23518APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building project Identification 1
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PFRMITNO.
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F^EJ ELL Cor�rS4a, T a
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION /FERMI
BUILDING-ELECTRICAI.PLUMBWG-MEC 'ICAL
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Cost Na`me: Uc.Nm
C1- a� X3'18o
CATEGORY
CONTROL y'�JlD
Architett/Engineer. LINO:
Tf�' aE O� 3 -
QTY ELECTRIC PE
FEE
BUILDING PERMIT INFO
Addrea:s/�j {jLj 4Ad,A
PEIMTISSUANCE
Ij�
(h' 13
LICENSEDCONTRACTOR'S CLARATION
Iherebyafflrm that l am licensed under provisions of Cha pter 9 (ournmesu,
ingwith Sseifon7000)of Divislon3.fthe Busineaand Pmf sudonsCmk, and my
license is In full tv and effect.
Llawe Class 6 u,' � A �
Date Contractor
APPLIANCES D L
JOB DESCRIPTION
�-WA --7:N
P
Ot AMPS
ARCl DECLARATION
]understand my pbwaha B sed as pubbcrerords. -
U be used
ER 1000 AMPS
SQ. Fr, FLOOR AREA 5/SQ. FT.
SIGNS ELECTRICL
Licensed Profenloa
OWNER -BUILDER DECLARATION
IherebyafRrmtlut lam exempt fromthe Contractor's License law for e
e_l 6 G! Q Q
L E D I '
IAIRC
MAA
POLE INS!.
following meson. (Senior 7mt.5, Buslnres and Prof.ss ., Code: Any dty or
countywhlchrequlresapermittowmtmd,altegbnpmve,demollsh,.rrepair
I4t /1 p p
anystrunum prior to its Issuance, also requlresthe applicant forsuch permit to
file a signed statement that he ls licensed pursuant to the provisions of the
EViCPS
1\V/� BVI
- NO 1100 ECIRIC
t ETS TCIfF$HXILRFS
Contranor'a Licenselaw(Chapter9(rommencing with Srctlon 7000).! Divi-
'o n3 of the Businem and ProfembwCode)orNat heatexemptthere(romand
the baso for the alleged exemption. Any violation of Section 70315 by any
applicant fora permit subjects the applicant to a civil pealty of not more than
U
D (7
NE DENTIAL ELECTA �'ET'
five hundred dollars ($50U).
❑I, as owner ofthe property, or my employees with wages as theirsole
STORMS
TYPECONSIRUCTION
somprhsation, will dotal work and thestructure la not Intended or offered for
ale (See. 70K Business and Pmfessi.ns Code: The Contractors License law
docs not apply to an owner of property who builds or improves thereon, and
doessuch work himself or through his own employers, provided that svc
ZOCC.
GROUT'
RIS. UNITS
Improveme amnotintendedorofferedforsale.lf,howevegthebuiMing r
improvement) widwithinoroyearofcompidbNtheowner-bu0derwill have
try�. rden of proving that he did not bund or improve for purpose ofsele.).
"L as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business and Procat uns Code:
QTY, PLUMBING PERMIT FEE
FLOOD ZONE
APN
PERMIT ISSUANCE �a
The Contractor's License law does nes apply to an owner of property who
Wilds of improves thereon, and who contracts fee such pro" with a
cgN(adents) licensed pursuant to the Commerce's License Law.
1,-J I am exempt under Sec masonB k P C for this mason
ALTER -DRAIN &VENT -WATER (I:A)
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
DRAINS FLOOR ROOF, AREA, COND.
SANITARY Y N_
RECEIPT I
Owner Date
WORKMAN COMPENSATION DECLARATION
❑I herebyaffirm arm that I have a certificate of consent to self -metre, ora
certifiate.f Workers'Compensation Insurance ma certified ropy thereof(See.
3800, lab C.Zs -
FIXIVRES PER TRAP 'a
SCHOOL TAX Y N
RKC HIT N
GAS EA. SYSTEM -1 INCA OLITLETS
PARKFIT Y N
RM T B
Policy 0
Co any
GAS FA. SYSTEM -OVER 4 (EAI
BUILDING D I VIS ION FEES
MetlRed copy at hereby famished.
F1 Certified copy at filed with the city Inspection division.
GREASE/WDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE
f
CREASETRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
PAID
V s
SEWER -SANITARY -STORM F.A. 2WFT.
COMPENSATION INSURANCE
(This section need nes be completed lithe permit is for one hundred dollars
Date Remi ted
WATER HEATER w/VENT/ELGCTR,
ENERGY FEE Y_ N_
/
6 0-00
($100orless.)
I cortify that In the performance of thework forwhich this permit is lssued
WATER SYSTEM/TRFATINC
I shall not employ any person in any manner sa as to become subject to the
Worker' Compensation Laws of California. Data
PAID
NEWRESIDENTIALPLMB.SQFT.
Applicant
Date Remi t#
NOTICE TO APPLICANT: If, after raking this Certificate of Exemption, you
should Wcorrn sub)ect to the workers' Compensation provlslow ofthe Labor
TOTAL:
s
BUILDING "
-0
Code, you must forthwith comply with such provatlons of this permit shall be
deemod revoked.
CONSTRUCTION LENDING AGENCY
SEISMIC REE
I hereby affirm that there e, a censtrunton lending agency for the perform
ance ofthe work for which that permit at Issued (Sec. 3097, Cie. C.)
Lender's Name
lender's Addm
1 cer ifythat I have read thisapplicationand statethat theabove Information
Is ecord. Iagrmto complywith all city and county ordles.cosand tate laws
T G
ELECTRIC FEE
PLUMBING FEE
QTY. MECHANICAL PERMIT FEE
MECHANICAL FEE
1
PERMIT ISSUANCE ` ��
FEES PAID:
-
relating to building consuunfon, and hereby authorlu representatives of this
city to enter upon theaWve-nonuave property for inspection purposes.
(We) agree to save, indemnify an d krep harmless the City of Cupertino
ago lost I. i its, pdgmonts, emeand expenses which may in anywayacaue
agai City coruacti eofthe wantingof this permit.
a T Zqp
g at dAppilamt/Contractor I Data 33
ALTERORADDIOMECH.
Date Receipt#
AIR HANDLING UNIT 07010,000 CFM)
SUBTOTAL:
AIRHANDLING UNIT(OVER 10,000CFM)
CONSTRUCTION TAX
EXHAUSTHOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (TO 100,00 BTU)
Date Reeei tit
dlth ee applicant or future building occupant store orhandle hacardous
material as defined by the Cupertino Municipal Code, Chapter9.12, and the
Health and Safety Cade Section 25532(a)?
❑ Yes �j No
Will theappliant or hours building occupant use equipment or devices
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
VENTILATION FAN (SINGLE RESID)
ISSUANCE DATE
which emit hares rdous air =is minants as defined by the Bay Area Air
Quality Management District?
Y's No
have read the haves cus matertalsrcquirements under Chapter 6.95 of
the Morris Health k Safety Code, Sections 25505,5533 and 75534. I
building dues not rrcntly have a tenant, that it It my
understand that if the Ww
u
® p
V" A
APR 29
BOILER -COMP QHP OR 100,000 BTU)
BOILER-COMP(OVER 10,00) BTU)
NEW REST DENIIAL MECIL SQFT.
responsibility to notify the occupa rat of the requirements which moat be met
prior to Issuance o/ a Certificate of Occupancy.
Y /y' 9
Owner or authariud agent Bam
CII Y Ur. (;U t'i uvl
ISSUED BY:
T
OFFICE COPY