23334APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification
Budding Addrew: J
PER.MITNO.
23334
wnera r one:
Confiradoes Na c e:
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT���'
BUILDINGELECTRICAIPLUMBING-MECHANICAL
A
CATEGORY
CONTROL N
rchitect/Engineer. Lk. Na
QTY - ELECTRICPERMIT FEE
BUILDING PERMIT INFO
Address:
PERMIT ISSUANCE
❑ El El
CONTRACTOR'S DECLARATION
I hereby affirm that l arm licensed under provisions of Chapter 9(mmmenc
ingwlth Section 7DO0)of Divl1to0 ofthr B.al.esand PrafesslonsCode,and my
license islafull lorce Lic.dct.
License Claw Lich
Dale Contractor
ARCHITECPSDECLARATION
I understand my plans shill be used as public records.
Licensed Profesional _
OWNERBUILDER DECLARATION
I hereby affirm that I am e exempt from the Contractor's License law for the
following reawn.(Section 7miS,Buslvesand Pro(eslons Code: Any dtyor
muntywhichrequn apermittommtructalter,bmprove,de.lBh,orrepair
anystmc mpdortoi 3 sane,aiserequbeatheappli=tforsuchpermitto
file a signed statement that he 1s horned pursuant to the provisions of the
Contractors License Law (Chapter 9 (rommencing with Section 7000) of Divi-
slon 3 of the Business and Pmfesiors Code)orthat he is exempt therefrom and
the basis for the alleged exemption. Any violationof Section IRDS by any
applcantfor a permit subjects the applicant too civil penalty an
not exam than
fiv Bred dolla(¢500).
I, .......
s owner ofhe property, or my employees with wages as their sele
mpcnaatlo., wilId' othe work and thestrocture le not intended or offered for
sale (Sec.7034, Business and Profesiov Code: The Conhactor's License Law
does not apply to an owner of property who Wilds or improves therron, and
who doessuchwork h(mselforthrough hi -ow -employes, provided thatsuch
Improvements are not Intended proffered for sale. If, however, the W ilding or
Improvement is sold within aneyearofcompletion, the owner -Wilder will have
t e rdenofproving that he did not WOdorimproveforpurposeofsln.).
{ as owner of the pmperty, am exclusively contracting with licensed
contractors to consumer the project (Sec. 7044, Business and Profesions Code:
The Contractor's License Law does not apply to an owner of property who
Wilds or improves thereon, and who contracts for such pkajeats with a
contractor(s) licensed pursuant to the Contractor, License Law.
1:11 am exempt under See. B & P C for this reason
APPLIANCESRESIDENRAL
PANELS
JOB DESCRIIPIION
�s (]C�WQ
(� �(�E"/r FT �(—
201-IODO AMPS
OVER 1030 AMPS
SQ. FT. FLOOR AREA $/SQ. Fr.
D I
E R
^�
J
VAL A'DON
Q lei.
� VV
SIGNSELECTRICAL
SPECIALCIiCUIT/MISC
TEMP. METER OR POLE INSr.
POWER DEVICES
SWIMMING POOL ELECTR3C
OUTLEISSWITCHESFTXTURFS
NEWRESIDENTIALELECTR e•QFI.
STOW I5
TYPE CONSTRUCTION
OCC.GROUPRFS.UNTS
TOTAL:
Qiy. PLUMBING PERMIT FEE
PERMIT ISSUANCE
ALTER -DRAIN &VENT- WATER (EN
FI.O WNE
APN
BACKFLOW PROTECT. DEVICE
FEE SUMMARY
Owner Date
WORKMAN COMPENSATION DECLARATION
❑I hereby affirm that I have a cenificatc of ci n sem to self -Insure, or
certificate of Worker Compewatlon Insurance or a cenllied ropy Ihenn((Sec.
380E Lab C.)
Policy It
S
DRAINFLOOKROOF, AREA, COND.
