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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Bell dln vru ed Identification
Build}ng Address:
108-73'W D2
PERMIT NO.
20472
one:
\ , IWLU li Oft y 5?C
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION it PERMIT
BUILDING-ELECTRICALPLUMBING-MFLFIAMCAL
A
c�
Contracto(s Nanne:� Lic. No:
..IL
CATEGORY
CONTROL N
Architect/Engineer. Lk. No:
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Addm,sa: pQj (�J Qzc AT Da, Ofile1
PE2MITISSUANCE a. U�
❑ �I ® ❑
'LY
LICENSED CONTRACTORS DECLARATION
Ihamby affirmthat l amlicamed under provisionsof Chapter9(commenc
Section 7000)of Divisloo3oftheeusinessand Pm(essionsCode, and my
Ilona Is in Judi force and affect.
License Class Lk. a
Date
Date Contractor
ARCHITECTS DECLARATION
I understand my plain shall be used as public records.
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affinntlut I am exempt fromthe Contractor's LicenseLaw for the
following x.ame.(Section 7031.5. Business and Professions Code: Any city or
cmnywhichrequhesapermittommtmd,sitep Improve,dem lB h,orrepair
anyatmdhHe prIerto its issuance,also requires theapplicent forauch permit to
Ole a signed statement that he is licensed pursuant to the provisiom of the
Contrador's License Low (Chapter 9 (commencing with Section 7000)of Divi-
sion 3 o(the Business and Profession, Code) or that he Is exempt therem
froand
the basis for the alleged exemption. Any violation of Section 7031S by any
applicant for. prmn t aubjaenthe applicant to a civil penalty of not mom, than
O c hundred dollars (5500).
owner of the pmpeny, or my employees with wages as their sole
c mpcnsatlon, wtlldothe work and thestmctureh not Intended or offend for
.Is (Sec 7040 Business and Profession Code: The Cmdractofa License Law
does not apply to an owner of property who Wilda or improves thereon, and
who does such work himselforthrough his own employees, provided that such
me
improvents arc not Intended craffered for sale. If,howevegthebuildingor
Improvement h sold within oreyearofcompldion, the owner-budderwili have
t�r rden of proving that he did not Wild or Improve for purpose of sakJ.
LJ L as owner of the property, am exclusively contracting with licensed
motradors to con,Vuct the project(Sce. 7044, Business sed Professions Code:
The Contoctor's License law docs not apply to an owner d property who
Wilds or improves Merron, and who contacts for such plojeds with a
cgft(actor licensed pursuant to the ContractLicense Law.
1_J I at a Crept note Sec. B & P C for this mason
Ownerci Data
WORKMAN COMP SATION DECLA TIO
(]I hereby eRirm that 1 have cem0ate of consent to self -insure, ora
certificate of Workera'Compen,ation Insurance ora certified copy thereof(Sec.
3800,Lab G)
Policy 9
( APPUANCFSRESIDENTIAL
JOB DESCRIPTIONirgwith
P r
Zjjb1
PANELS
UP TO 200AMPS
201-1000 AMPS
OVER 1000 AMPS
SQ. FT. FLOOR AREA
/SQ. FT.
SIGNS ELECTRICAL
SPECIALCIRCUIT/MLSC s
TEMP. METER OR POLE INST.
[{OWER DEVICES
VALUATION
OU7LETSSW[TCIiFSFlX'IVRFS {,'�'1
�
NEW AESIDEMTAL GLECTR --emsFT.
STORIES
TYPON
E CONSTRUCTI
I
t//
n f: TOTAL 0.V
QTY. PL BNa PER IT FTE
PERMIT ISSUAN E V D
g 'Z 0
�.� DRA & WATER (Efs)
OCC.GROUP
IS.
RUNITS
FLOODzONE
nPN
BACKFLOW OT' .DEVICE
FEE SUMMARYols
DRAINS FLOOR ROOF, AREA, COND.
