23562APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building project Identification
Building Address:
PFRMIT NO.
SOS l�EAcN cc .rav" & c'
23562
wnere
�L�r. Z'!
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
C},�
�l
Contractors Name: Lm. No:
BUILDING-F3.F-CTRICALPLUMBING-MECHArICAL
CATEGORY
CONTROL If
Architect/Engineer. Lie. No:
QTY ELECTRICPERMIT FEE
BUILDING PERMIT INFO
Address:
Imo' �( ❑ ❑
L-T� JOB
PERhBTISSUANCE
LICENSED CONTRSDECLARATION
under ce(Chapter
T herebyion7Dthetl iv licensed oftheerp Business and
ingweh In full force andeffect fthe Buslnessand Tho(esslonsCade, and my
license Is In full force and
APPLIANCESRESIDENTIAL
JOB DESCRBrpION
`V
PANELS
License Claw LION
e. N
6
Date Contractor
ARCHITEGTSDECLARATION
(understand my plans shagheusM upubllc records
I
OOS
i?"
P�C.a L,
OVE OVER 1000 A000&MT'S
SQ. PT. FLOOR AREA $/SQ. FT.
SIGNS ELECTRICAL
Licensed Pro(essfaml
SPECIALCIRCUIT/MISC
OWNER -BUILDER DECLARATION
I hembyaf0rrothet I am exempt from the Contractor's License Law for the
E IN A'
TEMP. METER OR POLE INST.
following mason.(5ection 70315, Business and Professions Code: Any city or
county which mquimsa perttocomnn
mi truct, alter, improve, delbh,or repair
' V
^
anystmctum pda
orto its baaance, aborequireslheappBnt forsuch permit to
fth, a signed statement that he b licensed pursuant to the provbbrs of the
('OWER DEVICES .. V'
{l% ,R
SWIMMING POOL ELECTRIC AT
Contractor's License Law (Cha pier 9 (commencing with Section 7000) of Divi-
alon3 of the Business and professors Code) or that he b exempt therefromand
the Lvsb for the alleged exemption. Any violation of Section 7WlS by any
tn
applicant for a permit subjects the applicant to a civil penalty of not morehe
An
OIIILET -SWITCHES- TXTURES
five hundred dollars (S500).
❑ 1, as owner of the property, or my employees with wages as their sole
NEW RESIDENTIAL ELECTR SQ.FT.
STORIES
TYI'ECONS'IRUC'1'ION
compensation, will d o the work and the structure is not intended or offered for
uk: (Sec. 7064, Business and Pne essiore Code: The Contrador's License law
does not apply to an owner of property who Wilds or improves thereon, and
who doessuchwork himself orthrough hisownemplayees, provided that such
OCG GROUP
RES. UNITS
improvements are not intended proffered for sale. If, however, thebuilding or
Improvementbeold within oneyearofcompletion, theawner-budderwill have
en ofpmving thathedid not Wild or improve for purymc o(sab.).
as owner of the property, am exclusively mntncting with licensed
of
m rartprs to romtmct the project (Sec.7044 Business and Professlom Code:
QTY. PLUMBING PERMIT FEE
FLOOD PONE
APN
PERMIT ISSUANCE
Contactor'. law does fid apply to an owner of property who
Wilds or Improves thereon, and who contracts for such ptojects with a
cgW(adorts) Banned pursuant to the Contractor's License Law.
I_I 1 am exempt under Sec. B & P C for this reason
ALTER -DRAIN &VENT WATER (FA)
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
DRAINS FLOOR, ROOF, AREA, COND.
SANITARY RFCID'1'N
Owner Date
WORKMAN COMPENSATION DECLARATION.NRES.
❑1 hereby affirm that I have a certificate of consent to self -insure, ora
certificate oMforkrmi Compensation Insurance ma certified copy thenrof(Sec.
3800, Lab C.)
PER a
FIXRECEIPT
SCHOOL TAX Y N
N
GAS EA. SYSTEM -1 INCA OUTLETS
PARK FEE Y N
RECEIPT N
policyS N
Cy
CAEA. SYSTEM -OVER 4 (FA)
DING DI VIS ION FEE S
rtl(led copy on hereby furnished.
Certified copy b filed with the city inspection division.
GREASE/INDUSIRL WASTE INTFItCEPTOR
PLANCHECK FEE
GREASE TRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
PAID
EA. 7001x1'.
COMPENSATION INSURANCESEWER-SANITARY-STORM
(This Nertion need net be completed lithe permit is fpr One hundred dollars
Date Recti t#
F3EA77R W/VEM/m cr.I.R
ENERGY FEE Y_ N_
($100)orless.IWATER
I drolly that in the performance of the work forwhich this permit is lssued,
WATERSYSITM/TREATING
1 shall not employ any person many manner soas to Wcome subject to the
Workcn'Compenmtionlawsof Califomia. Date
PAID
NEWRESIDENTIALPLMB. SQ.FT.
Applicant
Date Reed t#
NOTICETO APPLICANT: If after making thisCertlBcate of Exemption, you
shmld become subject to the Workers' Comperwtlon provblon+of the Labor
TOTAL:
In
U TNGco
CodGyou mu at forthwith comply withsuch provisimaorthis permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
SEISMIC FEE _ _ I
I hereby affirm that there b a construction lending agency for the perform-
ante of the work for which this permit as Issued (Sec. 3097, Civ. Q
Lender's Name
Lenders Address
I certilythatl have read this application and statethattheabove information
bconcu.Iagree to comply withal city and county ordinances and state laws
TOTAL.
ELECTRIC FEE
PLUMBING FEE
QTY. MECHANICAL PERMIT FEE
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID:
relating to building construction, and hereby authorize representatives of this
city to enter upon the above-mentioned property for inspection purposes.
(We) agree to save, Indemnify an d keep harmlessthe City of Cupertino
against BabNfles,judgments, cormand expenses which may in anyway accrue
Date Receipt#
ALTER ORADDTO MECH.
AIR HANDLING UNIT (T010,000 CFM)
SUBTOTAL:
aga cost said Ci nas m.oe of the nit gofthi It
4/
Sig tureof Appliant/Cs r o m
11 UBMATERIA ISCLOSURE
Will the applicant or houre building oc ant store or handle hazardous
material as defined by the Cupertino Munidpal Code, Chapter 9.1 7, and the
I lealth and Safety Code Section 25537(a)7
O Yrs No
Will the applicant or tore Wildingoccupantuseequipmentordevices
AIR HANDLING UNIT (OVER 100DOCFM)
CONSTRUCTION TAX
EXHAUST HOOD IWVDIICT)
CONSTRUCTION TAX PAID:
Date RCCeipt#
—
HEATING UNIT 00103,000 BTU)
-
HEATING UNIT (OVER IDg000 BTU,
TOTAL
VENTILATION PAN (SINGLE RESID)
ISSUANCE DATE
which emit havrdous air contaminants as defined by the Bay Area Air
Quality Management Detrict7
4Ys ❑❑No
have read the hazardous materials redo lmments under Cha pier 6.95 of
pq,
F P6
BOILER-ODMP OHP OR 100,00 BTU)
BOILr-COMP 100,OW BTU)
the California I Iealth & Safety Code, Sections 25505, 75533 and 75534. I
understand that if the building does not currently have a tenant, that it b my
i]
(loft g1992
NEW RESIDENTIAL MECH. SQ.FT.
mu
rosponsibility to net ify the occupant of the requirements which =at be mel
prior to Isuance of a Certificate of Occupancy.
p#
A
IggppD gY:
Owner or authorized agent Date
TOTAL:
OFFICE COPY