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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification
Building Address:ante
L>8 7a Ess hk is
PERMIT NO.
2 4 3 5 7
. hone:
nem. O .2573--a-7'71
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BUILDING-ELECTRICA4PLUMBING-MMLH MCAL
A A A
ci�n raart.? ante:Lk. No:
�1D SOl7/ 39x35
CATEGORY
CONTROL
Architect/Engineer. Lic. No,
QTY ELECTRICPERMIT FEE
PERMITISSUANCE
BUILDING PERMIT INFO
Addm,,:�o3� !�/aadard Rd ST g51zy
1� ❑ ❑ ElLICENSED
LiJ
CONTRACTOR'S DECLARATION
I hercby a(firmttat l am beeesed under provisions of Chapter9(rommare
'ngwith Section 7000)Of Dlvision3ofthe Busimmand Professioes Code, and my
license le In full( rce and effect
Lkm.0 ss _Lie.# t73
Date Contractor Oni's�
ARCHITECTS CLARATION 11
I understand my pbm shall be usN as public records.
Licensed Profeektoml
rcOWNER-HOLDER DECLARATION
[heby a!llrtmenthatlaxempt(romthe Contrsctors License Law fm the
county grcasequinmaper QU$Business and Professions Code:Acympair
countywhkh mquiresa permittommtmct, Ater, Improve, demroRsh, orrepalr
any structure prior to Its Issuance, also requires the applicant for such permit to
file a signed statement that he is Reensed pursuant to the provbiom of the
Contractor's License law (Chapter 9 (commencing with Section 7000) of Divi-
Am 3 o(the Buslnessand Professlme,Code) Orthat he is exempttherefromand
7QHS re any
the barb for the alleged exemption. Anyt tolacivi of penalty
appRuntfor apermit SM. the applicant toatlWl pemltydnut more than
live hundred dollar (5500).
Lasownerofthc ro y p y B
p party, or he em b es with ova esu them sole
compensation, (em. tion, will do work and the , Code:
b not intended or cense Law
sale (Sec. 7060, Business and Pro(esslom Code: The ContractoJe License Law
does not apply to an owner a property who builds or improves thereon, and
whodoessuchworkhi.l(orthroughhisownemploynes,provldedthatsuch
improvements arc not Intended proffered forsale. I(, however, thebullding er
improvement b sold within one year.!completion, the Owner-budderwill have
t Olen of proving that he did not bund or improve for purpose of sale.).
L as Owner of the property, am exclusively contracting with licensed
ronb actors to construct the project (Sec 7066, Business and Prefeskons Code:
The Contractors License Law dm not apply to an owner of property who
builds or Improves thereon, and who contracts fee such p(.jees with a
offgR1[actor(s) Bcenwd pursuant to the Contractor's License Law.
learn exempt under Sec. B k P C for this mason
APPLIANCES RESIDEN[IAL
J08 DPSCRIs770N
PANELS
UP TO 2DO ANTS
201-1000AMPS
OVER 1000 AMPS r
SQ. FT. rL R AREA
—ED IN
111
`JI'I R
Q a
.2- —7J
$M. FT.
SIGNS ELECTRICAL
SpECIALCIRCUIT/MLSC
TEMP METER OR POLE INST.
-T�
POWER DEVICES ,G
SWIMMING IDOL ELECTRIC
_
O(T LETSSWITCHI&FlXrURES -
VALUATION
/�DD' o�
NEW RESIDENTIAL ELECTR SQFr.
SI'ORIFS
TYPE CONSTRUCTION
OCC. GROf1P
RES. UNITS
TOTAL:
QTY, PLUMBING PERMIT FEE
PERMIT ISSUANCE
ALTER -DRAIN k VENT -WATER (ErU
FT.00DZDNE
ApN
BAIX PLOW PROTECT DEVICE
FEE SUMMARY
Owner DateDRAINS
WORKMAN
FLOOR ROOF, AREA, COND.
