195520
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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Address: FVVVI !Ta' /a-�
8 Building Project Identification fl 41PNZ s 35 -3e34 �t Pte✓ (�`�l
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A A A 11
CITY OF CUPERTIN4 BUILDING DIVISION
APPLICATION/PERMIT
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der.Name: n_ c. Na:
CATEGORY
CONTROL N
�d+ L r O
BUILDINGSLECTRICAL-PLUMBINGMECHAMCAL
Aro Iters/Engines. Ic. No:
^; ELECTRIC PERMIT. �'FEE�
BUILDING PERMITINFO'
PERMITISSUANCE
Addrcas:
® ❑ ❑ ❑
LICENSED CONTRACFO W 5 DECLARATION
I hereby affirthatlicensed order psof Chapter c
APPIIANCESRESfDENT1AL
JOB DESCRIPTION
PANELSaf
inhSecBc 7000)ofDrv1s3oltheBudnexuand lmfesdonsCodeand my
,
lirroxinhill
effect
License CIa ti
UPTO2DDAMPqP
_
Date ConContndor r
ARCHITECTS DECLARATION
e used as public rerds
I understand my plans shag bco
^FA
701-1000 AMPS
OVERI000AMP5
SQ. FT. FLOOR
SM.FT
SIGNS ELECTRICAL
Licensed Professional
SPFCIALCIRCUIT/MISC
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors License Law for the
TEMP. METER OR POLE INST.
following reason. (Section 70315, Business and Professions Code: Any dry or
muntywhich requiresa pemdt tommtmM alter, improve, demlLL h, orrcpair
anyrtacturc priortolb Lwranee,alw requires NeappBantfm cued pemdt to
fide a signed statement that he b licensed pursuant to the provisions of the
POWERDEVICES
SWIMMING IDOL ELECTRIC
OUTLETSSWTTCHESFIXTURFS
Contnnors License Law (Chapter 9(mmmeneing with Section 7000) of Divi-
slon3 of the Business and Profemlans Code) or that heir exempttherefromand
the basis for the alleged exemption. Any violation of Section 70315 by any
fora permit subjects the applicant to a civil penalty a not more than
VALUATION
��
3,1000applicant
five hundred dollars($SM.
F1I, as owner of the property, or my employees with wages as their sole
NEW RFSIDEN'flAL IiLECTR SQFI.
OWES IYI' CONSTRUCTION
mmpensation,willdo the work, and theswcture is not intended or offered for
sale (Sec 70K Business and Professloru Code: The Contractor's License Law
it. nm.pply to an owner a pmpeny who Wilds or improves the.,and
who docs such work himself orthrough his own employees, provided that such
OCC.GROUP RFS. UNITS
TOTAL:
ImprovemcNs are not intended or offered for sale. If, however, the building or
Improvement Weld within one yearofcempletion, the owner-builderwlll have
tis rdenaf proving that he did not build or Improve for purpose of sale.).
QTY..` PLUMBING PERMIT. FEE'
FLOOD ZONE APN
Lj L u owner of the property, am exclusively contracting with licensed
conrndors to mnsw6the prof t(Scc 7014 Businessand Professlom Code:
PERMIT ISSUANCE
The Contractors License law does not apply to an owner of property who
builds or improves therem, and who contracts for such pt jecb with a
eqW[actor(gEcensed pursuant to the Contnctor'a License Law.
L j I am exempt under Sec B & P C for this reason
ALTER -DRAIN & VENT- WATER (M
FEE SUMMARY ^;
"
BACK FLOW PROTECT. DEVICE
.
DRAINS. FLOOR ROOF, AREA, COND.
SANITARY RECEIPT N
Owner Date
WORKMAN COMPENSATION DECLARATION
1 hereby affirm that I have • cenlBate of consent to self -insure, ora
ni0aeo(Workeri CompensaHan Insurance or a¢riffled copythim f(Sec.
