20682APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
BnRdin Ponied Identification/ T
Building Address: I11(.o
PERMITNO.
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CITY OF CUPERTINO-BUILDING DIVISION'
APPLICATION / PERMIT
A
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ort a daName: - _ uc. No:
BUILDING-ELECTRICA PLUMBINGMFCPIANICAL
CATEGORY CONlAOLjI� 1
100 `I J
Architect/EnginRn Lk. No:
QTY _ ELECTRICPERMIT FEE
BUILDING PERMIT INFO
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Address: '� �UuC7�rir)2
ex
PERMITISSUANCE �./
APPOANCESRESIDENTIAL
LICENSSE O A OR' D: R ON
I hereby affrmthat l arelicensed under provfelonsof Chapter9(commnic
OB DESC ON
Ingwith SMion7OOD)of Dlvision3ofthe Buslnessand Prolid sionsCode, and my
Iicensc la in I If 'and off of
License C n, Lk. N
PANELS
_
/j7—��—��-/�)�� }
• •N—/ r L
Date Contractor P
ARCHITECTS DECLARATION
I orders and my plans shall W used as public records.
"
201-IODOAMPSS
OVERI,,,AMI'S
SQ. FT. FLOOR AREA) /
E/e.Q, FT.
LicensedL Professional
SIGNSELECTRICAL
P+s V
SPECIAL CIRCUIT/MISC
OWNER -BUILDER DECLARATION
I hereby affirm that lam exempt from the Cont ractors License Law for the
following reason. fSeRlo^7MIS, Business and Professions Code: Any city or
cwntywhich requiresa permit tocuestruct, alter, improve, demolbh,or repair
L,J'lil (J
TEMP. METER ORPOLE INST.
anystructure prior to its issuance, also requiresnheappliant fns such permit to
file a signed statement that he Is liwnsed pursuant to the provisions of the
POWER DEVICES
SWIMMING POOL ELECTRIC
_
OUTLETSSWITOFEFSFIXTURFS
Contractors License Law (Chapter 9(commencing with Section 7000) of Divi-
sl0n3 ofthe Busindeand ProfmdonaCde) nation he tsexempt therefromand
the basis for the alleged exemption. Any violation of Section 7631.5 by any
oppliantforapermitsub(ectstheapplkanttoadvllperultyanumoretlwn
VALUATION
YVS L. -
fivehundrddollan($S00).
❑ I, as owner of [he property, or my employees with wages as their wk
compemadon,wllldothe work and thestructumisnot intended or offered for
sale (Sec. 70dd, Business and Profmlom Code: The Contractors License Law
NEW RISIDENTIAL ELECTR SQ .FT.
STORIES
TTTE CONSTRUCTION
TOTA
does not apply to an owner of property who Wilds or improves thereon, and
who doessuch work himself or through hisownemplcyees, provided that such
improvement are na intended proffered formle. IL however thebullding or
OCC. GROUP
RPS. UNITS
Improvement Lssold within oneyearofcompletion, theowner-bullderwill have
thMen of pmvingthalWdid not build orlmprove for Purpose ofsaleJ.
6O L as owner of the Property, am exclusively contracting with licensed
to construct the project (Sec. 7644 Business and Professions Cde:
-
QTY. PLUM I Rrni
FLOOD ZONE
APN
P
TJhneu�anon
o^tenor's License Law does not apply to an owner of property who
Wilds or improves thereon, and who contracts for such ptojects with a
ryDljanor(e) homed pursuant to the Contractor's License Law.
LT I am exempt under Sec. B k P C for this reason
AL - I
BAIX T.DEV
FEE SUMMARY
DILAIS NF
SANITARY RECEIPT N
Owner Date
WORKMAN COMPENSATION DECLARATION
❑I hereby affirm that 1 have a certificate of consent to self -Insure, ora
certificate of Workers Compensation Insurance ora certified copythereof(Sec.
3800, Lab C.)