SANITARY Y_ N
RECEIPT
COMPENSATION DECLARATION
QI hereby affirm that I have a oertiRatc of consent to xel4msure, or a
cemifioteof Work m'CumNmatlonlm mncemacertlfk copythercof(Sec.
380D. Laab C.) _
#
��
FD(TUIR PER TRAP
GAS EA. SYsrEM.1 INCA OUTLETS
#
SCHOOLTAX Y N
RECEIPT#
PARK FEE Y_ NPolicy _
RECEIPT #
Com any e,had. s..-1 '�
CAS FA. SYSTEM -OVER 6 (FA)
BUILDING DIVISION FEES
�Ceniied ropy 6 hereby bhity
L�Getlified copybfiled with the city Impaction division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thissetlionnead not hecompleted lithe permit bforonehundred dollars
($1 W) or less.)
1c,difythat In theper(omanceo(theworkforwhichthis permitiseenad,
J shall not employ any person In any manner so as to become subject to the
Workms Compensation laws of California. Date
Applicant
NOTICETOAPPLICANT:If, after making t his Certiflute of Exemption, you
should become subject to the Workers' C.mp,.mArcn pmvbiomu of the Labor
Code, you must forthwith comply with such provibbas or this permit shall W
deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a mmmuction lending agency for the perform, nceof the work for which this permit b Issued (Sec. 3097, Civ. C.)
Lender's Name
Izn oarsfythADAddrag;
I certitylhatl have real[hbappRutbnand stmethattheabovelnImmattee
Lsmmtt. l agree to complywith all city and county ordina,mand state laws
relating to building romtroction, and hereby authorize representatives of thin
city to enter upon the Above-mentioned property for impaction purposes.
(We) agree to save, Indemnify an d keep harmless the City of no
against liabilities, judgments, mets and expenses which may in anywue
gAmt said City l con the granting o his permit.
/ALRHANDLINGUNTT(OVFR10,000CFM)
GREASE/INDUSIRL WASTE INTERCEPTOR
PLANCHECK FEE
PAID
Date Recci t#
GREASE TRAP
SEWER -SANITARY -STORM) EA. 200ET.
WATER BEATER W/VENT/ELECTR
ENERGY FEE Y_ N_
PAID
Date Recei t#
WATRRSYSTEM/TREATING
NEW RESIDENTIAL FILMS. SQFT,
TOTAL:
B IL I C ' E
is
TOTAL:
SEISMIC FEE
ELECTRIC FEE
QTY. MECHANICAL PERMIT FEE
PERMIT ISSUANCE
PLUMBING FEE
MECHANICAL FEE
FEES PAID:
ALTERORADDTOMECHU
AIR HANDLING UNIT (To 10,000 CFM)
Date Receipt#
SUBTOTAL:
CONSTRUCTION TAX
5lgmmreofA pliant/Co rot r at
HAZARDO MATERIAL UISCLOSU E
Will the applicant orfuham building occupant store or handle has
material as defined by the Cupertino Municipal Code, Chapter 9.12,
HeAth and SafetyCode SWI.n 25532()?
yes No
WIIl the applicant or future building occupant use equipment Or
whichemithaeardousairmataminants as dented by the Bay Area QuBOILER-COMP
mh,,terietions2re5,2553 aChapte
Calif.rnla Health&SafetyCoe, Setll.ns 7550.5,75533 and 2553understand that if the building does not correctly have a tenant, thay
resposibility to notify the occupant of the requirements which must
to Issuance of a Certificate ofOccepancy.
EXHAUST HOOD (W/DUCT)
CONSTRUCTIONTA X PAID:
HEATING UNIT(TOID its, BTU)
Date Recei t#
HEATING UNIT (OVER 100,0001 TIq
TO
VENDIATION FAN(SINCLI SEND)ISSUANCE
DATE
1QQ#�prior
i.Ownero.....orim
BY: _a( V a -
OHPOR 100,000 BTU)
BOILER-COMP(OVQt ]OO,000BN)the
NEW RESIDENTIAL MECH. SQ.FT
x8mitpate
TOTAL: ISSUED
OFFICE COPY