21345APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification's
Building Address:
1 PERMIT NO.
IW
deRn�c �ossom P'R_
. 21345
rte. one:
A '
�� %iU 9i4La/aQ• a'JIS�–o2/0�0
CITY OF CUPERTINO, BUILDING DIVISION
APPLICATION / PERMIT
/�
C ttarue.No:
Ea
AlwmoelzQTY
BUILDING-E7.ECTRICAL-PLUMBING-MECHANICAL
CATEGORY,
CONTROLN
Architect/Engineer. Lk. No:
ELECTRICPERMIT FEE
BUILDING PERMIT INFO
Address: _
PERhITISSUANCE
ry
1:11:1-
LICENSED CONTRACTOR'S DECLARATION -
Iherebyaffbmthatlam Bcrosedunderpra ionsof Chapter9(mmmen
APPLIANCES-RFSIDENTIM,
JOB DGSCRBxIION
PANES
PANS
-
ingwith5edion7000)of Divisim3ofthe Businesand ProfemionsCode, and my
license is In fo deffect _
Wwnse VssG � LIC.N
Date ifs Contractor 040v /
F�aQCP/*
201-1000 PS
ARCHITECTS DECLARATION
I understand my plans shag be used as public records
OVER 1 AMPS -
SQ. FT. FLOOR AREA
$/SQ. Fr.
SIGNS ELEC -�
Licensed Protesiovl
IALCIFCNT/ML9C
OWNER -BUILDER DECLARATION
I hereby affirm that l am exempt fromthe Contractor's License law fm the
following reason. Section 70315, Business and Professions Gude: Any city or
cmntywhichmquiresapermittommtmd,alteglmpmve,demolbh,orrepair
anystmmmpdortolb Lsmance,a LsomqulrestheappBcant (ar such per ite
file a signed statement that M is licensed pursuant to the provisions ofl he
ContractoreLicense Law (Chapter 9(commencing with Section 7000) of F.
sion3ofthe Businessand Pmfemlom CWe)orthathebexempttherefmmi d
the basis for the alleged exemption. Any violation of Section 7031.5 bya
applicant for a permit subjects the applicant to a civil penalty Of not mom t, p
five hundred dollars (SM. \
nI, as owner of the property, or my employees with wages as their k
ompeneation,willdo the work,, and the structure Is not Intended or offeredrfor
silo(Sec7066,Busi and Prafesslom Cade:The Contractors Liconx Law
-
lex X a
TRUP ME[FR OR POLE INST.
it
p0 DEVICES
n wp _,
SWIMMINGPOOL ELCTRIC
It
1 �E' SWATCHES KrURES
NEWENTIAL EL TR SQ.FP.
-VALUATION
JTYPE
STORIES
CONSTRUCTION
does not apply to an owner of propertywho builds orlmprwes thereon�a
who doessuchwork himself orthraagh hlsownemployees, provided that such
impmvementsamnwt tendedorofferedfwule.lf,hmvever,thebuildingorU
OCC.GROUP
RFS. UNITS
.
TOTAL:
improvement bsold withinoneyearofcompletlon,theuwner-bullderwlllhsve
tryrden of proving that M did not build or improve for purpose of sale.).
tyL as owner of the property, am exclusively contracting with Huesca
contractors to construct the project (Sec. 70M Business and professions Code:
The Contractor's Llmnse law does not apply to an owner of property who
Willa or Improve thereon, and who contracts for Mach jr,j is with a
c n
I,-Jbactor(s) limed pursuant to the Contractors License Law.
I am exempt under Sec. B & P C for this reasonOUTSIDE
QTY, PLUM INGPERMIT FEB
ELGOD-eONE
APN
'
pFRMRISSIIAN
I
ALTER -DRAW &VENT- WATER (EA)
FEE SUMMARY
BACK FLOW PROTECT. DEV ICE
FEES
DRAINS FLOOR ROOF, AREA, COND.
SANITARY RECOPN
Owner Date
WORKMAN COMPENSATION DECLARATION
1 hemby afflmn that I have a certificate of concent la calf-inmrc, or a
e flute of Workers'Compersatlonlesurance or a unified copythemof(Sec.