380], lab CJ
F.IX.�IaEg.pgrUs
SCHOOLTAX Y_ N_
RECEIPT N
GAS EA. SYSfiM-1 WC40UTLllS
PARK FEE Y N
RECEIPT N
Policy N
Com ray
GAS FA. SYSTEM -OVER d (FA)
BUILDING DIVISION FEES
MCenlfied copy Is hereby furnished.
F-ICenified copy is filed with the city imp anion division.
GREASE/WDUSIRL WASTE INTERCEPTOR
PLANCHECK FEE
GREASE TRAP
CERTDICATE OF IXEMPFION FROM WORKERS'
PAID -L— 54o14
SEWER -SANITARY -STORM EA. 200FC
COMPENSATION INSURANCE
(this section need nor be completed if the permit is foto. hundred dollars
(SIM)orless.)
I certify that N the performance of the work forwhich this permit Is issued,
Date Recei t#
WATER HEATER W/VENT/ELECTR
ENERGYFEE _ N_
WATER SYSTEM/TREATING
I shall not employ any person In any manner so as to become subject to the
WorkeCompensation Laws of California. Date
rs
Apphemt
PAID
Date Recei t#
NEWRERDENTIALPLMB. SQFT.
NOTICETO APPLICANT: R, after making thus Certificate of Exemption, you
should become subject to the Wurkeri Compensation provisions of the Labor
TOTAL:
BUILDIN(- 1717P r63 00
Code, you twin forthwith comply with such provisions or this permit shall be
SEISMIC FEE
deemed revoked.
CONSTRUCTION LENDING AGENCY
Ihereby a(fimnthnr there ba construction lending agency for the perform
is
ance of the work for which this permit issued eiec. 3897, Civ. C.)
lender's Name
Lenders Address
TOTAL:
ELECTRIC FEE
PLUMBING FEE
QTY. 'r l' MECHANICA6 PERMIT . FEE .'
MECHANICAL FEE
Icentfyth.tlhavercadthuappli.ti.n.M statethattheabovelnfonrutlon
Is correct. I agree to comply with all city and county ordinances and state laws
relating to building ronstructlon, and hereby authorize reprc.+entatives of thin
dry to enter upon the xWvcmentioned property for inspection purposes.
(We) agree to save, Indemnify an it keep harmless the City of Cu pen Ino
agabotll.b tiespdgments, ortsarid expenseawhichmaylnanywayacwe
PERMIT ISSUANCE
FEES PAID:
x.16- 90
Date Receipt#
ALTER ORADDTOMECH.
AIRHANDUNGUNTT(I'010,000CFM)
SUBTOTAL: 3 a
NR HANDW NC UNH (OVER IO,000CFM)
CONSTRUCTION TAX
against sal ftyimm� ry" ofthegrantiagofthisperrnit.
-�� N
ga rent Appga t ntramar Date
DOUS MATERIALS DISCLOSURE
Will the applicant or future building o pant store or handle hazardous
EXHAUST HOOD(W/Dl1CD
CONSTRUCTION TAX PAID:
Date Recei t#
HEATING UNIT (TO 100,000 BTU)
material as defined by the Cupertino Municipal Code, Chapter 933 and the
I ealth and Safety Code Section 25533(a)3
❑ Yes MN.
Will the applicant orfuturebullding occupant useequlpment or devices
which emit hazardous air mntandants as defined by the Bay Area Ale
Quality Management Dlstnct7
Ye No
have read the hazy nus matenab rcquimmenn under Chapter 6.925 of
` the alifornia Health&SafetyCede Sections 25505,25533 and 25.534.1
C
I understand that if the building does not cametly have a tenant, that it is my
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
VFNIILATION FAN (BINCLE RESLD)
ISSUANCE DATE
a .ND
.JAN
BOILER -COMP OPE' OR 100,000 BTUs
BORER-COMP(OVp2100,00) BTU)
NETV RESIDENTIAL MECH. SQFC.
responsibility to notify the occupant of the requirements which must be met
a�a ^
QtY binert
prior to issuance ofa Certificateof Occupancy.
VI
s1lJ �IRS
ISSUED BY_"""'Y'�
Owner or authorised agent Dare
TOTAL:
OFFICE COPY