20262APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification
Bulldog Addres/
PERMITNO.
^
tress
0
G G G
waro a one:
654
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
UA
A A A
-9-
c°ntractor'aName: Q r Lie.No:
Y
CATEGORY
CONTROLN
Amh4m/En 2 3-c23c�9 Lit. No:
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INF
C
Address: p„t,
pERMITISSUANCE
❑
LICENSED CONTR CTOR'SDECLARATION
I hereby affire that l amllcrosed under provWonsof Chapter9(con.c
ingwlth Section 7000)of Dlvlsion3ofthe Buslne isand Prole,emesCode, and my
Itcense b In full fo and affect.
License Class Lic.p
APPUANCESRESIDENTIAL
JOBDESCRflMON
PANELS
Date Conlactar
ARCHITECPS
I understand my ptsns a used pern s.
/
/3%/)'a /
201-1000A.MPS -
OVER 1000 AMPS
SQ. FI. FLOOR AREA
$ SQ.
SIGNSELECTRICAL
Licensed Profealovl
OWNER -BUILDER DECLARATION
I herebyaffirm that I am exempt from the Contractor's License Law for the
following eastern. (Section 7011.5, Business and Professions Code: Any city or
county which requmesa permittocorstact, alter, improve, demolish, oreepair
anystmdurepriortoitsbeaance,ahorequimstheapplluntforauchperMtto
file a signed statement that he Is Bcensed pursuant to the provisions of the
Contractor's License Law (Chapmr 9 (commencing with Section 7000)of Divi—
Mona of the Business and Professions Code) or that he b exempt therefrom and
the barb for the alleged exemption. Any Violation of Section 70315 by any
applicant fora permit subjectathe applicant to a civil penalty of not more than
five hundred dollars (SSW).
❑ 1, as owner of the property, or my employees with wages as their sole
compensatlorywillciothe week, and the structure b not intended or offend for
'
SPECIAL CIRCNT/MLSC
7g{p.MEI'ER ORI'O1.E INST.
POWERDEVICES
VALUATION
nC/� �•
C
OUTLETS -SWITCHES -FIXTURES
♦
NEW RESIDENTIAL ELFCTR SQ.FT.
TORIESTTE
CONSML•CTION
sale (Sec 7094, Business and Professiare Code: The Contractors Lim. law
does not apply to an owner of property who Wllds or improves Ihereory and
who does such work himself or through his own employees, provided that suchOCC.GROUP
improvements am not intende i c roffBred forsale. If, however, the building or
Improvement issold withinoneyearofcompleiorytheowner-builderw8l have
thf,jia rdenofpeoving that he did not build or improve forpurposeofsale.).
"L as owner of the property, am exclusively contracting with licensed
rontractors to mnsHuct the project (Sec. 70K Business and Profusions Code:
The Contractor's License Law does not apply m m owner of property who
Wild. or improves ehereory and who contracts fon such plojecta with a
ctt actor(s) licensed pursuant to the Contractors License Law.
LJ I am exempt under Su. B A, P C for this mso
an
AES. UNITS
TOTAL:
QTY. PLUMBING PERMITFEE
PEtMH15SUANCE nye
� lJJ
gygm-DRAIN A VENT -WATER (EAa
Q s
FLOG ZONE APN
FEE SUMMARY
QI1Tq1 11F EEL
BACK FLOW PROTECT. DEVICE
Owner Dace
WORKMAN COMPENSATION DECLARATION
01 hereby affirm that I have a urtifiute of consent to self -insure, or a
certificate of Workers'Compens mon Insurance ora certified ropy thereof (Sec.
3800, Lab C.)
Policy Y
DRAINS FLOOR, ROOF, AREA, GOND.
5
SANITARY Y N_
RECEIPT Y
L FDnURE`-PER TRAP L' (ySCHOOL
TAX Y N_
RECEIPT M
GAS EA. SYSTEM -1 INCA OUTLETS
PARK FEE Y N
RECEIPT Y
#BION
Com any
GAS EA. SYSTEM -OVER 4 (EA)
BUILDINGCEIPT
FEES
❑Certified copy b heed with the ed.city
❑CertUied copy b filed with the city inspection division.
GRFASE/INDUSIEL WASTE INTERCEPTOR
PLANCHECKFEE
CERTIFICATE OFEXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thiaseetionneed not becimpleted lithe permit bforone hundred dollars
($I W)or less.)
