21558APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Preen Identification
RuOding Ad T� f i+_rL r• a I
IyM1 one:
PERMITNO.
, 21558
wners ams:
CITY OF CUPERTINOBUILDINGDIVISION
APPLICATION / PERMIT
BUfLDINGELECTRICALPLUMBING-MUCHAMCAL
i
C marts%e Name ' 'N1 Lie, No.
"E//Ki jZq
CATEGORY
CON7ROLN
Arc ited/�— Englnner— LIc. No:
QTY ELECTRIC PERMIT
BUILDING PERMIT INFO
-
Add.
❑ EL�i PLUMB
I 6 1:1❑
e�FEE
PERMITISSUANCE I yQ'}
LICENSED CONTRACTOR'S DECLARATION
I under R.9 rovblonaofeadonsCode, and
ing�time.h in fon7000)o(Dleffect fthe BuannsadPmfessioneCnde, ad my
Ilanss Isis fait jo ,yid effect. L /Zt
License Class G. U Lic. p 5 j 7
Dale Lrnvmc or
ARCHITECTS DECLARATION
I understand my plan shag be used as public recoels.
Licensed Pmfeselonl
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
IoBowmg reams.(Section 7031.5, Business and Professions Code: Any city or
cwntywhich requires a permit reconstruct, alter, Improve, demolbh,orrepalr
any structure prior to its Issuance, a bo requires the applicant forsuch permit to
rile a signed statement that he Is licensed pursuant to the provision of the
Contractors License law (Chapter 9 (commencing with Stolon 7000) of Dlvl-
,on 3 ofthe Buslnessand Profession Co,10orthat hebexempttherefromand
the basis for the alleged exemption. Any violation of Seaton 70115 by any
applicant fora permit subjects the applicant to a civil penalty of no room than
five hundred dollars C$51)0).
1, as owner of the pro, or my employees with wages a their sole
❑perty
compensation, wBl do the work, and the structure Is not Intended or offered for
.In (Sec. 7044, Business and Penfossion Code: The Contractor's License Law
does not apply to an own, of property who Wilds or improve thereon,and
whodoessuchworkMmeeBorthrough hleown employe", provided that such
Improvements are not Intended orof(emd forsale. If, however, thebuile ing or
Improvement i3 ld within oneyearofcompleiog tM ownervbulldcrwlll Mve
t rdeno/ provingthat he did notbuildorlmprove for purpose ofsale.).
UL ae owner of the property, am exclusively conlracting with I --p.
contractors to construct the project (See. 7044, Business and Prefessimu Cade:
The Contnnoe. License Law does net apply to an owner of property who
or Improves themes, and who contracts (a such p(u)ega with e
cr�(acior(s) Banned pursuant m the Contractor's License Law.
L) l am exempt under Sec. B k P C for this mean
APPLIANCESRESIDENTIAL
JOB
JOB DESCRE'DON
T r'Y�•J ��L.�
PANELS
A— UP TO 200 ANTS
201.1000 AMPS
OVER 1000 AMPS
SQ. FT. FLOOR AREA
'
$/SQ. FT.
SIGNS ELECTRICA
SPECIALCIR T/M
T1AP.M 4 OR EINSf.
PO DEVICES
— I n
S NG E
IOLFELSWIA413`ImFl+�RES
VALUATION
NEW R FN•ITpLE ECTR
STORIES -
TYPE CONSTRUCTION
TOTAL:
QTY. PLUM GPERMIT FEE
OCC.GROUP
RFS. UNITS
IT ISS CE
ALTER -DRAIN k VENT- WATER (EA)Wilds
FOOD ZONE
MIN
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
DRAINS- FLOOR, ROOF, AREA, COND.
pp•TUpEq, PER TRAP
SANITARY Y_ N_
RECEIPT N
Owner Date
WORKMAN COMPENSATION DECLARATION
❑1 hereby affirm that I have a cerdfiate of consent to self -Insure, or
ani(IateufWorken'Compewtlonlnurance oracertifb(5e
d copythereo(c.
