23693•
•
OZ
z
f: N
Q j
Wp
(L
D Z
Uo
U. ~
OW
r a
F N
Z
U—
APPLICANTTO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification
B"'Idmg Address:
i®3�a I��TAaw)0 C.+
PERMIT NO.
23693
nevaName:
"LAU-eQ
CITY OF CUPERTINO- BUILDING DIVISION
APPLICATION / PERMIT
BUILDING-ELECTRICAI.PLUMBING-MECHANICAL
A
Contactor'a Name:
W r- J�''�� I
CATFiGORY CO OL N
BUILDING PERMIT INFO
Architect/Engineer. Lic. Nor
QTY ELECTRICPERMIT FEE
( q Imu /
Address: P.Q. 60Y'37J 5•J' GA' I!
SLUG ELELI PLUMB M�H
� 1:1 1:1 1:1LICENSED
PERMIT ISSUANCE
CONTRACTOR'S DECLARATION
I hemby affirm that l am licensed under Emulsions of Chapter 9(commene
ingwith Sretion700Tof Divislon3 ofthe Businessand PrefeadmosCode, and my
license Is In full fora and died.
LicenseCbss LIt.I
Date Contactor
ARCH1=5 DECLARATION
I understand my plans shall be used as public remMs.
Licensed Professional
OWNER -BUILDER DECLARATION
I herebyallrmthat l am exempt fromlhe Contractors Liana Law for the
following reason. (Secootlon 78)1.5, Business and Professions Cole: Any city or
cntywhichrequlresapermRtommtmd,alteglmprov demlB h,orrepair
anysuuctom priorto its bsuance,abe, requirestheappBant forsuch perouto
file a signed statement that he b Ilecrud pursuant to the powbioru of theFIA
Contrador'sLicense Law (Clupter9(commencing with Seaton 7000) of Divi-
alon 3 of the Business and Profevbr eCode) orthat he is exempt therefromand
the basis for the alleged exemption. Any violation of Section 7031.5 by any
applicant fora permit subjects the applicant to a civil penalty of not morethan
five hundred dollar. (SM.
❑ I, as owner of the property, or my employees with wages as their sob
compensation, wllldothe work, andthe structure is not Intended or offered for
sale (See. 7014, Business and Professions Code: The Contactors License law
don, not apply to an owner of property who builds or improves thereon, and
who docasuch work himself or through his own employee, provided that such
improvements arc not Intended... fered forsake. If however,thebuildingor
i pmven ntbwldwlthlnomyearofcompldWgtheawner-bWlderwillhave
th,s*rdan of proving that he dideut build or improve for purpose ofsale.).
u L as owner of the property, am exclusively contracting with licensed
contad.rs to construct the project (See 700 Business and Professions Code:
The Contractor's License law doe not apply to an owner of property who
or improves thereon, and who contain for such projects with a
do,(.) licensed p. onancto the Contractor's License Law.
LJ 1 am exempt under Sec B k P C for this reason
APPLIANCES -RESIDENTIAL
JOB DESCRO'HON
�1' ♦��
PANELS
UP TO 2DOAML�-
201-1000 AMPS
OVFRIODOAMPS
SQ. Fr. FLOOR AREA $/SQ. FT.
E1♦`1 '
L.-. Ind' 9 V
+� R�
) �I'
E ! lit l
4z
SIGNS ELECTRICAL
SPECIAL CIIICNT/MISC J I V IS
/
TFl`(P'MEI'CR OR IDLE INST. (', iJ IC
POWER DEVICES
SWIMMING POOL ELECTRIC r'
OUTLETSSWITCHFSFTXTURES
VAL
! O
Sb
NEW RESIDENTIAL ELECTR SQFf.
STORIES TYPE CONSTRUCTION
OCC.GROUP RES. UNS
TOTAL:
QTY. PLUMBING PERMIT FEE
FLOOD TONE APN
PERMIT ISSUANCE
ALTER -DRAIN k VENT WATER (EA)Wilda
FEE SUMMARY
BACKFLOWPROTECT.DEVICE
—
DRAINS FLOOR, ROOF, AREA, COND.
