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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project identification
Budding Address:
PERMIT NO.
22264
cone s ams ;1 one:
/) j' Uj�L� �!1
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION i PERMIT
l
oar. ame:
caner Lie. No,
') I
BUILDING-ELFCnUCAL•PLUMBING-MECHAMCAL
CATEGORY
CON7%IO aFM/ LQ
Archltett/Engimer. z Lk No:
/45L �2 72- IRQTY
ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Address: ,,M SF L/p 90/10
❑ ❑
PERMIT ISSUANCE �•
LICENSED CONTR'ACTOR'S DECLARATION
]hereby offbm/hat l am Licensed under pnwWonsof Chapter9(commne
IngwitieSecti.n7000)al Divinion3oflhe Bualwsand PrefessionsCode,and m
APPLIANCES -RESIDENTIAL
JOB DESCRIPTION
Breoee la In fuR and effect
Llcense_clsy�_Lic. X 1 3 7 3
PANELS
Date '•sur /A' �r ContraRor_
201-1000 AMPS
ara ARCHITECT'S {LpRAT10N
IudemtaMional ehaLihe used as pubecrcms rd
my
se
Licend Professional
OVER IOW
FT. FLOOR AREA
J w
S/ .FT.
0171 Ane`�
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC
OWNER -BUILDER DECLARATION
I hereby affirm that i am exempt from the Contractors License Law for the
following reason.(Section 7031.5, Busmen and Professions Code: Any city or
countywhich requbea a permit to cothm
.uct, alter, Improve, deolhM1, orrepalr
TEMP. METER OR POLE INST.
su
anyatcture prior to it. Issuance,also requires the applicant for such permit to
file a signed statement that he is licensed pursuant to the provisions of theO
POWER DEVICES
SWIMMING TOOL ELECTRIC -
/ OUTLETSSWITCHFSFD( URFS
Contractors License Law (Chapter 9(commencing with Section 7000) of Divi-
slor3 ofthelluslnessand ProfessimeCodO.,that he is exempttherefromand
the basis for the alleged exemption. Any Violation of Section 7031.5 by any
applicant fora permit subjects the applleam to a civil penalty of not more than
ALPATION
live 1, as ownerdollarof
Las owner of the property, or my amours n with wages sole
NEW RESIDENTIAL ELFCTR SQ,FT.
STORIES
TYPE CONSTRUCTION
compSec.70 n,wWBothework Intended., offeredfor
(Tac
file (Sec. 70K Profesgoratmcturch C
an Code: The CompactorsIlumm Law
to owner
wer of property
whodn" nm pplytorkhi n north pghhis be mplalds improve,pidedthat and
whodanauchwork hem eBarthrwgh hlaownemplgen, provided tM1atsuch
OCC.GROUP
RES WITS
Improvements arc not Intended proffered tarsale. If, however, thebulldingor
Impmvementiswtdwlthlnormyearofcomple ion,theowner-builderwlllhave
p
tifi¢+men of proving that he did nm build or Improve for purpose of Wei.
LI S as owner of the property, am exclusively contracting with licensed
contnn a.to con roct the Project(Sec 7004, Business and Professions Code:
QTY. PLUMBING PERMIT FEE
PERMIT ISSUANCE
FLOOD TONE
APN
The Contractors License Law docs net apply to an owner of property who
build. or Improves thereon, and who contracts for such p(ojects with a
fit(acro,(.) licensed pungent to the Contractor's Lt... Law.
LJ 1 am exempt under Sec B h P C for this reason
ALTER -DRAIN AVENT- WATER (EA)
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
DRAINS FLOOR ROOF, AREA, GOND.
PER TRAP
SANITARY Y N_
RECEIPT Y
Avner Date
WORKMAN COMPENSATION DECLARATIONI•D('fURFS
❑I hereby affirm that I have a certificate of consent to self -Imre, or a
3catfif80%lateofWorkeri Comper.atlon lruurancaore adi(kd copythemo((Sec.
