21958APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY N.C.Re
BuildingProject Identification
Building Address:
/ 7MI'C alaL IU
PERT NO.
21958
s ante. one:
APPLICAA
—r- �Q{r2- -
CITY OF CUPERTINO-BUILDINGDIVISIONE
APPLICATION / PERMIT
-L (�
0 — \
contran.raName. Lie. No:
BULLDINGELECTRICAL-PLUMBING-MFO LAICAL
CABY CONTROL0
Architect/Engineer. Lk. No:
QTY ELECTRICPERMIT FEE
BUILDING PERMIT INFO
Address:
PERAgTISSUANCE
1:1 1:1 ❑
LICENSED CONTRACTOR'S DECLARATION
t hereby affirmion7O hatlamgon3ofthe under prwandPisions ff h=sr9(e,andm
APPLIANCFSRESIDENI7AL
]pg DESCRB'TION
Ingwe fon (»v ofthegusinessand Pro(esslonaCode, and rtry
force of
license Is In full force and effect.
is lexa.
PANELS
License Clam Lk.p
Date Contractor
UP IQ 20 AMPS
—
201-1000AMIS
ARCHITECTS DECLARATION
1 understand my plana shag be used u pubbc records.
OVER 1000 AMPS
SQ. FT. FLOOR AREA
$/SQ. FT.
ISIGNS ELECTRICAL
Licensed Profossionl
SPECIALCIRCUIT/MLSC
OWNER -BUILDER DECLARATION
I hereby afOrmthat I am exempt from the Contractors License Law for the
TEMP MEI'ERORPOLE INST
following reason.(Section 7031.5, Business and Professions Code: Any city or
county which requires a permit to construct, alter, Improve, demolexh,orrepalr
anystmcture prlorto its hantance,also requirestheappllcam for such permit to
file a signed statement that he Is licensed pursuant to the provisions of the
(OWER DEVI
NC LELE
Contrciofa License Law(Chapter 9(con..cing with Stolon 7000).( Divi-
slut, 3 ofthe Business and Professions, Code) or that he 0 exempt thercfromand
LUATION
the basis for the alleged exem"n. Any violation of Section 7031.5 by any
applicant fora permit subjects the applicant to a civil penalty of not mom than
OL4E*.gTCHEqW6ES
R . TR SQ.ET.
ETiv ndrcd dollars ($500).
e owner of the property, or my employees with wages as their sok
STORIES
TYPECONSIRUCTION
mpensation,will do the work and the structure is not intended or oftemd for
sale lSoc.70K Busiress and Professions Code: The Conhaciole License law
does not apply to an owner of property who Wilds or improves t hereory and
whodmssuchworkhimself orthrough hlsownempleyees, provided that such
OCC. GROUP
RES. UNITS
TOTAL:
Improvements arc not Intended oroffered forsale. IL however,thebuilding or
improvement bsold withinoneyearofcomplmiory theowner-bullderwill have
QTY, I ttUMBING PERMIT FEE
tIB,�a rdenof proving that he did nm build orlmprove for purpose of sale).
L_j L as owner of the property, am exclusively contracting with licensed
contractor to contract the pro' . 7074 Rwlnem and Pro(emlov Code:
FLOOD ZONE
APN
PERM UANCE
The Coneonora Lkenx law do a m apply to an owner d property who
builds or Improves there. an o rontraeta for such p(ojeab with a
cgIltfa arts) mad t a tt th C tridea Lkenx Law.
LJ 1 a xempt un e B k P C for this reason
AL -DR UNkVENT-WATER(EM
FEE SUMMARY
BACK FLOW PROTECT. DEVICEOUTSIDE
FEES
DRAINS FLOOR, ROOF, AREA, COND.
SANITARY RECEIPT M
r
WO AN COMPENSATIONDECLARATION
❑I hereby a(fl that I have a certificate of consent to self -Insure, or a
certificate ofWorleri Compensation Insurance ora osnifled copy thereof(Sec.
