20982APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Builth Project Identification
Building Addresc -/
aJG —a 2— ?81/,
6
PERMITNO.
20982
iJwnor. Name one:
ti 2s? -615-01
CITYOFCUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BUILDING-ELBCTRICALPLUMBING-MECHANICAL
A
q _G--qp
Contractor's Name: Lk. N.:
B O
CATEGORY CONTROL p
BUILDING PERMIT INFO
Arehltect/Engineer. Lie. No:
QTY ELECTRICPERMIT FEE
Address:
❑ F-1 1:1LICENSED
PERARTISSUANCE
CONTRACTOR'S DECLARATION
I hereby eeflon mthmlam Bcenedunder ho0.sIrov nd Pre Chel...0 (mmd
Ingwlth Section 7000)ofDlvldon3 afthe BuslnesaandProleulanaC-ode,and my
license 1, in full forte and affect.
Licamee Claae_1Lk.M So
Date Contrador_
' ARCHITECTS DECLARATION
I understand my plan, shall be used as public records.
Limned Prvfa e local
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
following reason. (Scam. 70115, Busines and Prolesinn Code: Any cityor
countywhkhr"Nr aper ttomnhuc"ter,bnp.o ,demolbh,ormpa
any slmRure pdorto lb Issuance, alaorequlreatheappllcant forsuch permit t.
ills a signed state that he Is licensed pursuant to the provision o! the
Contractor's LiceneLaw(Chapter9,(commencing with Section 7000) of Dlvl-
sion3oflhe Buslnee.and ProfnationCod0orthatheisexemp[therefromand
the barb for the alleged exemption. Any violation of Section 7011.5 by any
ed exemption.
applicant fora thealleged
applicant to a civil penity o(nd nsrethan
five hundred dollars ($500).
❑ I, as owner of the property, or my employees with wages as their sok
rompensatloN will d o the work and the structure isnot Intended or offered fop
se (Sea 70K Businessand I micsimcs Code: The Co tmet.e. Lt.. Law
docs not apply to an owner of property who builds or improves thereon, and
who does such work himself or through hlsown employees, provided that such
Improvements are not intended oroffamd forage. If, however, thebuilding or
Improvementbsoldwithinoneycarofcomplet mtheowner-bullderwlll hove
t ben of proving that he did net build or improve for purpose of sale.).
L as owner of /he property, am exclusively contracting with licensed
contractors to contrud the pnject (Sea 7014, Business and Profession Code:
The Contrsctore Llmnse Law does net apply to an owner of property who
builds or improves; thereon, and who coMmeta for such pd
lolea with a
ayfl((actor(s) Beensed pursuant to the Contractors License Law.
LI I am exempt under Sec B k P C for this reason
APPLIANCESRESLDENML
JOB DESCRIPTION
n�--1--
1 ' I l l O
,
PANELS
XII -1000
OVER 1
SQ. FT. FLOOR AREA
S/SQ. FT.
SIGN
SPECU/l,i
TEMP.M OR LE
EO
bIN L EGTRIG __
S gG4 HESFI
VALUATION
V
sL S-Od `
WRESIDENTIA E SQ.FT,
STORIES TYIPECONSIRUCTION
J
TOTAL:
QTY. PLUMBING PERMIT FEE
OCC.CROUP RFS. UNITS
PERMIT ISSUANCE
ALTER -DRAIN &VENT- WATER (EA)
FLOODZDNE MIN
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
OUTS I
DRAINS FLOOR, ROOF, AREA, COND.
FIXTURES. PER TRAP
SANITARY Y N_
RECEIPT 0
Owner Date
WORKMAN COMPENSATION DECLARATION
❑I hereby affirm that 1 have a certificate of consent to self -insure, ora
certificate of Workers' Compensation Insurance or a cedl(ed copy thereof (Sec,
3800, Lab C.)
Policy p
SCHOOL TA% Y_ N_
RECEI NM
GAS EA. SYSTEM -1 INC.40UT7.EI'9
PARK FEE Y N
RECEIPT N
—
GAS EA. SYSTEM-0VFR 4 (21)
Cram acv �U LL
Wertined mp is he by th the cid.
CertNed copy is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Ohla section need not be completed lithe permit is for one hundred dollen
(SI ID)oify that
Icenot thatln the performance ny annerwork so as to becomewbjcrmit d to the
I shall not employ any person In any manner m u to become eub�ect to the
Workers Compencaten laws al California. Data
Applicant
NOTICE co APPLICANT: a oder nuking thisCertificate
shouldbecomeis Exemption, you
Labor
mus subject to the Workers' Compenatlon or this permit shall
Coda you rower forthwith comply with such provision or this permit shell be
deemed rooked.
CONSTRUCTION LENDING AGENCY
I herebyaf0rm that there is a construction lending agency forthe perform-
ance of the work for which this permit /s Issued (Sec. 3097, Civ. C.)
Lmdaea Name
Tenders Addres
I cedl/ythatl have read thisappilcatlonand nate thatthe above Information
bcorrect. I agree to comply with all city and county ordinances and state laws
relating to building construction, and hereby authmtu representatives of this
city to enter upon the above-menlloned property for impaction purposes.
(We) agree to ave, indemnify an IT keep erhs ethe City of CupertinoDate
against liabilities, judgment., copsand expenses which mayin any wa ac
againl said City In mnee<ryence of the gra nUng of this pannus
s /
BUILDING DI VISION Ff:ES
GREASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE
PAID
Date Recti til
GREASETRAP
SEWER -SANITARY -STORM EA. 200FT.
WATER HEATER W/VENT/ELECTR
ENERGY FEE Y N
PAID
Date Recel tic
WATER SYSTEM/TREATING
NEW RESIDENTIAL PLMB. SO.FT.
TOTAL:
BUILDING
t
SEISMIC FEE
TOTAL:
ELECTRIC FEE
QTY, MECHANICAL PERMIT FEE
PERMIT ISSUANCE
PLUMBING FEE
MECHANICAL FEE
FEES PAID:
ALTERORADDTOMECH.
Recei tp
AIR HANDLING UNIT 0010,000 CPM)
SUBTOTAL:
'
AIR HANDLING UNIT ROVER I0,0DOCPM)
CONSTRUCTION TAX
Slgntur Ap /Contractor t
HAZARDOUS MATERIALS DISCLOSURE
(lithe appllcanl or future building occupant stare or handle hazard...
material as defined by the Cu Perrino Mu nicipal Code, Chapter 933 and the
I lealth and Safety Code Ian 25532(-)7
❑ Yes N.
Will the appliant r lure building occupant use cqulprrenl or devices
hlch emit hazardous air contahnnts as defined by the Bay Area Air
lity Marugement D��ist Ncf�7
Ye, he sad do °
Tuvread salt et materials reons 255 5,25M3 and 2553.1 of
Cods Sections 255ntly 05,25M3 a t and25534. I
the CaliforniandtHealth building
understand IIty to notify
tify the occupant not a rreuirennves which thatitismy
rsor to Islity to notlfytheoctc of(.f the requircmente which at be met
prior m Lsuly9e of a Ce floats o!O party. ;7/V
INHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
_
HEATING UNIT (TO 100,000 BTU)
_
Date Reeei t>t
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
L
VENTILATION FAN (SINGLE RESID)
I$t�DATE
cp 6 �99p
ISSUEDBY:
BOILER-COMPOHPOR100,0(0BTU)
BOILGR-COMP BTU)
NEW RESIDENTIAL MECH. SQ.W.
Own�r a/u/o/ud agent 11--b/.I—
TOTAL:
OFFICE COPY
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