23090APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
—Building Project Identification
Build mg Addms:
5 I
PERMIT NO.
23090 O n O
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sera rte: A `IA—Ie lY Phone.
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CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BUILDINGELFCTRICAGPLUMBING-MECHANICAL
A A
^1
L•� 1
Contractor's Name:, Q secs N.:
CATEGORY
CONTROL 8
Archltea/Engineer. Lk. No:
QTY ELECTRICPERMIT FEE
BUILDING4PERMIT INFO
Address:
PERMITISSUANCE
*/r
El ❑ E]
LICENSED CONTRACTOR'S DECLARATION
I herebylicensedunder provisions of Chapter9c-
mgwlih&cdon7")ofDivislon3afthc BuaneesandPro(eeslonsC.de,and ray
license Is In file fob and kills..
UanseGla® O N2.2 3s-
Date Contractor
ARCHITECPS DECLARATION
I understand my plans shall be used as public rerorcls.
Licensed Pt.fesaforul
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Taw for the
following reason. (Section 7MIS, Business and Professions Code: Any city or
countywhich requires a permit tomwtmn, alteq impmve, de=lish,or mpalr
anystructure pdorto Its Issuance, also requlresthe applicant for such permit to
file a signed statement that he is ecensed Punuant to the provisions of the
Contractor'sLicense law(Chat Fur 9 (commencing with Section 9000) of Divi-
sen 3 of the Business and Profestlons Code).,the, he is exempt therefrom arad
the Wan for the alleged exemption. Any violation .f natty o 701.5 by any
five hand fora permit subjects the applicant to a civil penalty of race marc than
five hundred dollars ($SW).
❑ I, as owner of the Property, or my employees with wages as their sok
compensation, will do the work, and the structure is not Intended or offered for
sale (Sec. 7044, Business and Prefessl.ns Code: The Contractor's License Law
docs not apply to an owner of property who builds or Improves thereon and
who does such work himself or through hisown employees, provided that such
Improvements are not intended oroffered forsale. IL however, thebuilding or
Improvement bsold wilhln one yearof completion, the owner-bullderwlll have
t"eden of proving that he did not hued or improve for purpose of sale.).
"L as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 704, Business and Professore Code:
The Contractor's License law dues not apply to an owner of property who
Wilds or Improves thereon, and who contracts for such pp.jects with a
nactor(s) licensed pursuant to the Contractor's License Law.
E5BACK
1 am exempt under See. B & P C for this reason
APPLIANCES-RESIDENTIAL
)OB DESCRIPTION
�` , - • tea` r
M>♦JcJ j�a
PANELS
201-IODOAMN
OVER 1000 AMPS
SQ.FT.FIOORARFA
S/SQ.FT.
SIGNS ELECTRICAL
SPECLILCIRCUIT/MISC
Tps{P.METFR OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
VALUA7IOIj
1 I OO CPO
L
OUTLETSSWITCHES-FIXTURES
NEW RESIDENUAL ELECTR SQ.FT.
STORIES
OCC. CROUP
TYPE CONSTRUCTION
RIS.UNUS
TOTAL:
QTY. PLUMBING PERMIT FEE
PERMITISSUANCE
ALTER -DRAIN &VENT- WATER (EA)
1.TOp wNNE
ppN
FLOW PROTECT. DEWCE
FEE SUMMARY
Owner Date
WORKMAN COMPENSATION DECLARATION
01 hereby affimn that I have a certificate of consent to self -insure, or a
cenifiate of Workem' Compensation Iwuranmora certified copy thereof LSec.
MM, lab C.)
Policy Y
DRAINS FLOOR ROOF, AREA, GOND.
SANITARY Y_ N_
RECEIPT N
SC 1001, TAX Y N
RECEIPT M
FIXTURES.PERTRAP
GAS EA. SYSTEM -1 INCA OUTLETS
PARK FEE Y N
RECEIPT N
Com any
�CertlBed copy b hereby fumished.
Certified copy bfiled with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need ect W completed if the permit is for one hundred dollars
(SI0)rtifyt ain
I cent that employ any Person I an thework an as to b co eesubjecrmer is Issued
I shall not employ any Person In any manner m as to become subject to the
Workers Compensation Lawn olCall(ornla. Date
Applicant
NOTICETO APPLICANT. It, site, makingthb CenRloteof Exam ption,youNEW
should become subject to the WorkersCompensation provisions of the Labor
Code, you must forthwith comply with such prevbloro or this permit shall he
deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affimnthe there ei a conatmction lending agency for the perform-
ance of the work for which this permit b towed (Sec. 3097, Clv. C.)
Lender'. Name
Lender'sAddross
locAlfythatl have read thbappllation and staterhattheaboveml.rrtutwo
is correct. l agree to complywith alldtyand county ordleancesand state laws
relatingtoWllding eoeatroaion, and hereby authorize representative of thiocity to enter u Pon the above-mentsored property foe Wpeaion purposes.
(We) agree to save,Indemnify an d keep harmless theCityofCupenlno
against liabilities, lodgment., cous.edexpen whichmaymitrywayaccrue
against. City In co equenoa egr of this permit.
1, 1.1�
Sigwtureo(Appllant/Contras ` fr Date
HAZA TERIALS DISCLOSURE
Willtheappllant fuse building occupant store or handle hazardous
ennerlalaa defined by the Cupertino Municipal Code, Chapter 9.IZ and the
Ple❑alt Ycnd Safety Cole, SctlYloon 2S532(a)i
Will the applicant or future building occupant use equipment or devices
which emit hazardous air contaminants as defined by the Bay Area Air(alit. Mawgement D�'striNo7
read the haxa ousmaterials requirements under Chapter 6.95 of
California Health&Safety Code, Sections 75505,]5533 and 25534. Tunderstand that if the building does not currently have a tenant, that it is my
responsibility to notify the occupant of the requirements which most be met
priortoIssuanceofaCenifiateofOccupancy.
S
GAFA. SYSTEM.OVER 4(EA)
GREASE/INDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
PLANCHECC FEE
PAID
Date Receipt#
GREASETRAP
SEWER-SANITARY-SPORM EA. 2(X)FT.
WATER HEATER W/VENT/ELECTR
ENERGYFEE Y N _
PAID
Date Recei t#
WAT[R SY5ITM/TRGT[NO
RFSIDENIIAL PCMB. SQFT.
TOTAL:
EE
TOTAL
E
QTY. MECHANICAL PERMIT FEE
PERMIT ISSUANCE
ALTERORADDTOMECH.
AIR HANDLING UNI LTO lo,000 CFM)
FEE
RFEESPAID:
AL FEE
Receipt#
SUBTOTAL:
AIR HANDLING UNIT(OVEt H%"CFM)
EXHAUST HOOD(W/DUCT)
=RUCTIONPAID:
HEATING UNIT (TO 10,000 BTU)
ei t#
HEATING UE
000 BTL'TA
VENTILATIE RESID)
ISSUANCE DATE
i yes
tri `Fa4-ty'�
ISSUED BY:
BOILER-CO,000 BTU)h.vc
BOILER-COBT U)the
NEW RESIDSQFr
Owner m authoriad agent Date
TOTAL:
OFFICE COPY