19864APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Proied Identification
Building Address:
PERMITNO.
210 6 -7 m ftm rm Cr. CQ ec-R n a 0 ca1-9 C
19864
wnera ams. Phone.
FAAmv-L4#,I n6
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
c.^tr�d.ra Name: LIc. No:
sLms
BUILDINGELECTRICAI.PLUMBING-MFCIIANTCAL
CATEGORY C N :h
ArcMlect/Engineer. Lic. No:
QTY ELECTRICPERMIT FEE
BUILDING PERMIT/INFO
Add.
PERMITISSUANCE
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
Ihereection 70thatl ivislo 3ofthe erprssand sof Chapt Codeamenc-
Inense I. ectlon force andefect. (the Buslnevand Pro(esslonsCade,and my
license is in full Forex and died,
APPLIANCES -RESIDENTIAL
JOB DESCRIPTION
PANELS
CLk.N
Date
Date Conlrador
201-1000 AMPS
ARCHITECT 5 DECLARATION
I understand my plana shall be used as public records.
OVER IWO AMPS
SQ. FT. FLOOR AREA
$/SQ. FT.
SIGNS ELECTRICAL
r
Licensed Professo al
SPECIALCIXC M
OWNER -BUILDER DECLARATION
m
I hereby affirthat I am exempt from the Contractor's LI... Law for the
following reason. (Section 7071.5, Business and Profession. Code: Any city ora
county which requires a permit to construct, alter, Improve, derrnlish,ur repair
anystructuro pdorto its issuance, also requlrcathe applicant for such permit to
file a signed statement that he Is Bernard pursuant to the provisions of the
® B
—
TEMP.ME[fIItO
POWER DEVI
ST.
G E C
Contnctora License Law (Chapter 9 (commencing with Sectors 7000).1' Divi-
skm3 ofthe Buslnns and Professions, Code) orth.t he h exempt eherefrorrand
ALUATION
the basis for the alleged exemption. Any Violation of Section 7015 by any
applicant for a permit subjects the applicant to a civil penalty of not more than
OLIN sv f
%E�
fiv1-c�h� ndrcddollars($.50Q. -
IJ•, as owner of the property, or my employees with wages as their sole
NEW RES ALE
TYPE CONSTRUCTION
compensation,willdolhe work andthestrudure d n.Hntended or offered for
IN t
rt
sale (Sec. 70K Business and Pro(esfons Code: The Contradoes Liconse Law
does not apply loan owner of property who builds orimpreves thereon,and
doessuchwork Mmselforthrough hisownemplc, .provided that such
OCC.CROUP
RES. UNITS
TOTAL:
Improvements are not Intended oroffered for sale. If, however, thebuilding or
improvement issold within one yea ref complet Ion, the owner-bullderwfll have
thrden of proving that he did not build or Improve for purpose of vie.).
LI, as owner of the property, am eadusively contracting with licensed
contradors to construct the project (See 7064, Business and Professors Code:
QTY. PLUMBING PERMIT FEE
FLOOD LONE
APN
PERMIT ISSUANCE
The Contractor's License Law does net apply to an owner of property who
Wilda or improves thereon, and who contracts for such p(ojects with a
c Ott ct (a) licensed pursuant to the Contractors License Law.
B & P C for this mas
LII am exempt under Sec. on
ALTER -DRAIN &VENT- WATER BEA)
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
DRAINS FLOOR ROOF, AREA, COND.
SANITARY RFCEBrI' N
Owner Date
WORKMAN COMPENSATION DECLARATION
❑I hereby affirm that 1 have a certificate of consent to self -Insure, or
cediflcateofWorkers'Comperoatfonlmurancenracenlfiedcopythereof(Sec.
3800, Lab C.)
FIX.IVRGS PER TRAP
SCHOOLTAX Y N
RECEIPT M
GAS EA. SYSTEM-1INCA OUTLETS
PARK FEE Y N_
RECEOeT N
ComI. tl
GAS E.A.A) A. SYSTEM -OVER 6(
BUILDING DIVISION FEES
FCny
edffied copy V hereby furnished.
❑Certified copy b filed with the city inspection division.
GREASE/INDUSIRL WASTE INTERCEPTOR
PLANCH K FEE
r(� (�
GREASETRAP
CERTIFICATE OF EXEM PTION FROM WOR K ERS'
PAID ��71��'L�O
COMPENSATION INSURANCE
(Thiseedion need net he completed if the permit Is forone hundred dollars
gEryygR SAM"TARY SIORM EA "FT
RCCCI f# o
WATER HEATER W/VFM/ELECTR
ENERGEE Y_ N_
Y
0100) or les.)
I certify that in the perforommceof the work forwhicis this permit I. ieaed,
WATER SYSI.EM/TREATING
I shall not employ any person 1n any manner m ns to 1 me subject to the
Workers'Com n tion Lawsy fCalifo fa. cue
PAID
Applicant /yB"'I(L ' f//C' i
NOTICETO CANT:Il,a�r ngt ertBimteof Ex.mption,y.0
should become subFd to the Workers' Compers son provision. of the Labor
NEW RESID[NTIAL PCMB. SQ.FI',
Dale RCCei f#
TOTAL:
BUILDING FEE
Code, you rwst f.rthwith comply with such provisi.ns orthb pemNt shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
Ihumbyaffirmthat there is acomtrucilon lendingagency forthe perform-
re of the work for which this permit 6 Issued (Sec. 3097, Civ. C.)
Under's Name
Lenders Address
I mrtilythatl haveread this applicatonand statethat the above information
Lscomect. Iagree to comply with all city and county ordinances and state laws
relating tobullding construction, 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 harmiess the City of Cupertino
against liabilities, judgments, coYsand expenses which may In anywayaccroe
SEISMIC FEE a
TOTAL:
ELECTRIC FEE
PLUMBING FEE
QTY. MECHANICAL PERMIT FEE
MECHANICAL FEE
PERMIT ISSUANCE
FE P
Date Receipt#
ohx
ALTEROR ADDTO MUCH.
AIR HANDLING UNIT (TO 10,000 CFM)
SUBTOTAL:
against sald City to consequence of the granting d this permit.
AI A HANDLING UNIT (OVER IO,ODOCFM)
CONSTRUCTION TAX
,�G�y�ZG/9�
Sigralum.f Applicant/ tractor k/ Date
IXHAlJS'T HOOD (W/DIK"D
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (TO 100,0DO BTU)
Willthe applicant or future building occupant store orhandle hazardous
Date RCCeI t#
material as defined by ted Cupertino Municipal Code, Chapter 9.12, and the
Health and Safety Code Section 25532(a)t
❑ Yes MN.
Willthe applicant or future building occupant useequlpment or devices
HEATING UNIT (OVER 100,000 BTI)
TOTAL:
VENTILATION FAN (SINGLE REBID)
ISSUANCE DATE
which emh hazardous air contamloants as defined by the Bay Area Air
Quality Management DisWd2
Yes No
WnserYDl\ 0 Lalf�
::11�����no !ss ^fh1
BOILER-COMP(311POR 100,000 BTU)
BOILER.COMP(OVER 100,000 BTU)
have read the h.edou. materiab requirements under Chapter 6.95 of
the California Health & SafetyCode, Sections 25505,25S33 and 25534. I
understand that lithe building does not currently have a tenant, that it 6 m
ry V FF 1
0661 i1 Od.l
llU O U
NEW RESIDENTIAL MECH. SQ.FT.
responsibility to notify the occupant of the requirements which most be met
prior to issuance of a Certificate of Oavpancy.
ISSUEDB� 1
Owner or authorized agent Dae
TOTAL:
OFFICE COPY