22025APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
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Building Project IdentificationO
Bullding Address: Y�O L 3 0 W g I �• -
666E7 7014 -NJ oA, Lu 6aTT--VD 0 3 " R,,,
MOOT NO.
- 22025
rs ams:- one:
FAT_,"n YLI 4 Fik.L �
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BUILDING.ELECTRICALPLUMBINGMECHAMCAL
A
Contractor's Name: - - - Lk. No:,
CATH -GORY
CONTII&
lO
Architect/Engineer. Lie. Na:
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Addrcas:
PERMITISSUANCE-
LICENSED CONTRACTOR'SunderDECn, ofCh ON
Ihereby Sedi..700hatleml:erne6ftheB simmalana ofChapter
Ingwith Sedlon7(IOfI)o(DlWelon3ofthe BusinessandProtc eloneCod e,and my
license le In (u o rad d(ect.
Wcense Clam�Lica % -
ate //_Cv_Contncmr
ARCHITECTS DEC R
I understand my plans shall W used u pu i
Licensed Professional - -,
OWNER -BUILDER DECLARATION'
I hereby affirm that lam exempt from the Contractor's License Law for the
following mason.(Seddon 7031.5, Business and Professions Code: Any dry or
counlywMchrequbesapamnutomvtract,aeter,lmprove,demolhh,ormpalr
anystmu mpr rtolhhwamc abomquirntheapp8anifonuch permltto
dile a signed statement that he is licensed pursuant to the provisions Of the
Contractofs License Law (Chapter 9(ammencing with Section 7000) of Divi-
slon3 Of the Business and Professions Code) orthat he b exempt themfmmand
the bash for the alleged exemption. Any violation of Section 7ML5 by any
applicant for a permit subjects the applicant to a civil penalty of not more than
five [.undrcd dollare ($500).
u I, as owner of the property, or my employees with wages cue their sole
compensation, wllldothe work, and thestmomm Is not Intended or offeredfor
.In (Sec. 7004, Basins and Profession Code: The Contractor. Llanse Law
does not apply to an owner of property who builds Or Improves thereon,and
doessuch work himself orthrough his own employees, provided that such
Improvements are not intended oroffered forcale. If, bowevcq [he W ilding or
Improver ntbsofdwithlnoneyearofwmpletioMtheawner-bunderwlllhave
t)�uden of proving that he did not build or Improve for purpoac ofsa[AJ.
Lf L as owner of the property, am exclusively contracting with licensed
rontncton to conimct ec the project (S 7041, Business and Profession, Code:
The Contractor's License Law does net apply to an owner of property who
Wilds or Improve, thereon, and who contracts for such pku)em with a
�gR(factorb)licenrM pursuant to the Contractor', License Law.
' Lf I am exempt under Sec - B k P C for this reason
APPLIANCES -RESIDENTIAL
•�� ]08 DFSCRQ'17_ _ON_ _
SQ. FL. FLOOR AREA
7S/SQg�PI'�
L•r�, -r P )v
(y -y}•t rr�•t�s,a 2�d7
oe, (� amu`
-
PANFJS r
II ��� �— E I N
bFT0 AWS
OVER00
OVER iOOkWPS..V OV I H
SIGNSELEC /4n
SI'ECALCOtCUIT/M1SC
TFMp MEfE[t ORPOLE INST.
POWERDEVICES .
SWIMMING POOL ELECTRIC
I.E
UISES
SWITCHFSFIXIL R`�
VALUATION,
� L^�
`�[L �/I,111�3 �Ci•
NEV RMi DFNTIAL ELECTR SQ.FT,
STOMES I TYPE CONSTRUCTION
i
aay•�
TOTAL: l W
QTY, PLUMBING PERMIT FEE
OCC.GROUP RFS UNITSwho
pp p ISSUANCE I^1 M
l 4 kms✓
FLOOD ZONE APN
ALTER -DRAIN A VENT- WATER (EN x{,i
a
-
BACK FLOW PROTECT. DEVICE
FEE SUMMARY
OUTSIDE
DRAINS FLOOR ROOF, AREA, COND,
-.
FIXTURES PER TRAP ..
� - •
SAMTARY Y N_
RECEIPT If '
Owner Date - -
WORKMAN COMPENSATION DECLARATION
❑I hereby affirm that I have • cert Hone of consent to kelt-Insure, or a
corlticate of Worken'Compersationlnuranaora certified copy thereof (Sec.
