21923APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Project Identification
Ba -0G o L,v
PERMITNO.
21923
/2�re ame: one:
/' el2 a 61"61J
CITY OF CUPERT[NO BUILDING DIVISION
APPLICATION / PERMIT
BIALDINGQ.ECTRICAI.PLIIMBING-MECHAMCAL
A A
q
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Cees actm'sName: Lle. m
Z x-�t / T= 1 L
CATEGORY CON TROLX
Architect/Engineer. Lie No:
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Address: ',
PERMITISSUANCE
FIV ❑ - 1:1 El
(�y
CONTRACTOR'S DECLARATION
I Mreby affbm that lam license under provltlonsofC1uaptar9(commenc
Ingwlth Section 7000)of Dlvistmn3ofthe Businmand PmfeWm&Code, and my
license le In full force and died. -
License Clam Lie#
APPLLANCISRESIDENITAL
JOB DESCHR"DON
rn n
PANES
Date.Contractor -
701-1000 AMPS
ARCHITECTS DECLARATION
I undmtand my pla..b H be used es public reseed.
OVER 1000 AMPS
SQ. Fr. FLOOR AREA
$/SQ. ET.
SIGNS ELECTRICAL
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt tram the Contractor's Licensee Law for the
SPECIAL CEtCU1T/MISC
_
TFNP.METFRORI'OLE INST.
following reawn.(Sect1on 70315, Business a nd Profmlons Code: Any city or
ce intywhich requires a permit reconstruct alter, Improve, demolLsh,orrepalr
any structure prior to Its Issuance, also requires the applicant for such permit to
file a signed statement that he Is licensed pursuant to the provisions of the
Contractor's License Law (Chapter 9(comrametag with Section 7000) of Divi.
sloe 3ofthe Buainmand Profe.imus Cade) or that he is exempt therefrom and
the basis for the allege exemption.'Any violation of Section 70115 by any
appllcant fora permit subject. d the applicant to a civil penalty net more than
� -
Rv�e jmn. ownemd r of
Lf I, d owner of the property, or my employees with wages as their sole
POWER DEVICES' --
SWIMMING POOL ELECTRIC
OUILBTSSWITCHES FIXTURES
VALUATION
(x)v
NEW RESIDENTIAL ELECTR' SQ.FT.
STORIES -
TYPE CONS,RUCTION
compensation, wHl do the work and the structure is not Intended or offered for
sale (Sec 7044, Bueireas and Professions Code: The ContrictoY@ License Law
-
does eat apply to an owner of property who builds or improves thereon, and
who doessuchwork himself orthrough hlsoweemploym, provide that such
OCC.GROUIs
RES. UNITS
Improvements are not Intended proffered for sale, If, however, the building or
improvemenHssold within oneyearofcompldloqtheowner-builderwillhave
TOTAL:.
. .
tlajZurden of proving that he did notbugdorlmpmveforpurpmeafsakJ.
L j L as owner of the property, am exclusively contracting with licensed
contractors to creamed the project (Sec. 7044, Business and Profmbres Code:
QTY, PLUMBING PERMIT' FEE
FLOODZON
PERMIT ISSUANCE
'
APN
The Contractor's License Law does not apply to an owner of property who
Wilds or improves thereon, and who contracts far such pwjcd. with a
el5actor(O licensed pursuant to the Contractor'@License Lew.
(_I I am exempt under Seo B k P C for this masonria
ALTER -DRAIN &VENT - WATER (EA)
-
_
BACK FLOW PROTECT. DEVICE
FEE SUMMARY
DRAINS FLOOR ROOF, AREA, CONI.