G,
N_�
SANITARY Y_ RECEIPT N
Owner Date
WORKMAN COMPENSATION DECLARATION
[:]I hereby affirm that I have a arti0ate of consent to self -Insure, ora
certificate ofWorkers'Compenaation Insurance or a aalfkd copythereof(Sec.
380, lab C.)
FIXTURES. PER TRAP
SCHOOLTAX Y N
RECEIPT If
GAS F.A. SYSTEM -1 INCA OUTLETS
PARKIN Y N
RGCG[I'T p
Polity a
Com any
GA. SYSTLTI-0VER d (EA)
S EA
BUILDING DIVISION FEES
❑Certified copy b hereby furnished.
❑Certified copy Is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(This sedioned neout W completed lithe permit b for one hundred doklae
(81 Wl or less.)
I Batty that in the performance urine work (..which mice permit b issued.
I shall not employ any person In any manner so as to become subject to the
Workers'Comp� tion laws of aBemi. Date—li_gL
App@ant—plQl'e1A
GREASE/INDUSI'RL WASTE INTERCEPTOR
PLANCHECK FEE
PAID
Date RCtt`I tin
GREASE TRAP
SEWER -SANITARY -STORM EA.2fXIFI.
WATER HEATER W/VENT/ELECTIR
ENERGY FEE Y_ N_
PAID
Date Racei Iq
WATER SYSTGI/TREATING
NEW RESIDENTIAL PLMB. SQJ.T.
a
making
NOIICETON' ANT: orkersk om a sationCertifaviste of Exemption, you
after
should bemrrc subFxt to the Workers' Compensation provbi.na.(the Labor
Cdq you at forthwith comply with such provblona.rthb permit shall be
domed revoked.
CONSYRUCPION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the perform-
ance of the work for whlch thb permit Is Issued (Sec. 3097, Cro. C)
Lender§ Name
Landers Addreaa
I omifythat I have mad this application and statethatthe above Information
is correct. I agree to comply with all city and county ordinances and pate laws
relating w building construction, and hereby authorize representativesof this
city to enter upon the aWve-mentioned property for inspection purposes.
(We) agree to ave, Indemnify an d keep harmless the City of Cupertino
agaimt liabilities, jadgna nts, costsand expends which may In any way accrue
against ity In uence of the gran ofthll,Regnit.
Sigf.WA of Ap liant/ComractF R• Date
HAZARDOUS MATERIALS DISCLOSURE
Willtha.Pplicant or future building occupant store or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.1 2, and theL-
I lealth and Safety Code Seeti.n 25532(a)?
❑ Ye [n No
Will the applicant or future building occupant use equipment or devices
which rout hazxNous air contaminantsas defined by the Bay Area Air
Quality Management District?
Yes
4havemad the ❑ No
F N materials requ immots under Chapter6.95of
the Ca Biennia Health 6 Safety Code, Sections 25505, 25533 and 25534. 1
understand that ifthe xilybuilding
occupoes of notcurrentlyhaves tenant, that it Is my
responsibility craw rad
to nBitythe occupant ofthe requly have requirements itbe ret
prior to issuance of a Certificate of Occupancy.
TOTAL:
BUI
SEISMIC FEE
—
TOTAL:
ELECTRIC FEE
PLUMBING FEE
QTY. MECHANICAL PERMIT FEE
MECHANICAL FEE
PFRMITISSUANCE
FEES PAID:
ALTERORADDTOMECH.
Date RfCCIP[ii
AIR HANDLING UNIT (TO 10,000 CFM)
SUBTOTAL:
AIR HANDLING UNIT (OVER 10,WOCIM)
CONSTRUCTION TAX
EXHAUSTHOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HEATING UMTUO 100,0001HU)
Date Receiptin
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
VENTILATION FAN(SINGLE RESID)
ISSUANCE DATE
n
tl" a'9
/IMAY 1 5 T9
ISSUED BNt e a '
Q(T
BOILER -COMP (3111' OR 100,0(* BTU)
BOILER-COMP(OVER 100,000 BTU)
NEW RESIDENTIAL MECH. SQ.FT
Owner or authodnd agent Date
TOTAL:
OFFICE COPY