21083APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification
Build Ing Add ra.s:
100 IMI ¢ ,
PERMIT NO.
f") al O �'1
G I I8 3
wnerfj{1�y� Ta•r' ` 'r G1� of wn :
f] �13
CmArachm's Name: Lie. o:
CITY OF CUPER17N0.DUILDING DIVISION
APPLICATION I PERMIT '
BLILDING-ELECTRICALPLUMBINC-MECHAMCAL
��I� C C
CATEGORY
CO OL78 _3
L��J
Arc r/Engineer: LIc, No:
GL G
Address: I Imo' i G tw II )/1_I,�A G'tiv
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that am licensed under provisions of Chapter 9 (comourno
ingwith Section 7000) of Division 3 afthe Bual remand PrefnsionsCode, and my
license I. I. full force and effect.
Date Contactor
Date Clan Cont
ARCHITECPS DECLARATION
]understand my plarushall beused u publleremrds
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirmthat I am exempt from the Contractor's Licenu law for the
following reason.&at.70315, Business and Professions Code: Any city or
county which requbea a permit to construct, alter, Improve, demolish, or repair
anystructure prior to its lsauance, also requlresthe applicant(orsuch permit to
file a signed statement that he Is licensed pursuant to the provialos, of the
Contractor's License Law (Chapter 9(commencing with Section MOO) of Divi.
adon3 o(the Business and Pmtea kmsCade).,that he fat exempt therefromand
the bash (or.the alleged exemption. Any violation of Section 70315 by any
applicant furs pimitiubj.hatheapplicant toacivil penaltyofnot nnnthan
five hundred dollars (5500).
fI L as owner of the property, or my employees with wages as their sok
compensation,willd.the warOnd thestructere is not intended or offered for
sale (Sec 7066, Business and Professions Code: The Contractors License law
does not apply to an owner of property who builds or improves thereon, and
d.,.6 work himself or through his own employees, provided that such
improvcerentaere not Intended orof(ered forsale. If, however, the building or
Improvementbsbld wlthinoneyearofcompletion,the owner-bullderwill have
the of proving that he did nm build or improve for purpose of sale,).
as owner of the property, am exclusively contracting with licensed
mutont. onnm.ict the project (Sec. 7014, Business and Professlons Code:
Contractor's Llcesae Law don nu apply to an owner of property who
Wild. contracts or Improves thereand who contrafor such p(ojem with a
ryB(ractor(.) ficensed pursuant to the Contractor's License Law.
0I am exempt under See. B k P C for this romn
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
y 13 r� LU MB mi�H
w Jia
PERMITISSUANCE
APPLIANCESRESIDENMI,
JOB DFSCRE'TtON
't C
F= J aZ
L) PGV DE
�'�tl'TY
PANELS
MI -IOW AMPS
OVERiWOAMPS
SQ. FT. FLOOR AREA
f/SQ. FC.
SIGNS ELECTRICAL
SPECIALCRCUIT/MI5C
TEMP. METER OR POLEINST.
POWER DEVICES
SWIMMING POOL ELECTRIC
OLULET58WITCHESFlXTURES
VALUATION
NEW RESIDENTIAL ELECTR
RIES
TYPECONSTRUCTION
,
TOTAL:
QTY. PLUMBING PERMIT FEE
OCC, CROUP
RES. UNITS
PERMIT ISSUANCE IZm
-
ALTER -DRAIN [e VENC - WATER (FA) p[j
2.
FOOD ZONE
APN
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
OUTSIDE FEES
DRAINS FLOOR ROOF, AREA, COND.
�tTIREs PER TRAY �
SANITARY Y_ N_
RECEIPT s
Owner Date
WORKMAN COMPENSATION DECLARATION
Q[ hereby affirm that I have a certificate of consent to self -Insure, ora
cern,lC.) orken'Compensadon lrsurance ora rertl(led copy theroa((Sec.