FLXTURFS. PER TRAP
SANITARY Y_ N�'
RECEIPT p
Owner Date
WORKMAN COMPENSATIBN DECLARATION
❑I hereby affirm that I have 6 certificate.of convent to apythern,, ora
certificate of Worken'Comperuatlon lrsunnceere certified ropylhen,ef l5ec'
3800, lab CJ
SCHOOL TAX Y_ N_
REGEPf X
GAS FA. SYSTEM -1 INC40UILEM
PARKFRE Y N '
Policy X
-
RECEVr #
Com any
GAS FA. SYSTEM-0VER 4 (FA) �
BUILDING DIVISION FEES
edified copy Is hereby fumished.
Certlfled copy Is filed with the city Irupectlon division.
- GHEASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE
CREASE TRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
PAID '
SEWER -SANITARY -STORM EA, 200FI'.
COMPENSATION INSURANCE
(Thl.secHpnneedrad becompleted lithe permit L foronehundred dollars
($1 I0)erlessa
I f .s lashat N the performance ofthework forwhkh this permit is love,WATER
I shall not employ any person In any manner n as to became subject to the
Worken'Compematlon laws of California. Date
Date RCOeI f#
WATER I iEATER w/VENT/aECTR
ENERGY FEE Y N .
PAID
.
WATER Sy5fEM/TREATINX;
Applicant
NOTICE TO APPLICANT: If, after making this Certlfkate of Evemptlon, you
should become subject to the Workers' Comperuatlon provisions of the Labor
Date Recei t#
NEW RESIDENTIAL PLMB. SQ.FC.
NOTAL:'
Cade, you moat fon hwith comply with such provisions' or th Is permits hall be
deemed revoked.
B E
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
l hereby affirm that there b a mvtrudfon lending agency for the perform.
anm of the work for which this permit Is Issued(Sec. 3097, Civ. C.)
T
TOT
ELECTRIC FE E
ELECTRIC EEE
-
QTY. MECHANICAL PERMIT FEE
er's Na
Lendme
lender'sAddmea
I mrtifythaul have read thisappliestion and statethatthe above Information
'iscomet. I agree to complywlth all city and county ordinances and state laws
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID:
relating tobuliding construction, and hereby authmim representatives alibi.
-
eft I nterupon the Abu mentioned property (er Wpectlon purpose s,
agree to save, Ind keep harem the City of Cupertino
- ALTTRORADDTOMECH.
Date RCCCI t#
SUBTOTAL:
a to IIsbWdn,ju ere atsande pensees whlcherayinanywayacvue
ag I said City In n enc f the antiag of this permit.
AIR HANDLING UNIT (FO 10,000 CFM)
AIR HANDLING UNIT (OVER 10,010CFM)
CONSTRUCTION TAX
ofAppli est/ atractor Date
MIT LAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
DOUSMATERIALSDISCLOSURE
HFATINGUNBT(TO100,0001HU)ial
7�ull the applicant or future building oavpantmore or handle lvurdous
as defined by the Cupertino Municipal Code, Chapter 9.1$ and the
and Safety Code Section 7u532(a)7
n Yes No
DatC RCCCI t#h
}!EATING UNIT (OVER 100,0(10 BTU)
,TOTAL:
3a
VENTILATION FAN(SINGLE RESID)
ISSUANCE DATE
®AR�
SSfH1tR
j ����
OA '
OAK
Will the applicant or Nn, building occupant use equipment or devices
which emit hazardous air centamlearda as de0ned by the Bay Arca Air
Quality Management District?
4 Ycs 1'1 No _
havcread the hoar pus nutcrlals requirements undegChapter6.95of
the California Health&Safety Code, Section 25505, 75533and 25534.1
understand thatifthebuildingdoeenW.rre tlyhave atenanpthat ltle
BOILER -COMP OI'LP OR 100,000 BTU)
BOILER -COMP(OVM100,000RTU)
NEW RESIDENTIAL MECH. SQ.FT -
responsibility to notify the occupant of the requirements which most he met
prlo to issuance of a Cealficate of Occupancy.
V
ISSUED BY: L b W,U
Owner or authonaed agent' Date
TOTAL:
OFFICE COPY