20545•
R06
K O
�Z�
07s.�
Oy
° 0.u In
•
F— y
OC j
LU
CL
n
U_ O
LLh
OW
H m
2
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification
Building Address6
PER.WTNO.
20545
Phone:
=
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION 1 PERMIT
BUfLDING-E.FCTRICALPLUMBINGMECHAMCAL
A A
/ f7 CIO
CO U
Contract 's Name: LIc.No:
CATEGORY
CONTROL M
Architect/Engineer. Lic. No:
QTY ELECTRICPERMIT FEE
BUILD NG PERMIT INFO
Address:
❑ 11 ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirmthat l am licensed under provisions of Chapter9(cormnenc.
ingwith Section 7000)of Div.slon3ofthe Busimmand Profen msCode, and my
Class Laic. 9 ICU full force
license --
License Lie cc
Date Contractor
ARCHITECTS DECLARATION
I understand my plans shall W used as public reurds.
Limned Professional
OWNER -BUILDER DECLARATION
1 herebyaffirm that I am exempt from the Comradore License Law for the
following reason.(Smlon7MLs, Businessand Professions Code: Any city or
countywhichmryirnaper ttounstmd,alts,,Improve,demolish,orrepair
anystm=mptlortotts Lmuame,alsorequlrestheappUuntforsuchper tto
file a signed statement that he is licensed pursuant to the provisions of the
Contractor's License Law (Chapter 9(ummenciag with Section 7000) of eiDivi-
Divi-
sion 3 ofthe Bu ness and Professions Code) or that he is exempt therefrom and
the basis for the alleged exemption. Any violation of Section 70315 by any
applicant fora permit subjectsthe applicant madd re vil penalty ofnmothan
five hundred doiUrs(5,500).
MI, as owner of the property, or my employees with wages as their sole
c mpensaHoo,wW do the work and the structure Unce intended or offered (or
sale (Sec. 7046, Business and Professions Code: The Cmdo d0fs Limme Law
does not apply to an owner of property who Wilds or Improves therm.., and
whodoessuchworkMmself orthrough hisownemployen, provided that such
Improvementsare not Intended oroffered forsale. If,howevegthebulldingor
improvement Usold withinoneyxarofcompldlon,the owner-builderw.11 have
the�,ku�aen of proving that he did not build car Improve farpurpose of sale.).
�f-I, as owner of the property, am exclusively centrad.... with Hcensed
matmMm to mmtmd the pmjcd (Sec 70K Business and Profssbre Code:
The Contractor's License law does not apply to an owner of property who
W Ilds or Improves thereon, and who contracts for such ptgecta with a
C. cto U)Ikenxdpu htothe Co..tradofs LImma Law.
LJ 1 am ext p unE B A P C for this assn
APPLIANCESRESIDENTIAL
JOB DESCRIPTION
PANELS
201-1000 AMT'S
OVER 1000 AMPS
SQ. FT. FLOOR AREA
E/SQ. Ff.
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MLSC
gTMp METE.ORIOLE 1NSf.
POWER DEVICES 1
SWIMMING POOL ELECTRIC
VALUATION
/ / O ^ a
CT/ v
OUMETSSWI HlSFU(T'UR
NEW RESID LELECTR
STOWESTYrECONMUCTION
OCG GROUP
RES.UNUS
T A
QTY- PLUMB GPE IT E
PERMIT VAN
ALTER DRAIN k VENT WA
TER
,,TODD LANE
AI'N
'
BACK FLOW PROTECT. DEVICE
FEE SUMMARY
OUTSinp .I L.5
Owner !�. Data
1 ATIfSN DECLAR I
EDI hereby r that rave a certificate of consent to self-inwre, m aFIXTURES-
certincke.(Wor ri CompensaHonlmurance ora certl(kd copytheneof (Sec,
3800, Lab C.)
Policy #
DRAINS FLOOR ROOF, AREA, COND.
