24104APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Pro'ed Identification
Building Address: 3G Q�� I
PERMIT NQ. 4 1 0 4
Z
one:
LI—IL Lssda-
CITY OF CUPERTINO6BUILDING DIVISION
APPLICATION /PERMIT
BUILDINGELECTRICALML BING-MECIIAMCAL
A
`
1. Z
or,Name: Lm°
. .
rcNtM/Engineer. Llc No:
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Address: 46T3�-iiRE (3RQf�
LI ENSEDCONTRACTOR'SDECLARATION
I hereby affirm that l am licensed under provisions of Chapter 9(commere
Ing with Section 7000)of Division 3 ofthe Business and PrefesslonsCode, and my
,teens la In full! ddfed.
Lioness Cla®— Lic.p .O
Date Contractor
ARCHITECT'S DECLARATION
I understand my plamsha8 be used as pubRcrccords.
Licensed Professional
OWNER -BUILDER DECLARATION
Thereby a(frmthat lam exempt from the ContractorsLlrenae law (or the
and Prolevna Code!.1z dtyor
following reason.(Sectlon7031.5, Businmlo
countywhich requiresa permit tocorutruct, alter, impmve,demolbh, orrepair
snystmeture pdorto its issuance, also requireatheappliant farsuch permit to
file a signed statement that he Is licensed pursuant to the provisions of the
Contractors License Law (Cha pter9(commencing with Section 7000) of Divi-
don 3ofthe Businmand ProfmWm CWe)orthat he b exempt thercfwmand
the basis for the alleged exemption. Any Notation o15c tion 7fDIS by any
applicant fora permit subje is the applicam to a dvil pensley of na re nnthan
Me hundred dollars ($500).
❑I, as ownsr of the property, or my employees with wages as their sok
compensation,willdothe work andthe summers b not Intended or offered for
sale (Sec. 7044, Business and Professions Code: The Contractors License Law
does not apply to an owner of property who Wilds or improves thereon, and
whodocssuchworkhlmsclf orlhrough hisownempioyecs, provided that such
Improvements are not intended oroffered for sale. I( however, thebuilding or
improvement iasold within °neyearofcompltioe, the owner -builder will have
tl)9kurdenofpmving that he did not Wddorimprovefmpurposeo!sale.).
u L as owner of the property, am exclusively contracting with limned
contractors to construct the project (Sec 7044, Businm and Profmbns Code:
The Contractors Lioness law does not apply to an owner of property who
Wilds or Improves thereon, and who contracts for such InojeM with a
g5.,car(s) licensed pursuant to the Contractors License Law.
cgR((a
am exempt under Sec. B & P C for this masonOUTSIDE
CATEGORY
CON'}I�I/L
QTY ELECTRIC PERM FEE
BUILDING PERMIT INFO
PER.WTISSUANCE,
APPLIANCFSAE E
JOB DF$ JUJ-1 ION
AM � O
iF�I
PANELSI!'T,
Im T1.
1-1 PS
AMPS
SQ. Fr. FLOOR AREA
g O
~I _loll
��i ft 1
V Iss�
$/SQ.FT.
X2i8
(i
G N S E A
\ SPECIAL MI
P.M OR LE INST.
POWER DEVI
SWIMMIN POOL ELECTRIC
OULLETSSWITCH6SFIJCfURES
wwwVALUATION
!,
NEW RESIDENTIAL ELECTR SQ.FT.
STORIES
LYPECONSfRUCTION
OCC.GROUP
RTS. UNITS
QTY, PLUMBING PERMIT FEE
FLOOD ZONE
APN
PERMIT ISSUANCE
FLIER -DRAIN &VENT -WATER (EA)
A Cc__
FEE SUMMARY
BACX FLOW PROTECT. DEVICE
FEES
SANITARY ftFO N
Owner DateDRMNSFIOOIEROOP,AREA,COND.
WORKMAN COMPENSATION DECLARATION
❑I hereby affirm that I have a ontifiate of conssm to self -insure, or
mAifiate of Workers Compansation Insuranre or a atified copy thereof(Sec.