3800, lab CJ a
Poiiry p
SCI TOOL TAX Y_ N_
RECE)PT X
GAS EA. SYSTEM -1 INC.4OTILETS
PARK FEE Y N
RECEIPT M
GAS EA, SYSTEM -OVER 4 (EA)
C,o�mJ�any
BUILDDINGINGDI VISION FEES
,�JCertlOed copybhereby tumlahed,
/y`C1-Cenmea espy b tiles wlm lM ay Inpntmn afammn.
CERTIFICATE OF EX EM PTION FROM WORK ERS'
COMPENSATION INSURANCESEWE&SnMT•ARy-STGRM
a
(This gins need net be completed if the permit b forone hundred dollen
(f1I contless.) -
] ll sem employ
I shall nm employ any person f any manner n u to beams subject to the
oyite an Person It, any of num rkan an t cernan permitjest to the
Workers' Compenwtlon Laws a/ Call(omla. Date
ApplicaN077Cnt
NOTICE co APPLICANT: R, after making pee Ction pr a iof slou o the Labor
Comely become subject to the Workers' Compenxtbn provblon of the you
Coda you timet forthwith comply with each provision or this permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is m
a oaestctlon lend Ing agency for the perform
ane of the work for which thin permit is issued (Sec. 3097, Civ. C.)
Lender's Name
Lend¢/.Address
I ceri lfythatl have madthlaappllcationand gate that Neabove Information
Isanca[.Idgme to comply with all cityand county ordinances andante laws
relating to building contnnlon, and hereby authorize representatives of thio
city to enter upon the axovcmentlonel property for inspection purposes.
(We) agree la save, Ind emNly an d keep harmless the City of Cupertino
a a tlLt fit lm'pdgme is massed expense. which may In anyway acme
a nt.gd City In cone a calf granting o(thls pemni4
l 2Da 1-.90
CREASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE
PAID
Date Recei [p
CREASE TRAP
EA. moFT
WATER HEATER W/VENT/ELECTR
ENERGY FEE Y N
PAID
Date Reeel t1[
WATER SYSTEM/TREATING
NEW RESIDENTIAL PLMB. SQ.FT.
TOTAL:
BUILDING Fh •
SEISMIC FEE
TOTAL:
ELECTRIC FEE
QTY MECHANICAL PERMIT FEE
PLUMBING FEE
MECHANICAL FEE
PERMITL%UANCE
FEES PAID:
ALTER OR ADD TO MECH.
Date ReCei [tl
AIR HANDLING UNIT (TO 10,0D0 CFM)
SUBTOTAL:
AIR HANDLING UNIT (OVER 10,000 CFM)
CONSTRUCTION TAX
../
Slgpanreo(App HAZA tranmr Date
HAZARDOUS MATERIALS DISCLOSURE
gonipalCode,upant store Ch pierha In haundousthe
Wial as defined the future Cupertino
mental as defined by the Cupertino Municipal Code, Chapter 9.12 and the
IIe❑xltYox Safely CadMSeatloon 75532(x)7
Willtheappliant orfuwm building occupant use equipment ordevices
which emit hazardous air mntaminnts as defined by the Bay Area Air
Quality Mautgement District?
? Ya n No
[?have
haveread the th&S-f YCWe, ls Sections and 2554.1 of
the Gttandt HealthA building
understand that lithelobe theongdoes no taurrenayovents hich that it bay
does use 7tly have a tenant, that it
notify octupantof the upancyulrements which mustbemet
responsibility issuance
prior to issuance cafe CenlOale o(Ocmpanry.
IXIUUST HOOD (W/DUCT)
CONSTRUCTION TAX PAID:
HEATING UNIT (TO ICO,000BN)
Date Recef tN
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
VENTILATION FAN (SINGLE RESID)
ISSUANCE DATE
p�.,•G!'( t Ion�
s7`�,
asr�
� �yw+•-c�\
ISSUED BY:
BOILER -COMP O11POR 100,0(10 BTO
ROI1.1:R•cOMF(oVER700,000 R711).
NEW RESIDENTIAL METH. SQ.FT.
Ownerorauthonred agent Date
TOTAL:
OFFICE COPY