23843APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
Building Pra'ed ldemi(Iadn^
BuOd Ng Address: -
77 ZIZ
PERMIT NO.
/� /� /'� Q
Gl'J84
Phone:
Lh:4oma: N ER A/V Z.S7S
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BUILDING-ELECTMCAI PLUMBING-MMHANICAL
A
�y 2
Contra 'Name: Llc.Nm
~ QIQN
CATF-GORY
CONTROLN
MceRact/Engineer. Lic. No:
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
�jr
Addrem:7(
PERMITISSUANCE
❑ El
CONTRACTOR'S D RATION
I hereby affirm that son licensed under providoes of Chapter9(commce
ingwith Saction 7000)of Dividon3oftheBuslnesaand PmfedonsCode,and m
license is in full force and affect.
LlmnseChes LION
Date Contactor
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed Professlorul
OWNER -BUILDER DECLARATION
I hereby of imn that I am exempt from the Contractors Limme law for the
following reason. (Section 70115, Business and Professions Code: Any city or
county which requlreaa Pdmittororutruct, alter, Improve, demolbh,oreepair
anystmctumpdnrtolbW ance,dwrequima Neappllantfersuchpermitto
file a signed statement that he Is licensed puraueet to the provisions of the
Conladoes License law(Chapter 9(commenWg with Section 70110) of Divi-
don3 ofthe Bualn....d Pmfemb.Cade) orthat helaexempt themfromend
the basis for the alleged exemption. Any violation of Section 7031.5 by any
applicant fora perrnit subjects the applicant to a civil penalty of not mum than
five hundred dollars (sM.
n I, as owner of the property, or my employees with wages an their sole
compensation, will do the work and the structure is not Intended or offend for
mle (Sec. 7034, Buatnma and Pnofemlons Code: The Contractors License Maw
does not apply to an owner of property who builds or improves thereon,and
who doessuch work hlmselforthrough Msown employees, provided that such
Improvements are not Intended or offered for sok. It hmvcveq the building or
Improvementbsoldwithln oneyearofcompldbRtheowner-builderwillhave
that laurden of proving that hedid not bund or improve for purpose ofsaled.
LJ I, as owner of the property, am exclusively contracting with licensed
contacims to construct the pmjed(See. 7006, Buslnem and Professions Code:
The Contractor's License Law dm not apply to an owner of property who
builds or Improves thereon, and who coneacte for such ptokcts with a
cgngador(s) licensed pursuant to the Contractor's License Law.
L.J lam exempt under Sec B & P C for this reason
APPLIANCESRESE)FNTIAL
JOB DESCRIPTION
^ — OB,
/�"F ��
VAN __�, �, a•'� e
PANELS
201.1000 AMPS
OVERIODOAMPS
SQ. FT. FLOOR AREA
-
$/SQ. Fr.
SIGNS ELECTRICAL
SPECIAL CIRCNT/MLSC
TEMP, METER OR POLE INST.
IOWERDEVICES
b}yps{,VRNCIt70L ELECTRIC
OUTLETSSWITCIiFSFUTTIJRFS ®
VALUATI(]�
O KJ
NEW RE4DENHAL ELECTR
STORIES
TYPE CONSTRUCTION
-
TOTAL;
QTY. PLUMBING PERMIT FEE
OCC. GROUIs
AES. UNITS
PERMIT ISSUANCE �
ALTER -DRAIN &VENT -WATER (EN
FLOOD TONE
APN
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
DRAINS FLOOR ROOF, AREA, COND.
SANITARY Y N
RECREET 4
Owner Date
WORKMAN COMPENSATION DECLARATION
[]3 hereby orfirm that I have o lrou ate of conmat to self-ineure, or
ora certified copythereof (Sec.
3B0Q Mab CJ
3800,certifiLte ab
Polley N
FIXTURES, PER TRAP ��
SCHOOL TAX Y N
RECEIPT N
GAS F.A. SY9TEM-1 INCA OUTLETS
PARK FEE Y N
N
RFCEGAS
EA. SYSTEM -OVER 4 MAE
Cc any
DING D[
BUILDING DI VISION Fr. ES
I I Cartiled copy is filed hereby
CemtlOed copy ls rlhd wllh the tlty Inspection division.
the city
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Ohlexction need not be completed It the permit b(or ane hundred dollars
(5100)orlem3WATER
I artily that la the performance of the work forwhlch this permit is blued,
I'shall not employ any person In any manner so as to become subject to the
Workdx Campenvtlonlawsof Cidf.mla. Data
ApplicaOTICE
N
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you
should become subject to the Workers' Comperuation provisions of the Labor
Cade, you most forthwith comply with such provisions orthb permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
T hereby affirm that there is a construction lending agency for the perform-
ance of the work for which this permit is Issued (Sec. 3097, Civ.C.)
lander'. Name
Lesd.e.Acidress a
I rtifythat I have read thisappliatlonand statethattheabove Information
brorred,I agreeto complywlth all ciyand county ordinances and state laws
relating to building construction, and hereby authorize repedenatives of this
city to enter upon the above-mentioned property for Inspection purpose.
(We) agree to save, Indemnify an d krep harmless the City of Cu Fenton
against Hablutl', judgments, cors and expemm�w inanywayacerm
age [.at said City in c ... aquenceofthe n thbpe it
44 y �� 2
nature o(Appllant/Conrado Data
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or Future building occupant store or hand to hevardous
muterial as defined by the Cupertino Municipal Code, Chapter 9.1 2, and the
hlealth and Safety Cade Section 25532(e)i
❑ Ye In No
Will the applicant orfutureIndicting occupant use equipment or devices
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management DisMct9
Yes ❑1� No
ve me ,2materials requirements under Chapter 6.95 of
the Ca lffornia Health &Safey Code, Sections 25505, 2SS33 and 25534. 1
and erste rad that if the building does not currently have a tenant that It is my
responsibility to not lty an
the occupant of the requirements which must be d
prior to issuance of a Certificate or Occupancy.
CRPASEANDUSTRL WASTE INTERCEPTOR -
PLANCHECKFEE
PAID
Date Recei tic
GREASE TRAP
SIEWER-SANITARY-STORM EA moor.
-
HEATER W/VENT'/ELFOTR
ENERGYFEE Y N
PAID
Date Recei til
WATER SYSTEM/TREATING '
NEW RESIDENTIAL PLMB. SQI-T.
TOTAL:
BUILDING
-
SEISMIC FEE
�kT
ELECTRIC FEE r.r
PLUMBING FEE
QTY. MECHANICAL PERMIT FEE
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID:
Da[eReCei tic
ALTERORADDTOMECH.
AIR HANDLING UNIT CFO 10,0DO CFM)
_
SUBTOTAL -
AIR HANDLING UN(OVER ]O,000CFM)
IT
CONSTRUCTION TAX
-
EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
Date Receiptil
HEATING UNIT (TO 100,0)0 BTU)
HEATING (IMT (OVER Io0,000 BTU)
TOTAL
VENTILATION FAN (SINGLE RESID)
ISSUANCE DATE
Y'L L
��11pI
UIV 16 199.
t f
UUI�
ISSUED BY
BOILER -COMP OHP OR 100,000 BTU)
BOILER -COMP (OVER 100,000 BTU)'
NEWRFSIDENTIALMECH. FT
5Q.
Owner or authorized agent Data
TOTAL:
OFFICE COPY