GREASE TRAP
PAIDCp
Date RCOCI (#
SEWER -SANITARY -STORM EA 2a(FT.
WATER HEATER W/VENT/ELFCTR
ENERGY FEE Y_ N—
I certify that in the performance of the work for which this permit is issued,
I shall not employ any person in any manner so 'o the
Worken'CS
f�ka,
PAID
WATI7SYSITM/TREATING
NEW RESIDENTIAL PLMB. SQ}T,
•�
._
NOTICE TO MPLICANT:It, after making this Certifeate of Exemption, you
should bcmmesubjccttothe Wmken'Compmxxjjn provbionsofthe Labor
Cede,you mustforthwithmmpiywithauchprovlsiomorthisper tshallbe
deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there b a construction lending agency for the perform-
ante of the work for which this permit is issued (Sec. 3097, Civ. C.)
Lender's Name
Lender's Aaareaa
I certify thatl have read thisappButionand statethattheabove information
b cornet. l agree to comply with all city and county ordinances and state laws
relating to building mnstactlon, and hereby authorize representatives of this
city to enter upon the above-mentioned property for inspection purposes.
(We) agree to save, Indemnify an d keep harmless the City of Cupertino
against liabilities, judgment, m is an expenses which may In any wayaccme
agairestsald Ci In rons of a granting of this permit.
Date Retti t#
TOTAL:
BUILDING •E
TOTAL:
`
SEISMIC FEE
ELECTRIC FEE
QT'y. MECHANICAL PERMIT FEE
PERMIT ISSUANCE
ALTERORADDTOMECH.
AIR HANDLING UNIT (TO 10,000 CFM)
PLUMBING FEE
MECHANICAL FEE
FEES PAID:
Date Receipt#
SUBTOTAL•
AR HANDLING UNIT (OVER I0,IYXI CFM)
CONSTRUCTION TAX
®S
fSTFafum.i rat/Q nt t Dat
S MATERIALS DISCLOSURE
nithe appBunt orrcbuildingoavpantstoreorhandlehazardous
material as defined by the Cupertino Municipal Code, Chapter 9.12 and the
ilealth and SafetyCode icon 25532(a)7
❑Yeso
Wil emit the applicant or(umrcbuilding occupant use equipment ordevices
whkheMthazardoua air root minants as defined by the Bay Arca Air
Quality Management Dish
4 Yn No
EX I US'F HOOD (W/DUCT)
CONSTRUCTION TAX PAID:
Date RCCCI t#
HEATING UNIT HO 100,000 BTU)
HEATING UNIT'OVER"10,000 BTU)
'OVER "1"'0"
TOTAL:
VENTILATION RESID)
ISSUANCE DATE
BOILER -COMP OHP OR 100,0(0 BTU)
BOILER -COMP 100,000 BTU)
have read the has. ousmaterialsrcquimm ntsundcr Chapter6.95ef
the California Health & Safety Code, Sections 25505, 25533 and 25539. I
understancithatifthc building does not currently have a tenant, that it bray
requlmments which must be met
r¢ponsibllliy to notify theW-—.29
prior to issuance ofd inry.
N'EW RESIDENTIALMECH. SQ,FT,
/ - �q/
,49
nein razedDate
�
�
TOTAL: ISSUED
if
OFFICE COPY
ell
can
BE
i
IviAY U J 1,,
P�
ULDG. INSPECITY OCTION DE T
INQMER
,
l._ q 41' �F]. .
APPROVED
_�— IN ACCORDANCE WITH THE CITY OF
r
_ . " . CUPERTINO CODES AND ORDINANCES'
DATE
2X12 36 4_z�-..SIGNED�� [ t
i This set of paVLS
ns andons t
/ / be kept on the job at a,l t-mas and it s unT
/OZG G �c 1 ;���/ / c .bei i��.C�, E�— lawful to ma!;e ny caa1 P ,
on same W;Ih.;u, R.s or alterations
w fucn permission from
�. the buiidin: u; CJ
%J,r si ^ :� o G .— /' .� �.�, .� o PL, C.h• t.( Pa t;no.
/ - The stamp;ag o .h :.
SHALL N01 b,, ,.e ,l "' n na-pecilications
` nt, be an
n
approval of the v
'It any C14 d;uo. cin r, visi,.n-
0FRE COPY