38W,1ab CJ
FIXTURES- pEIt TRAP
SCI TAX Y N -
RECEIPT X
GAS EA.SYSTEM-i INCAOUTLLIS
PARK FEE Y N '
—
RF-CERPTN
PdkyX
Com an
GAS--0
FA' SYSEEMVER 4(EA)
BUILDING DIVISION FEES
ffCcrtiOed copy I; hereby furnished.
s�Certfe l ropy u tiled with the city Inspection division.
i' CERTIFICATE OF EXEMPTION FROM WORKERS'
CREASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECICFEE
PAID
GREASE TRAP
EA 200FT
COMPENSATION INSURANCESEWFRSANITARYS70RM
(This section need not be completed if the permit is for one hundreddollars
($100)orless.)
I umlythat in the performance of the work forwhich this permit b Issued,
Date RCcei t#
WATER HEATER W/VENT/ELILTR
ENERGYFEE' Y_ N—
-
WATERSYSTEM/TREATING
1 shall not employ any person in any manner, so as to become subject to the
Workeri Compensation Laws of California. Date -
PAID
NEW RESIDENTIAL PLMB. SQF.
Applicant
NOTICE TO APPLICANT: IL afier making this Certificate of Exemption, you
should become subjM to the Warkers' Compensation provisions of the Labor
Code, you Twat forthwith comply with such provlsloru or this permit shall be
decmedrevoked.
CONSTRUCTION LENDING AGENCY
Date Reuel t#
TOTAL:
BUILDING EE
�
SEISMIC FEE
O
TOTAL:
ELECTRIC FEE
I hereby affirm that there b a construction lending agency for the perform
ante of the work for which this permit Is Issued (Sec. 3097, Civ. C.)
Lender. Name
I.endce.Addme
Iurtifythat l have read thisapplicationand state that Neabove information
Iscomect. l agree to complywlth all city and county omLnanm and state laws
PLUMBING FEE
QTY. MECHANICAL PERMIT FEE.
MECHANICAL FEE
PERMITISSUANCE
a -
FEES PAID:
relating to building construction, and hereby authorlaerepresentative of this
city to enter upon the above-mentioned property for Inspection purposes.
(We) agree to save, Indemnify n keep harmiess the City of Cupertino
ug liabilities, ju g nb,metsa =p2 se which may In anyway accrue
ahis permit. tsald ty In roe /i4N•fc�e of ting of t
ll -If --90
%
_
ALTFRORADDTOMECH.
a
Date RCfCI(et#
AIR HANDLING UNIT (TO 10,000 OM)
SUBTOTAL:
AIR HANDLING UNIT— (OVER 10,000 GPM)Signature
CONSTRUCTION TAX
of Applicant/Contractor - Date
EXHAUST HOOD M/DUCn •- -
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous
HEATING UNIT (TO 100,000 BM
-
Date Recei t#
material as defined by the Cupertino Municipal Code, Chapter 9.1 2, and the
Health and Safety Cod ion 25532(a)i -
❑ Yea .. .. No
Will the a ppilcam or to re building mm pant use equipment or d evius
BEATING UNIT(OVER 100,000 BTU)
,
TOTAL:
VFNILATION FAN (SINGLE REBID)
s� SUANCE DATE ,
which emit hazardous air con Monts as defined by the Bay Area Air
Quality Management Fit
Ye No 9u pt
have mad the haz oust materials m Ircmenb under Chapter 5.95 of
�F •� �F (]
/ I+V 1 V l�s0.
BOILER -COMP PHPOR 100,000 BTI)
BOILER -COMP IU7,000 BTU)
the California Health & Salety Code, Sections 25505, 25533 and 75534. 1
uodeetandthatlfthe Wildingdoes noI it havrate na.L that it Ls my
es lbility to notify the ocev tOft equirements which most be met
-
isjhF asi #Xaa •r.M�-
NEW RESIDENTIAL MECH. b'Q.IT
prL[Ftb Lssuapce o!a CeFtific fOc r
�nerorF„a// .edagen CJI
iillll�y Yl ✓'1'6'1Tu1J#�y 1�-�CUJLI
ISSUED BY. Vv0'UC)N1`JN —
ncr or authorized agent P Date
�
TOTAL:
OFFICE COPY