SANITARY Y_ N_
RECEETM
F7XNRF5-PER TRAP a (,Q
SCIi00L TA%
RECEIPT N
' GAS Fn,. SYSTEM -I ACAOUTLETS \(,
PARK FEE Y N_
RECEIPT N
RECEPTVISION
Com any
ECertified copy is heed with the
Ej Certified ropy h filed with the city inspection division.
CERTIFICATE OF E(EMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thissectionneed not ccompleted ifthep,,net Lsforonehundred dollars
(fIN)orless.)
Illni(y thatoythe
I shall not employ any person in any manner m u to become subject to the
any domanceny hawcul,manner forwMoh Wapemdtbho the
Workers Compensation laws of California. Date
Applicant
NOTICE
If,NOTICETOMPLICAM:e ttermald ,s'Co pe sationkro is Exemption, you
should become subjectto the ply with such pmatbn provisions proute LaWr
Codgyou =at forthwith comply with such prowlon, or this permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there h a construction Iendlegagency for the perform
arm ofthe work for which this permit is tesued(sec. 3097, Civ. C.)
correct. I agree to comply with all city and county ordinance and state laws
relating mbuilding ron,tmction,and hemby authorize representatives ofthis
city to enter upon the above-mentioned property for inspMton purposes.
agree to save, Indemnify and keep harmless the City of Cupertino
1 habNOes, yedgmerts, cas and expenses which may in any wayaccrue
a W said City) on se uence of the granting of this permit.
GAS EA. SYSTEM-0VER4(FA)
GREASE/INDUSIRL WASTE INTERCEPTOR
BUILDING FF.GS
PLANCHECK FEE
PAID
Date Rewi t#
GRFASETRAP
SEWER -SANITARY -STORM EA. X)OFT.
WATER HEATER W/VENT/MECTR
ENERGY FEE Y N
PAID -
Date Reeei !#
,�s
WATER SYSIFM/TRGTfNG 6.00
NEW RESIDENTIAL PLMB. SQFT.
TOTAL:
BUILDING FEE
TOTAL: Zoe_VDLender°Name
Q'[Y. MECHANICAL PERMIT "E
PERMIT ISSUANCE
LTERORADDTOMECH.e)
HANDLING (SNIT 8010,000UBTOTAL:
, d dLender'sAddress
EEIcenitythatIluvercadthtsappliatlananddatetattheaWvein(omaaonve
MPAID:
Receipt#a
• L�
AIR DUNG UMT(OVER 10 CFM)
CONSTRUCTION TAX
Signs reo(Appllant/Con actor Cuts
HAL\R USMATERIALSDISCLOSURE
Will the applicant or future building occupant store or handle hazardous
material as deft red by the Cupertino Municipal Code, Chapter 9.1 2, and the
1❑alt yes Safety Code, Y
Section 2S532(a)7
Will the applicant or❑future building occupant use equipment or devices
which rout hasar,lous air contaminants as defined by the Bay Area Air
Quality Management Dishtd7BOILER-CO
,?ys No
haveread theh YUS materials requirements under Chapter6.95 of
Ia lialth & Sa(cty Code, Scctkua25505, 25533 and 25534. 1
the6mod
anthat i( thebuilding does not cermotly have a tenant, that it Is
to notify the occupant of the mquimmente which must beprianeed a Occupancy.
S u �
E%HAUS' IOOD(W/DUC
CONSTRUCTION TAX PAID:
HEATING (TOI BTU)
Date Rmej t#
HFATWGUMT( � 100000 BTU)
TOTAL:
.Qon
VENTILATION N CLE RFSID)
ISSUANCE DATE
'1k`
ISSUED BY: 1 A K0 \Av,
OHPORI 0DRTU)
BO LER- , P(OVFRIOO, TU)
FSIDENTIAL MECH. SQFTroy
Ow orierd agent to
TOTAL:
OFFICE COPY
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