that he b rons licensed pursuant to the pvisioof the
Contractors License law (Chapterl) (comnnncing with Section 7000) of Divi.sio
therefrom and
the basis bs for the exemption. Any Nidationthat f Section
exemption. Any violation of nation 70315 by any
the basis for the permit
applicant fora permit sufifl). he appncanttoa dWl penalty of nal more than
dollar
flue Lass owner thepr).
ML as owner of the property, or my employees with wage as their sok
POWER DEVICES (� �
gWI.4MINC POOL ELECTRIC
yALUATION
IpVTIt�/iT,�IV\I
I
OUTLEISSWITCHESHKIURES
NEW RESIDENTIAL ELECTR SQ.FT.
SIUMES
TYPECONSTRLCTION
compensation, do workand the s Intended o
Cdurcbnot iofferedfor
x,iidoe (Sec. 7W4, Business
Business Code: The License Law
to
does not apply roan owner of(prough who builds orlmprwnthereoRand
f property eves
apply or improves
who does such work himself his own employees,provided that such
OCC.CROUP -
RFS. UNITS
ed orough
improvements are not intended earof dfor sale. theo nvepthebuildingve
Improvement bsold withinoneyearofcwnpletion,theowner-bullderwlll have
t4LIfordenofproving, that he did not bund or improve for purpose cline.).
Lj L as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044 Business and Profewforu Code:lylw
TOTAL.
QTY, PLUMBING PERMIT FEE
PEWITISSUANCE
p)pOD7pNE
APN
The Contractors License Law does not apply to an owner d property who
Wilds or Improvn thereon, and who mnds ra(or such pds 4ojewith e
�g6t(acioR,)Ilarm posuantrothe Contractors License Law.
LJ I am exempt under Sec. B & P C for this reason
ALTER -DRAIN & VENT -WATER (EA)
BACK FLOW PROTECT. DEVICE
FEE SUMMARY
OwnerDRAINS
Date
FLOOR ROOF, AREA, COND.
_
FIJ(NRES PER TRAP'
SANITARY Y N
RECEIPT It
SCIi00L TAX V N_
WORKMAN COMPENSATION DECLARATION
Of hereby &!flan that I have a certificate of consent to self -Insures, ora
cedifioteo(Worker'Compemationlmuranceoraudifiedcopythe f6ec.RECEaTa
3R00,Iab C.)
Policy p
GAS EA. SYSTEM.1 INCA 0UTLFIS
PARK FEE Y N
RECEIPT X
Com any
nCertified copy is hereby Furnished.
Certified copyb filed with the city inspection division.
GAS EA. SYSTEM -OVER 4(EA)
_
GREASE/INDUSIRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
PLANCHECICFEE
GREASE TRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(fhb section need not be completed B the permit in for one hundred dollars
PAID
Date Recei t#
SEWER -SANITARY -STORM EA. 200F1'.
61N)orles,3
(certify that In the performance of me work forwhlN this permit is Issued,
I shall not emp oy any person In any manner so n ro bjed to the
Worker? Co tl nLaws of Ilfo .Date
Applicant rasa
NOTICE PLP ANEILa ermakingthis Cert cateo mpt n,
ah¢ald become subj set to the Worker' Compematlon pmvbiom of the Labor
Code, you most forthwith comply with such provisions orthb permit shall be
me
deed revoked.
WATER HEATER W/VENT/ELECTR
ENERGY FEE Y N —
PAID
Date Recei t#
WATER SYSTEM/TREATING
NEWRFSIDENTIALPI.MB. SQ}T,
TOTAL:
BUILDING FE
TOTAL:
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a comtrodion lending agency for the perform-
ance of the work for which this permit is Issued (Sec. 3097, Civ. C.)
SEISMIC FEE
ELECTRIC FEE
Lander', Name
Lender's Address a
1 certifythat I have read this appBratbmi at
naatethat 1heaWvelnforrvtion
Is roman. I qmc to comply with all city and county ordinances and state laws
relating to building corutrudfon, and hereby authorize representatives of this
city to enter upon the above-mentioned Property 'or Inspection purposes.
(We) agree to save, Indemnify an d keep harmless the City of Cupertino
agaleathabintks,judgments, maxand expenses which may manywayattrus
agaimt said City In conasquenn of the granting or this permit.
QTY, MECHANICAL PERMIT FEE
PLUMBING FEE
PERMUISSUANCE
ALTERORADDIOMECH.
AIR HANDLING UNIT lo,"CFM)
MECHANICAL FEE
FE SPAID.
-[v(J1f s—f/=ti (SLI
ate Receipt#
TAL:
SU!Rec
AIRHANDLING UNIT (OVER 10,000CFM)
CONSTRUCTION
Sigrutum of Applicant/Contractor Date
HAZARDOUS MATERIALS DISCLOSURE
E%HAUSTHOOD(W/DUCT)
CONSTRUCTION PA ID:
HEATING UNIT(TO 100,000 BTU)'
Will the applicant or future building occupant store or handle hazardous
material., defined by the Cupertino Municipal Code, Chapter 9.12, and the
Date t#
HEATING UMT(OVER 100,000 BTU)
TOTAL:
t
Health and Safety Codq$edion 25532(.)?
❑ Yea No
Will the applicant Aure building occup.M.nic equipment or devices
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management rid?
4Yes No
have read Health& s et mode, le requ 25505, 5533 an 25534.1 of
the California Hearth &Safety Code, Sections 25505, 25533 and 25534. I
VENTILATION FAN (SINGLE RESID)
1$SUAf��;l>q,.$E
U 6 7�,
i
BOILER -COMP QHP OR 100,IXq BTU)
BOILGR-COMP(OVIRIW,ON BTU)
understand that if the building does not cormntly have a tenant, that it is my
.possibility to notify the occupant of the requirements which must be met
prior to issuance or a Certificate of Occupancy.
NEW RESIDENTIAL MECH.SQFr.
.s�cVe aa.
tcl�i
Ownerorauthurizedagenl Date
"I. L:
ISSUED BY
OFFICE COPY