19622NO
H y
Ir 5
WD
CL
_
O
U_
LL ~
Ow
} IL
F- N
Z
U—
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building P,WIdentification I ..�x.p s� 1
Building Address: (�•l^ m�f-T L•
_Lo- . /)� A/ flw,t
PERMIT NO.
19622
Wners ante: Phone:
-p A
A P Pz e f 9 j"7A
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION, PERMIT
-2- S �O
cantrannraName: Lk. No:
P L ✓ IS�is'
BUILDINGMFIC'IRICALML BING-ME l} LAICAL
CATEGORY
CONTROL N
Architect/Engineer. Lie. No:
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Addreas:
PERM11TISSUANCE
❑ ❑ X ❑
LICENSEDhemand CONTRACTOR'S DECLARATION
I hercectionby rmthat lamecenaM underprssand of Chapter
MPLIANCESRESIDENTIAL
JOB DESCRIPTION
PANELS
ssions9de,and(comment,
70W)and efelon3oHhe Bualnessand ProfcsaionsCode,and my
my
It...
license is In /u8 force and effect
License Chea Lk.p
Date Contractor
UP TO 2DO AMM201
PL�u� 1
"\
1000 AMPS
ARCHITSHITECPSDECLARATION
I understand my plane shall be used u public records.
OVER1000AMPS
SQ. FT. FLOOR
sm.F7.
SIGNS ELECTRICAL Pre M)
Licensed Professional
SPECIALCIK T/M
OWNER -BUILDER DECLARATION
I hereby afRrnthat I am exempt from the Contractor's License Law for the
1L-MCMETPR Fill INST.
following reason.(Sct1on7031.5, Busincesand Professlon.Code: Any Ctyor
coantywhkhrequimsaper ttommtmd,alteq Impmve,de=ti h,ormpalr
anystm=mpdortolts Wuance,al mqulrestheappllnntfo w&perMtto
file a signed statement that he is Bernard pursuant to the provisions of the
DEVI
Kv
Contractors License Law (Chapter 9(commencing with Section 7000) of Divi-
cion 3 of the Businessand Pmfemiom Code) orthat he is emmptthemfmmand
Sk4AM1 NG ELECT
VALUATION
the basis for the alleged exemption. Any violation of Section 7 15 by any
applicant fora permit subject.the applicant to a civil penalty of nR more thin
O ETS TCFIFS
five hundred dollars ($50U).
❑ I, as owner of the property, or my employees with wages as their sole
L ECTR FT
STORIES
TYPECONSTRUCTION
compensation, wOl do the work, and the structure is not Intended or offered for
sale (Sec. 7064, Business and Professions Code: The Contractors License Law
does not apply to an owner of property who builds or Improves thereon, and
who doessuchwmkhlrself orthrough hisown employees, provided that such
OCC.CROUP
RFS. UNITS
TOTAL:
Improvements are not Intended oroffered for sale. If, however, thebuildleg or
improvement isseld within one,yearofcompletion, tMowner-bullderwill have
the*rden of proving that he did not build or improve for purpose of sale.).
LI L as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7064, Business and Profesilons Code:
QTY, PLUMBING PERMIT FEE
^�
FLOOD ZONE
APN
PERMIT ISSUANCE ^ �.
�n
The Contractor's License Law does not apply to an owner of property who
builds or Improves therear, and who contracts for such ptojecb with a
,0.t ttor(e)Bcenscd pursuant to the Contractor's License Law.
c l_l I am exempt under Sec. B k P C for this m
ALTER -DRAIN kVENT- WATER (EAI
FEE SUMMARY
BACK FLOW PROT[CT. DEVICE
DRAINS FLOOR ROOF, AREA, COND.
SANITARY RECE N
Owner Date
WORKMAN COMPENSATION DECLARATION
❑1 hereby affirm that I have a errdficate of consent to self -Nam,' or a
certificate ofWorken' Coepenution Insurance m a certified copy thenrof(Sce.