3800, Lab C3
L:U('ll]RES PER TRAP
SCHOOL TAX Y_ N_
BBC= N
GAS EA. SYSTEM -1 INCA 0IfILETS
PARK FFE Y N_
RECEB'1 X
CPolicy N
omOany
m•
S
GAEA. SYSTEM -OVER 4 (PA)
BUILDING DIV 151 ON FEES
d.
Cenlfled copy is hercbytcity
OCerti(ied ropy V (lied withh the the city inspection division.
GREASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE
GREASE TRAP
CERTIFICATE OF E%EM"ION FROM WORK CRS'
PAID
SEWER.SANITARY-STORM EA. 20DFT.
COMPENSATION INSURANCE
(Thlssectlon need net be completed if the permit Is forom hundred dollar
Dale Recei 111
WATERHEATERW/VENT/ELECTR
ENERGYFEE Y_ N_
($100) or loss.)
1 comfy that In the performance of the work f.rwhich this permit is Issued,
WATER SYSTEM/TREATING
I shag not employ any per.n in any manner x m to become subject to the
Workers Compensation Lawsof CalRomla. Date
PAID
NEWRESIDENTLALPLMB. SQX-T.
Applicant
Date Recel tel
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you
should become subject to the Workers' Compensation provision of the Labor
TOTAL:
BU1 DINC"E
Code, you must forthwith comply with such provisions orthis Ferrell, shall be
deemed invoked.
CONSTRUCTION LENDING AGENCY
SEISMIC FEE
_
I hereby dorm that there is a construction lendingagency forthe perform-
ance of the work for which this permit b heated (Sec. 3097, civ. C3
lenders Name
Lenders Address
I cert lfy that I have read this application and state that the above information
hcorrect. l ugreeto comply with all city and county ordinances and state laws
TOTAL;FTE:
ELECTRIC FEE
PLUMBING FEE
QTY. MECHANICAL PERMIT
MECHANICALFEE
PERMIT ISSUANCE
FEES PAID:
relating to building construction, and hereby authorfu representatives of this
city to enter u Pon the aWve-mentioned property, for Inspection purposes.
(We) agree to save, inclemently an d keep harmless the City of Cu pert.ALR
against liabilities, judgments, crossed expenses which may In any way accrue
ALTERORADDTOMECH.
Date ReteiPtq
HANDLING UNIT (7010,000 CFM)
SUBTOTAL:
against said City In consequence of the granting of this permit.
AIR I-IANDUNc 11MT (OVER lo,oOoCFM)
CONSTRUCTION TAX
Signature of Applicant/Contractor Date
EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
)iEATING UNIT (TO 100,000 BTU)
Date Recei tel
Will the applicant or future building occupant store or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.12, and the
I kalth and Safety Code Section 25532(a)7
M Yea NON.
HEATING UNIT (OVER 100,000 BTU)
Pig "OTAL:
VENTILATION FAN (SINGLE RESID)
,
Willtheapplicant orfumre building occupant use equipment ordevices
air contaminants as deRudb the Ba Area Alr
which Management
Quality Mawgcment D ct7 y y
No
ISSUA CE DATE
p
/rA�
C, Y
BOILER -COMP PEO'pR 100,000 BTU)
MOILER-COMP(OVER 100,000 BTU)
4Yes
havcmadlhehaz cue mattIft requ lrenents under Chapter 6.95 of
the California Health ASafetyC e, adore 75505, 75573 and 7SSJ4.I�/ya
understand that if the but gd can cumentiyhaveatenant,thatlt Lcmy
NEW RESIDENTIAL MECH. SQ.IT.
ori tonmity th o p rt the requlrcments which must be mot
Fri 1_ encs.f.Certl'c a anay.
3 L2 g/
UT^ss�eA
ISSUEDBY:Z. WRCA "V�
or mit.thori agent Date
TOTAL:
OFFICE COPY