SANITARY Y_ N
RECEB'T#
PER TRAP
GAS E.A. SYSTEM -1 INCA OUTLETS
SCHOOL TAX Y N
RECEIPT#
PAIU FEE Y N
RFCEB'T #
Co any
CAS FA.SYSTEM-0VER4(EA)
BUILDING DIVISIONFEES
�Cetined copy is hereby NmUhed.
E3 Certified upy Is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORK ERS'
COMPENSATION INSURANCE
(Thissedion need not becompleted lithe permit taforonehundred dollars
(51I ochi less.)
I11am employ saperformanceofthework. astoobthiseemdt Is issued
I shall not employ any person f any manner m u to become subject to the
Workcn'Compensatlon laws of Gllfomla. Data
Applicant
_
GREASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE
PAID
Date RCcel t#
GREASE TRAP
SEWER -SANITARY -STORM EA. 200ET.
WATER
WATER HEATER W/VENT/E.ECTR
ENERGYFEE Y_ N_
PAID
Dale RCCCI t#
WATER SYSTEM/TREATING
shouldNoriETOAPPLjCt to mi maCompisaftionkmeo(Ex, ofthen,you
shouldbecome subjectto the ply with such rovisinprovelomofthe Labor
Code, you muse forthwith comply with such provisions orchis permit shall be
deemed nevok d.
CONSTRUCTION LENDING AGENCY
them isaermHumonlanding 07ncyforthe perform
Thereby work fffirnothator
ante ofthe work(car whichthis permit isissued (Sec. 3097, CIv.CJ
Lenlander's Name
Lender's Address
e mad comply is wappBcationandunty ordinances ndgamaa on
land. Ia agree to
mUtl.g.lagreetocmkmctioh,a.th dtyand uithmunlnancesand gate lam
relatingtobuildingco above-ion,and hereby rty ori nrepresentationofthiscity to enter upon the above-mentioned property foriwpedlon purpose.
agree to save, Indemnify an d keep harmless the City of Cupertino
against liabilities, judgments, cots and expenses which may In any way accrue
against mid City in consequence of the granting of this permit.
NEW RESIDENTIAL PLMB. SQ.FT,
TOTAL:
EE
3_OO
TOTAL:
EE
5
QTY. MECHANICAL PERMIT FEE
PERMIT ISSUANCE
ALTER OR ADD TO MECH.l(We)
AIR HANDLING UNIT ITO IQODO CFM)
EE
L FEE
MFEESPAID:
3,.] O
Receipt#
SUBTOTAL:
AIR HANDLING UNIT (OVER I BaDO CFM)
CONSTRUCTION TAX
Signatureof Applicant/Contractor Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.1 2, and the_
Iinithand Safdy Code dio..2S532(a)?
M Yea MN.
Will the appl.cam orfuture building occupant use equ ipmcnt or d evicts
which emit haaardous air untaMwnb as defined by the Bay Area Air
Qua lily Management District?
Yes No
have read the h=a�materials requirements under Chapter 6.95 of
the Ca Bfomla Health h Safety Code,SmU-na 25505,25.533 and 25534.1
understand that ifthe building don not currently have atewni, that It is my
res; madbiWyta 1 the occupant of the requvtments which must be met
p'r ruan Crnlfkateof Occupancy.
Owners tI Data
EXHAUST HOOD(W/DL'CO
CONSTRUCTION TAX PAID:
IiFATIKC UNIT (TO 100,000 B'Hn
Date RCCei t#
HEATING UMT(OVER 100,000 BTU)
L:
VENTILATION FAN( SINGLE RESID)
I$$UiCI ATB
"1 pp (�[7
JUIN ()(y 199
/s y,
�IQ�,1iUpe(gQQ
[,
BOILER-COMP(3HP OR 100,0(0 BTU)
BOILER-COMP(OVER100,000 BTU)
NEWRESIDENTIALMECH., SQ.I•T.
TOTAL: ISSUED
OFFICE COPY v