FEES
SANITARY Y N�
RECEIPT N
FIXTURES PER TRAP
SCHOOL TAX YN_
RECEIPT N
GAS EA. SYSTEM -1 INCA OUTLETS -
PARK PEE Y N
RFGEI'T
Cam any
[jCenlRed copy Is hereby furnished.
❑ Certified copy is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(rhlsaettlonneet nut becomPleted RtW permit isforone hundreddollars
(5100) or los.)
I cenlfythat is the peeformanceofthe work forwhlch this peirmt is Issued,
I shall not employ any person In any manner w s to become subject to the
Worker%Compenwtionlawsof California. Date
Applicant
GAS EA. SYSTEM-OVER4 RIA))
GREASE/WDUSTRL WASTE INTERCEPTOR
N
BUILDINGDI DIVISION FEES
PLANCHECK FEE
PAID
Date Recei t#
GREASETRAP
SEWER-SAMTARY-STORM EA. 200FT.
WATER HEATER W/VENT/ELECTR
ENERGYFEE Y N —
PAID
Date Regi t#
WATER SYSTEM/TREATING
NOTICE TO APPLICANT :If, ,hermaksng this Cmlflcate of Exemption, you
should became subject to the Workers' Campematlon Provisions of the Labor
Code, you must forthwith comply with such provBions or this permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
I hre
eby aorkf that there i a construction lending agency for the perform
acre of the work far which this permit l9 Issued (Sec 3097, Clv. C.)
Lander, Name
1<naerreaaanda
Ils—Itagreetve ptywappucitiondcountyordinances a dmateltiw
reroingt building empty with allcityhembrothoriedinaemsand mate laws
relatingtgbuilding rohe abOve- on,and hereby property
or inspection
n pe do n urposolthis
tinyto W) agree
n d property less the Cityp f Cups.
to ave, Indemnify an
(We) agree ns, save, indemnify and keep enwhich the City of Cupertino'
against liabilities, y nb, sand expenses which may In any aya
against uld lty�l eof the granting of this permit.
NEW RESIDENTIAL PLMB.__SQFT.
TOTAL:
BUIL ING -E
TOTAL:
SEISMIC FEE
ELECTRIC FEE
QTY. MECHANICAL PERMIT F'EE
PERMRISSUANCE
ALTER OR ADD TO MECH.
PLUMBING FEE
MECHANICAL FEE
FEES PAID.
Date Receipt#
-
AIR HANDLING UNIT RO tO,000 CFM)
SUBTOTAL:
AIR HANDLING UNIT (OVER 1 Betio CFM)
CONSTRUCTION TAX
igm rep t D e
R OU MATERIALS DISCLOS RE
Will the k or fu uiiding occupant store or handle hazardous
material as !i by the Cupertino Municipal Code, Chapter 9.12, and the
tle❑alih and Safety Cade, Stiction 25532(,)7
Yes ❑ No
Willtheapplicant car(uturcbullding ocevpant use equipment or devices
which emit lurzrdous air contaminants as defined by the Bay Area Air
Quality . arsgement District?
4 Y.•s No
have read the Nazar us rtstedala requlmrrcnts under Chapter 6.95 of
the California Health & Safety Code, Sections 25505, 25533 and 25533. I
understand that l(thebulldingdces not mrmntly have atenanp that It /s my
responsibility no notify the occupant Of the esq mments which mut benrct
prior to issuance of a Certificate of Ompancy.
EXHAUST HOOD(W/DUCT)''
CONSTRUCTION TAX PAID:
HEATING UNIT (TO 100,W0 BTU)
Date Recel f#
HEATING UNIT (OVER 100000 BTU)
BTU
TOTAL.
VENTILATION FAN ISMGLE
,�va
!f$�I,IAAI('F DALE
� 7 , UU
a.�
�.` ! qn,a
/ JLJ"
city Ur �•�r
.Cr7IIFl/Yv
BOILER -COMP OHPOR 100,0M BTU)
BOILER COMP(OVFR 100000 BTU)
NEW RESIDENTIAL MECH. SQFL
Ownerorauthorized a gent Date
TOTAL: ISSUEDBY:
OFFICE COPY