FIXWRES PER TRAP
SCHOOLTAX Y_ N_
RECEIPT N
GAS EA.SYSTEM-1 WCAOUTLEIS
PARK FEE Y N-
RECm'T p "
Policy N
Com any
GAS EA. SYSTEM -OVER 4 (EA)
BUILDING DIVISION FEES
EfCertifled ropy Is hereby famished.
❑ Certified copy Is filed with the city Irepe Man division.
GREASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE
GREASETRAP
CERTIFICATE OF EXEMPTION FROM WORKERT
PAID
SEWER-SANITARY-STORMEA.200FT
' COMPENSATION INSURANCE
(Dissection need not W complend If the permit is for one hundred dollars
($100) or less.)
I certify that N the performance of the work for which this permit is fssud,
1 shall not employ any person in any runner so as to become subject to the
Workers Compensation Laws at Ca1Borao. Date
Applicant
NOTICETO APPLICANT: If, after making this Certificate of Exemption, Y.
should become subject to the Workers' Compemation powul ro of the Labor
Cde, you most forthwith comply with such provbiom or this permit shall be
Date Reeei t#
WATER HEATER W/VENT/ELECTR
ENERGYFEE Y N—
PAID JJ<
Date Recel t#
171
WATERSYSTEM/TREATINGl
NEW RESIDENTIAL PLMB. SQ -FT.
TOTAL:
-
BQIL12INQ
SEISMIC FEE r -
deemed "'mhed'
'CONSTRUCTION LENDING AGENCY
IherebyaBlrmthalthere bacorsmudon lendingagency forthe perform:
arm of the work for which this permit b bound (Sec. 3097, Civ. C.)
ledeName
Lebeness Aaamaa
TOTAL:
2
ELECTRIC FEE via t
PLUMBING FEE O.
TY, MECHANICAL PERMIT E
Q FEE
FEE i7.2
Icertify that l have mad this application and state that the above Information
b corrca.Iagree to comply with act city and county ordinances and state laws
elating to building construction, and hereby authodre representatives of this
city to enter upon the above-mentionod property for inspection purposes.
PERMIT ISSUANCE
FEES PAID:
'
Date Receipt#
ALTER OR ADD'IO MECH.
(We) agree to save, Indemnify an d keep harmless the City of Cupertino
ago ilithw,jadgmenb domandexperi.whlchmayleanywayaccrue
.it dCity lAh done etre fth anungwmbpermi
AIR HANDLING UNIT (TO 10,000 CFM)
"-SUBTOTAL:
AIRHANDLING UNIT (OVER 10,O110CIM)
CONSTRUCTION TAX 7j
t _
9GJ�j
IXHAUSi HOOD(W/DUCT) -
CONSTRUCTION TAX PAID:
Date Recei t#
Sigto " Ilca^t/Cont tar to
1 HAZARDOUS MATERIALS DISCLO U
e applicant or future building occupant store or handle hazardous
material as defied by the Cupertino Municipal Code, Chapter 9.12, and the
livalthardSafetyCode Section25532(a)P
❑ Yes in No '
Will the applicant ufflutur, building occupant use equipment or devices
PLEATING UNIT (TO IfD,000 BTU)
HEATING UNIT (OVER 100, 0BTU)
TOTAL'
VENTILATION FAN(SINGLE RESID)
ISSUANCE DATE
which emit hararelous air contaminants as defteed by the Bay Area Air
Quality Management trin7
BOILER -COMP OTB'OR IW,IXD BTU)
Yes o
Thavereadtheh oNmutedalsmquimr nbunderChapter6.95of
the California Health k SafeyCdeSection 25505,25533 and 25534. 1
understand that if the building dcesnot currently have a tenant, that it b my
tytoytheo panto thereq ircmentswhich mustb rte
nor aa
pain roisuance Ca fi teof Occupancy:
rrA4V �j 'T /�
I„11 1 ��}(7
C
BY�
UEDV.
BOILER-COMP(OVER100,000 BTU)
NEW RESIDENTIAL MECH. SQ.FT.
TOTAI
)boozed t Date Z
OFFICE COPY