3800, lab C.)
tl p�.rr Ppg.1.RAIr �'
L- s
SCIi00L TAX Y_ N_
RECEIPT N
GAS F.A.SYSTEM-11NG4 OUTLETS
PARK FEE Y N —
RECEIPT N
Policy N
cc
Com any
GAS EA. SYSTEM.OVER4(FA)
BUILDING DIVISION FEES
ertdied copy U hereby furnished'
❑Certified copy is filed with the city InspttHan division.
GREASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE
GREASE TRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
PAID
SEWER -SANITARY -STORM EA.2WFT.
COMPENSATION INSURANCE
(This secilon need not be completed If the perob isfor one hundred dollars
Date RCCCI t#
WATER HEATER w/VENT/ELECTR
ENERGY FEE Y— N—
(5100)Drlc..)
Iunifylhatheth er(omunce oft ork for which this permit is Issued,
WATER SYSTEM/TREATING
I shall not fp y person In an er se ss to been ne u jet[ to the
'tomesCom s ion [.of no. Date
PAID
NEWRFSOENTIALPLMB. SQ.FT.
Applicant
NOTICETO APPMCAN7VII,,dm, making Wtrfrrlflateaf Exemption,you
should become subject to the Workem'ConTemation provisions ofthe LaborE�Ns�
Code, you must forthwith comply with such provisions orthis permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
Date Recd t#
TOTAL:
L6t59e^S 4LfR F+ t6to"
BUILDING '•E
SEISMIC FEE
TOTAL:
ZtaD
ELECTRIC FEE
I hercbya(firmthatthem U a construction lendiagagency forthe perform-
ante of the work for which this permit U Issued (Sec. 3097, Civ. C.)
lender's Name
Lender.Addres.
I certlfythat l have read this application and statelhat theabovelnformatlon
b correct. I agree to comply with all city and county ordinances and state laws
PLUMBING PEE
3110D
QTY. MECHANICAL PERMIT FEE
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID:
relating to building construction, and hereby authorize rcpresentatives of this
city to entero nthe above-mentioned propertyforinepectionpurposes,
(We) -gr saves Indemnify an d keep baroness the City of Cupertino
agalnstliabl 11 , jadgmants,roatsan x Fa. which may In anyway accrue
ALTER OR ADD TO MECH.
Date RCCCIPI#
AIR FIANDLING I1MT (TO lO,WO CFM)
SUBTOTAL:
against lyloomerquenaeof egr rating ofthbpermit.
�9
AIR HANDLING UNIT (OVER 10,000CFM)
CONSTRUCTION TAX
igrsture of Applica Contracor Date
EXHAUST HOOD(W/DUC'D
CONSTRUCTION TAX PAID:
HAZA RDOUS MATERWiSS DISCLOSURE
Will the a ppliant or future building occupant store or M rad to hazardous
HEATING UNIT (TO 100,000 BTU)
Date Rccel t#
material as defined by the Cupertino Municipal Code Chapter 9.1 2, and the
Fimkh and Safety Code Section 25532(a)?
❑ Yes tn No
Will the applicant or future building occupant use equipment or devices
HEATING UNIT (OVER 100,OW BTU)
TOTAL:
Z,CV
VENTILATION FAN (SINGLE RESID)
ISSUANCE DATE
which emit hazardoua air contaminants as defined by the Bay Arca Air
Quality Management District?
Yes M No
i have read the bzMua materials requirements underChapter 6.95 of
�Q
S
BOILER -COMP QHP OR 100,M BTU)
BOILER-COMP(OVER 100,0DO BTU)
the California Health k Safety Code, Sections 25505, 25533 and 25534. I
tifthebuildingdoesn.tmrrcntlyhaveatcnantthat it is my
L�
NEW RESIDENTIAL MECH. SQ.FT.
ounderstao
reeponsib i to notify the oc t ofthe requimmentewhich .,the mon
priors ce ofa Certl fi Occupancy.
0.11:5
ISSUED
i senta
TOTAL:
OFFICE COPY