23202APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
BuildinPLeTIdentification
Bu0?Zs:
PERNME NO.
L t,Nr✓ >
320
2
sere aces:I phone.
L A.1 / L -L l 2S'1G797
CITY OF CUPERTINO-BUILDING DIVISION
- APPLICATION /PERMIT
I
`
o.trador.Name: Lte.N.:
BUILDING-ELF-CTRICAI.PLUMBING-MFCHA AL
CATEGORY
CONTROL N
Architect/Engineer. Lac. N.
QTY ELECTRI�W41T FEE
BUILDING PERMIT INFO
Addma: �C� 1 Lih
PERAETISSUA CE
LrJ'
LICENSED CONTRACTOR'S DEC RATI N
I hereby affirrnthat l see licensed under provisions otChapter 9(commen
Ingwith Se on700D)of DiviMm3ofthe Buelmnand PrereulonsCode, and my
license Isle full fume, Ioand effect.
License Class LION
APPLIA CES ENTIAL
P
� D
Dale Contractor
-1000 AMPS
VER 1000 ANTI'S
ARCHITECTS DECLARATION
I underetand my phns s1uB be used u public rcmrda I
Licensed Professional
Uj
. Ff. FLOOR AREA
SIGNS ELECTRICAL
OWNER -BUILDER DECLARATION
I hereby affirm that I a n exempt from the Contractors License Law for the
following reason. &&don 7031 S, Business and Profession. Code: Any city or
county which requiresa permit to construct, alter, Improve, demolish, or repair
anystmmmpAortoib Lswance,al mrcquimtheapphanttorsuchpemdtto
file a signed statement that M V licensed pursuant to the provisions a( the
Contractor's License Law Chapter9(commencingwith Section 7000)of Diel-
don3ofthe Budnessan l ProfessiunsCode).,that heisexemletherefromand
the basis for the alleged exemption. Any violation of Section 70312 by any
applicant for .permit subj�. applicant too dWl penaltyofnot morcthanfii
Rve a do %M.
as owner of the property, or he employees with wage r their w
CmpenuHon,wlll do the work and thestmcture is net or off for
I -PO � 7016, Business and Profemiau Code: The Contractoe. Lt.. Law
SPECIAL CIRCNT/
gyp. M POLE INST.
CES
NG POOL ELECTRIC
OUTLElSSW(TCF;FSFIXIUR[5
VALUATION
D� Q
(((
NEW RESIDENTIAL ELECTR SQFT.
STORIES
TYPE CONSTRICTION
TOT
QTg PLUMBING PERMIT FEE
PQtMR15SUANCE
ALTER -DRAIN &VENT -WATER (En)
does not apply to an owner of property who builds or Improves themes, and
whodoes such work himxelforthrough Mro
s own employees, pvMed that such
Improvement, are not Intended oroffered forsale. IL havevep thebuilding or
Improvement b wld within oneyearofc.mplatioe, the owner -builder will have
to rden of proving that he did not build or Improve for purpose ofsale.).
Lj L as owner of the property, am exclusively contracting with licensed
contractors to construct the preject(Set 7016, Business and Professions Code:
The Comment's License Law does net apply to an owner of property who
bullas or Improves thereon, and who contracts for such p(ojem with a
hunsed pursuant to the Contractors License Law.
Off,
LJ I am exempt under See. B k P C for this reason
OCC. GROIII'
RFS. UNfIS
FLOOD ZONE
APN
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
OUTSIDEFFES
DRAINS FLOOR ROOF, AREA, COND.
Fp(•fURES PER TRAP
SANITARY Y_ N_
RECEIPT N
Owner Date
WORKMAN COMP aNSAT10N DECLARATION
❑I hereby affirm that I have a certlRate of consent to self-Inwre,
SCHOOL TAX Y NRECEIPT
or a
3800, Lab C.)Worken'Compeuatlonlmuranoe ora certit4d copythereo((gec.
M
GAS -EA. SYSTEM -1 INCAOUILEIS
PARK FEE Y N
Polley p
N
RECEGAS
Cafany
EA. SYSTEM -OVER 4 (EA)
DING DT
BUILDING DIVISION FEES
Certified copy is hereby furnished.
❑CertBied copy V (lied withhthe dInspection division.
ty
thcity
EAGRSEANDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE
GID
GREASETRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Th.scctlonneedn.t becompleted lfthepermit lsforoehundred dollars
(8100)orless)
for which this permit Is c timed,
I certifythato the pemo In any
I dull not employ any person In any eunner at u to become ubJM to theWork
Compenulion Laws o(Gllfomla. Date
PAID
Da i [#
SEWER -SANITARY -STORM EA. 200FT.
WATER HEATER W/VENT/ELECTR
ENERG Y� N
PAI
WATER SYSTEM/TREATING
Applicant
Applicant
N'OIICE TO MPLICANT: If, after making this Certl(latc of ExempOon, you
[ ecei t#
NEW RESIDENTIAL PLMB. SQ.FT.
should beccem subject to the Workers' Compensation p.'=e ofthe Lebo,
Code, you must forthwith comply with ouch provisions or this permit shall be
deemed revoked.
OTAL:
UI D ^�
SEI C FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lend Ing agency for the perform
ante of the work for which this permit is Issued (Sec. 3097, Civ. C.)
�/
ELE TRIC FEE
Lender's Name
Lenders Address.
I cortl(ythat I have readthisappliatlonand datethattheabovelnformatl.n
Lscomet. l agree to complywith all cityand oxuntymdlnancesand state laws
QTY. MECHANICAL PERMIT FEE
' PERMIT ISSUANCE
PLUMBING FEE
MECHANICAL FEB
FEES PAID:
relating to building construction, and hereby authorize representatives of thi.
dtytoenterupon the above-mentioned property for inspection purposes.
Me) agree to save, Indem sly an d keep harmless the City of Cupertino
DB[D el f#
ALTETIORADDTOMECH. �e
SUB OTAL:
against llabilltles, judgmtra, n%sand expenses which my lnaeymyacame
Inst said CI In sequence of the granting of this permit.
AIR HANDLING UNIT (170 10,000 CFM)
AIR HANDLING UNIT (OVER l0,000CFM)
CONSTRUCTION T X
nathre or lion/Contractor Date
EXHAUST HOOD(W/DICT)
CONSTRUCTION XPAID:
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (T01(10,000 BTU)
Will the applicant or future building occupant store or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.1 Z and the
Health and Safety Code Section 75ra37(.N
r] Yes No
Mrs
Date R el t#
Aj
T O
HEATING UNIT (OVER IW DM BTU)
VENTILATION FAN (SINGLE RESID)
ISSUANCE DATE
Will the applicant building pact use equipment or device
which emit hazardous air coNaminants as dented by tot Bay Area At,
BOILER -COMP OHP OR 100,000 RED)
Quality Management District?
Yrs n❑ No
?f
BOILFR-COMP(OVER 100,000 BTU)
have read the Fazallow eulerlals requlrcmcnH under Chapler6.95 of
the Califomu Health A Safety Code, Sections 25505,25S33 and 75536. I
understand that lithe building does not currently have atenant, that It b•my
dJ
gas.
NEW RESIDENTIAL MECH. SOFT.1 I
mpnnsibility to notify the occupant of the requirements which =at be mot
prior to Issuance of a Cerifiateof0cmpancy.
//''�I,v
017'g e
ISSUED BY:
Owner or authorized agent Date
70
OFFICE COPY