Polis Lab C.)
P.IIry Y
SCHOOL TAX Y N
RFOE PT M
GAS EA, SYSTEM -1 INCA OUTLETS
PARK FEB Y N
Y
RECECAS
EA. SYSTEM -OVER 4 (EA)
Com any
DING DI
BULL DIVISION FE IS
ECerti ied copy h filedhereW tumts city
Certified copy h (fled with the city Impaction division.
CREASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE
CREASR7RAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
need fid becompleted B/he perrdt Jointure, hundrN d.11an
(D)
PAID
Date RCmI tM a�
SEWER.SAM.I.ARY-STORM EA 200F •
WATER HEATER W/VENT/E.FCTR
ENERGYFEE Y N
PAID
m Inttion
(5100).fcertifythat
Imfythat In the performance of the work for which this pertnithsued,
I shall not emplo any p n In any mnner w n me b'ctto the
step we of Gslf/}m elw.7]6L�%
WATER SYSTEM/]BEATING
Applian"
Applicant ,ralK�v,ahp2
Date Repel til
NEW RESIDENTIAL PLMB. SQ.FT.
NOTICET23 suboatotLICAT making pe tion penis Exemption, you
subp Workers' Com n pwvhlm of the Labbe
?OTA
Code,shmiyou =a
Code, you moat forthwith comply with such provislora orchis permit shall be
with co provinces permit
deemed revoked.
BUILDING •
CONSTRUCTION LENDING AGENCY
SEISMIC FEE
I hereby of con that there is a concoction lendlegageruy for the perform
ante of the work for which this permit h Lnued bee 3097, Civ, C.)
Landers Name
Laederb Address
I ndlfythatl have readthisappiicaflonand statethat theabove Information
].correct. l agerato comply with all cityand county ordinance, and gate laws
relating to building construction, and hereby authorize representetives of this
TOTAL:
ELECTRIC FEE
Q'IY. MECHANICAL PERMIT FEE
PERMIT ISSUANCE
PLUMBING FEE
MECHANICAL FEE
FEES PAID: 676
city to enter upon the above-mentioned property for inspection purposes.
(We) agree to save, Indemnify an d keep harmless the City of Cupertino
agalne bllltle., ju menta, co.ts.nd expense. which may In anyw accrue
A t dChy nsequenca oft of this permit.
C L
ALTERORADDTOMECH.
ate RCCCI fN
AIR EIANDLINC UMT(TO ID,ODO CFM)
SUBTOTAL:
AIR HANDLING UNIT (OVER I0,OD0CEM)
CONSTRUCTION TAX
gmtue of Appllcom/Contnctr I Date
EXHAUST HOOD (w/DI1CT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (TO 100,000 BTU)
Willthe applicant or future building occupant tom or handle hazardous
mtsrlal as defined by the Cupertino Municipal Code, Chapter 9.12, and the
Health and Safety Cade Settlor 25532(a)?
F1 yes No
Will the applicant., core building occupant use equipment or devices
Date Recei tic
HEATING UNIT (OVER 108000 BTU)
TO E
VENTILATION FAN (SINGLE RESID)
ISSUANCE DATE
which emir haardous air contaminants as defined by the Bay Area Air
Q11a.fity Management District?
Yn ❑❑ No
�k
AlDy�
BD
BOILER -COMP OEN OR 100,000 BTU)
BOILER-COMP(OVER 100,DBD BTU)
have read the Faardou.mredah requirements under Cha pier 6,95 of
the California Health A Safety Code, Seat.. 25505, 25533 and 25536. I
NEW RESIDENTIAL MECH. SQ.Fr.
understand that if the building docs not currently have a tenant, that It is my
responsibility
ponsibility to notify the occupant of the requirements which must be met
1 199
Prior to issuance of a Certificate of Ocwpa nq.
Vllil un UUrr"IFIV
ISSUE•DRY: V• �kVG�.I
/Tune, oraurharized agent Dare
TOTAL:
OFFICE COPY