3800, ab CJ
Lab
Policy M
SCHOOL TAX Y N
RECEIPT Y
GAS EA. SYSTEM -1 INCAOUTLETS
PARK FEE Y N
RFCEl 8
GAS EA. SYSTEM -OVER 4 (RA)
Com any
BUILDING DIVISION FEES
Certified copy is hereby th the ed.city
r-1 Certified copy hfiled with the dly lupectbn division.
CERTIFICATE OF O(CMPCION FROM WORKCRS'
COMPENSATION INSURANCE
(Thiess s.) need not be completed It the permit is for one hundred dollars
($1 Wor
)fess0
Ill not employthat In any pehe oron In an thunnere work so n to b bumshis subjeormit I. Issued,
I shall not employ any pLabn In any manner ro u m become subject to the
Workers' Compensation Laws of California. Date
Applicant
rakermaking this
NOTICE TO subject to ..it..C.mfloue
p,.I.Exemption,you
Compensationprovhis p ofthe Labbe
sowedbecome .forth tothe ply with
Cade, you must forthwith comply with such provlslou .,tole permit shall be
.)come.) revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there Is a construction lending agency for the perform
ance ofthe work for which this permit is Issued(Sre. 3097, Civ. C.)
Landers Name
1 cedifythatl have read this application and stauthat theabove Informationis correct. I agreeto comply with all etyand county ordinances and state laws
relating to building construction, and hereby authorize representatives .(this
city to enter upon the above-mentioned property for Inspection purposes.
(We) agree to ave, indemnify an d keep harmless the City of Cu pert Ino
agalnat Ba es,judgments, cossand expenses which may In anyway amue
agalubal try irouseq nc of grantin pt this permit.
np_j f
Data
SI vurcoppHAATEF IALS DISCLOSURE
Will the applicant or future b ading occupant store or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.1 7, and the
I le❑alt'a od Safety Cade, Section 25537007
Will the applicant orlumrc building occupant use equipment or devices
which emit haxardous air contaminants as defirad by the Bay Area Air
Quality Management District?
Yet
F1 Yes No
read the Fara ocN materials requirements under Chapter 6.95 of
the California Health A Saf Code, Sections 75505,75533and 75536.1
understand that if the Wilding don not currently have a Iennnt,that It h my
rampant of the rcqulrenents which must W met
req
responsibility to of a Certificate
prior es Issuance of a y the oc to of Occupancy.
CREASE/INDUISTRL WASTE INTERCEPTOR
PLANCHECK FEE
j,AIDI`r{�0
Date Recei t#
GREASE TRAP
SEWER-SANITARYSTORMEA700FT
WATER HrATERW/VENT/GLECTR
ENERGYFEE Y N —
PAID
Date Remi t#
WATER SYSTEM/TREATING
NEW RESIDENTIAL PLMB. FC.
TOTAL:
D Nin, FEE
MIC FEE
,y
TOTAL: �Lr�
TRIC FEE
rE
QTY. MECHANICAL PERMIT FEE
MBING FEE COLender'sAddrea.
HANICAL FEE
PERMIT ISSUANCE
PAID:
Date Recei t#
P
ALTERORADDTOMECH.
AIR HANDLING UNIT ITO 10,000 CFM)
SUBTOTAL:
AIR HANDLING=(OVER IO,ODOCI•M)
CONSTRUCTION TAX
EHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:anRDOU
Date Reeei f#
HEATING UNIT (TO 100,ODO BTU)
HEATING UNIT (OVER 100,000 BTN
TOTAL:
VENTILATION FAN (SINGLE RESID)
ISSUANCE DATE
Q w.w
PAMI
id�� Q J1( �
les g A
ISSUEDBY:
BOILER -COMP DHP OR 700,0410 BTU)
BOILER-COMP(OVER100,000 BTU)
NEW RESIDENTIAL MECH. SQ.17
Owner or authorized agent Date
TOTAL:
OFFICE COPY i
1
CITY OF CUPERTINO
INSPECTION DIVISION
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