3800, lab C.) „ _
IkyN
Cam any R
rtBud copy b hereby famished.
❑ etlfied copy V filed with the dty inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(rhlssm, on need not be completed B the permit Is foram hundred dollars
($1M) or lm)
1 cemlytha N the performance ofthe work forwhich this permit Is issued,
I shall not employ any person in any manner so asto became subject to the
Workers Compensation Laws of California. Data
Applicant
FIXTURF'PFR TRAP r
SCHOOLTAX Y_ N_
RECEIPT a
GAS EA. SYSTEM -1 INCd DIITLETS
PARK FEE Y N
AINN
GAS EA. SYSTEM -OVER FA
VEft4()
BUIL DING GDIDIVI51 NFEES
GREASE/INDUSIRL WASTE INTERCEPTOR
PLANCHECK FE�
PAI nollI
to LI t#
` C
7.d
GREASE TRAP
SEWER -SANITARY -STORM FA. XVFr.
WATER HF.ATFRW/VENT/E.ECTR
ENERGYFEE Y N_
PAID
Date R 1 f#
WATER SYSITAf /TREATING
NEW RESIDENTIAL PLMB. SQ.Fr.
ite of Exemption, you
NOTICE TO APPLICANT: Il, after making this Cetfia
should become subject to the Workers' Compensation provisions ofthe Labor
Cade, you must forthwith comply with such provisions orthb permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a mretrution lending agency forthe perform-
an ofthe work forwhlch this permit b boved(See. 3097,CIv.C.)
lenders Name
Lender's Address
I aNlythat I have read thisappliationand statethattheabove Information
bcattract. la to comply with all dtyand county ordinances and state laws
horize representatives of this
relating to it ng rareV.edpmpNen"tyfo'buPW1orPurPam`
city to en r thea vfor inspection purposes.
(We) u an 'as
an the City ofCupertino
s,ju, n hich nuyle anywaymeme
zgabIzlzstsaid !yin nof Ed I
�
Signsture f p0 t ontraeto Data
H RDOUS ATERIALS DISCLOSURE
Will the applicant oreurebudingoccipan ode, hhand le hazardous
eatetal as defined by the Cupertino Municipal Code, Chapter 9.1Z and the
alth and Safety Cade Section (a)i
Pk=(a)?—�
❑ Yea jkN°
the applicant orfutum building occupant use equipment ordevices
which emit harardous air contaminants as defined by the Bay Area AU
Quality Management District?
Yes MN.
have read the h. -M., materials requirements under Chapter6.95 of
the California Health & Safety Code, Sectioes 75505, 75533 and 75534. I
understand that if the building don not currently have a meant, that it E my
responsibility to notify the occupant of the requirements which must be met
prior to Lssuancc of a Cert1(Icato of Occupancy.
TOTA -
BUI
A
SEISMIC FEE
T
ELECTRIC FEE
PLUMBING FEE
QTY. MECHANICAL PERMIT FEE
MECHANICAL FEE
PE4MIT ISSUANCE assa's,
11
FEES PAID:
ALTER OR ADD TO MECH.
Date RCOTALagaust0obili'
-
AIR HANDLING UNIT(T010,000 CFM)SUBTOTAL:
MRHANDLING UNIT (OVER I0,000CFM)
CONSTRUCTION TAX
EXHAIJSTHOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HEATING UMTCIO 1fD,0008L1n
Date RCC 1#
TING UNIT 100,000 BTU)
HEATING ER
TO
VENTILATION EAN(SINGLE RESID)
a—Will
ISSUANCE DATE
UU
SEP�Jr. 11gg2
�(��ss��,r...�//,�I������.
ISSUED BY: �•� ryurrnIByu
BOILER -COMP OHP OR 100,000 BTU)
BOILER-COMP(OVER 100,0(0 BTU)
NEW RESIDENTIAL MECH. SQ.Fr
Owner or authorized agent Date
OFFICE COPY