380, Lab C.)
I'dlcy a
SCI100I. TA% .Y • N
RECEIPT X
GAS -EA. I SYSTEMINC.40UTLIlTS
-
PARK FEE -Y N_
RECEIPT a -
GAS EA. SYSTEM -OVER 4 (EA)
Com any
BUILDING DIVISION FEES
ertl0ed copy h filed with the tlty inspection division.
2tertlBed copy h herebytume city
CERTIHCATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This l..on need not be completed if the permit hfor one hundred dellen
(f1I mKiless.)
Ea n the m waksor which this permit Is booed,
] ll Am that employ an person
I shake nm employ any perwa f any manner at u to beam¢ subject to the
Worken'Compenntlon Law, of CaBtornh, Date
rat
AppilcNOTICE
GREASE/WDUSTL, WASTE INTERCEPTOR
PLANCHECK FEE
PAID
Date Raced t#
GREASE TRAP
SEWER -SANITARY -STORM EA. 200FT.
WATER HEATER W/VENT/ELECTR
ENERGYFEE Y - N —
PAID
Date Recel t#
- WATER SYSTEM/TREATING
'NEW RESIDENTIAL PLMB, SQ,FT,
NOTICEco eoubJAPPLICANT: tohe orlm'Co [hissationlateo(ons oft the
aode,yo mus avbpcttO the ply wit'such pruasonpmvhiomrmit s Lab be
dcc you must forthwith comply with each provisions orthh permit shall be
deemedrevoked.
CONSTRUCTION LENDING AGENCY
Ihereby affirm that there is a wnstmcuon lending agency for the per(orr..
anceufthecoonkforwhkhthhper thbsued(Sec.3097,Civ.C.)
Lendcr'e NamO
I.endera Address -
I Amifythai l have read this applicathmand statethat theabove information
Iscored. I agreeto comply with an city and county ordlnanoaand state laws
Mating to building costmaton, and hereby authorise representatives of this
city to enter upon the above-awntloned property for impenlon pu rpoan.
(We) agree to save, Ind fy an d kap harmless the City of Cupertlw
agaWtliabilitin,judg ,.sand expense, whlchmsyln yw accrue
agalrs o ens o([he granting of this perm
-
.TOTAL:
U ICb
�t
r
SEISMIC FEE O
TOTAL. //.sy.�•��
ELECTRICFEE
QTY: MECHANICAL PERMIT' FEE
PLUMBING FEE
_
MECHANICAL FEE
r��•yt
PERMIT ISSUANCE JsL�a/
FEESHANT
Date Receipt#
ALTERORADDTOMECH. qv�d
AIR HANDLING UNI'T(TO 10,ODOCPM)
SUBTOTAL:
AIR HANDLING UNIT (OVER 10,000CrM)
CONSTRUCTION TAX
Signature A ant Contra - rte
HA2 RD0 ATERIALS DISCLOSURE
Will a pilcant or tutu Eding occupant store or handle hazardous
materia efined by the Cupertino Municipal Code, Chapter 9d$ and the
Health and'Safety Code Section 25532(A)?
❑ Yea No _
WlIt the applicant or(uNre building occupant use equliment or devices
which em8 hanrdous air contamlwnis as defined by the Bay Area Air
Quality Management District?
4Yes n No r
havereadthehazaid'ouamaterialsrequfir eAtaundcrChapler6.95of
the California health h Safety Code, Sections 25505,25533and 25534. 1
understand that if the building does not currently have a tenant, that it h my
responslbil lty to not By the occua
pant of requirernta which =At be met
prior to issuance of a Certificate of Occupancy.
EXHAUST HOOD (W/DUCT)
CONSTRUCTION TAX PAID:
Date ReceI t#
HEATING UNIT (TO 100,000 BTU) '
_
HEATING UNIT (OVER I W,000 BTU)
- .
TOTAL'
r�
VENDLATION PAN (SINGLE RESID) —1,
ISSUANCE DATE '
'
i
� � 7Y M�a
/y�},
•��aa5 ((
ISSUED
BOILER -COMP OTO' OR 100,0M BTU)
BOILER-COMP(OVER 100,000 BN) -
NEW RESIDENTIAL MECIi. SQ.FT
Owner or authoriud agent Date
TOTAL:
OFFICE COPY