21706APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification
B°`air° Addm'a21706
s PNr Q��oK �,r oT 3 6 s- 1 /� c r
PERMIT NO.
ger me:,� nesse
CI�OFCUPE APPLICATION PERMIT
Z. iA
tractor Name: LIc. No:
BUILDINGELECTRICALPLUMBING-MECHAMCAL
CATEGORY
CONTROL
A itcct/ gin. i
QTY ELECTRIC PERMIT PEE
BUILDING PERMIT INFO
Addre s
PE]iAUTISSTIANCE
LICENSED CONTRACTOR'S DECLARATION
(hereby affirm that l am licensed under provision. of Chapter 9(commm
ingwlth Sectlrn7000)of Dlvlslon3 ofthe Bu eresanciProfessions Code, and my
license is In full /paps and LkeM .
Date as -�_�_
Date Contractor
APPUANCESRIESIDENIIAL
OB DESCRIPDON
PANELS
UP TO 200ANIPS
301-I000A.MPS
ARCHITECPS DECLARATION
I understand my plans.hall be used as public records.
OVERI=AMPS
SQ. FT. FLOOR AREA
S/SQ. FT.
SIGNS ELECTRICAL
Licensed Professional
OWNER -BUILDER DECLARATION
Thereby a(flrmthatlam e.emptfromthn Contractors Llcen.ILwforthe
SPECIALCMCUIT/MISC
TEMP. METER OR POLE INST.
following reason. (Section 70315, Businesard Profeslons Code: Any city or
countywhich requires m
a permit reconstruct, alter, improve, deoltsh,orrepalr
L�-{1J �•/YI
anystm=N pr rtoitsL ancg, is equlrnthaapp8ontforsuchperMtto
file a signed statement that he is licensed pursuant to the provisions of the
POWER DEVICES
SWIMMING IDOL ELECTRIC
Contractor's License Law(Chapter 9(commencing with Section 700)) of Dlvl-
.ion 3 of the Business and Profeslons Code) orthat he is exempt therelromand
VALUATION
the basis for the alleged exemption. Any violation of Section 7031.5 by any
opp8cant for a permit subjem the applicant to a civil penalty of nor more than
q %�
OUTLETSSWITCHES-FI RES
NEWRESIDENTIALELECTR SQ.FT.
live 1, asoddolhrshepr.
I, as owner of the property, or my employes with wage as thele dole
/ G
SIDWES
TYPECONSTRUCTION
compensation, will Bothe work and the atrostumh not Intended or for
coffered
ale (Sec 7014 Business and Profesbns Code: The Contractoh License Law
does not apply to an owner of property who Wilds or Improves thereon, and
who does such work himself or through his own employees, provided that such
OCC. GROIRa
RES. UNITS
Improvements art not intended proffered for.ale. I( however, the W ilding or
Improveerrm lasold withinone yearofcomplcilen, theowner-Wllderwlll have
TOTAL:
t Men of proving that he did not Wild or Improve for purpose of sale.).
L as owner of the property,
p Percy, Se exclusively m, and ngwith licensed
contractorset construct the project (Sec. a and Profeslons Code:
QTY, PLUMBING PERMIT FEE "
PERMIT ISSUANCE
FLOOD ZONE
APN
apply to an
The Coor improves
esLicthennse Law don not apply tct an owner of property who
c It a t r Imprwo thereon, and who contracts for se L ptopcts with a
pursuant to the Contractor's License taw.
co, LttjjactoKU exempt
LJ I am eacmp under Sm. e & P C for this reason
ALTER -DRAIN& VENT- WATER (EAI
BACK FLOW PROTECT. DEVICE
FEE SUMMARY
DRAINS FLOOR, ROOF, AREA, CONE.
FO(TlJRES PER TRAP
SANITARY Y N_
RECEIPT N
Owner Date
WOR "AN COMPENSATION DECLARATION
Qf hereby affirm that I have a certificate of consent to .elf -Insure, ora
certificate of Workers' Compensation Laurance or a certified copy thereof (Sec.
3800, Lab C.) -
Paliry N
SCHOOLTAX Y _
N
RECEB NN
GAS EA. SYSTEM -1 INCE OUTLETS
PARK FEE Y N
RECE( N
GAS EA. SYSTEM -OVER 4 (EA)
Com any
BUILDING DIVISION
DING DI
Wcnified ropy. is herebyth the city
I� Cenl(icd copy u filed With the city inspection division. 7"`
GREASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECKFEE
GREASE(AAP
CERTIFIGTE OF EXEMPTION FROM WORKERS'
COMPENSATION
(Thl.sectbn need one b° completed lithe permit V ne (proM1undmd dollars
PAID
Date RCCeI t#
S
SEWER-SANITARY-SIDRM FA. fiOFT.
s1m)°`Ina.)
I endify that In the perfomunceof the work forwhich ll. pennR 1. iss rd,
worm �wTERw/vEvc/ELFrrR
ENERGY FEE Y N
I shall not employ any person In any manner n as to bemerc subject to the
Workcn'Compensationlaws of California. Dat
PAID
WATER SYSIR7/,IRFA,D[x
Applicant
NOTICEco esubjeAM:e aftermakingthis
sationCertificate
pm o/Exemption, you
Code. become forth a the Workers' Compensation provisionsofthe Labor
Coda you mart forthwith comply with such provisions or this permit shall be
seemed men".
Date Remi til
NEW RESIDENTIAL PLMB. SQ.FT.
TOTAL:
BUILDING FEE
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
Thereby onthat them ki a mmtrucilon lending agency for the perform,
ce of the work for which this permit L issued (Sec. 3097, Civ. C.)
TOTAL:
ELECTRIC FEE
in
render'. Name's s' I r
Lender'.AdderT
I cedifythat I have mad this appllcationard statethat the above Information
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
MECHANICAL FEE
("!
FEE
is correct. Iagree to comply with all city and county ordinances and mate laws
relating to building mnstructirn, and hereby authorUe representativem of this
PERMIT ISSUANCE
city to enter upon the aWvcmentioned property for inspection purposes.
(We) agree to ave, Indemnify an d keep harmles the City of Cupertino
against liabilities, Judgments, comsand ea per.. which may In any wayaeerue
against said City In consequence of the granting of this permit%
C 1� M mnoor `�1
ALTERORADDTOMFCH.
Date Receipt#
AIR HANDLING UNIT (TO I0,W0 CFM)
SUBTOTAL:
AIR HANDLING UNIT(OVER 10,000 CFM)
CONSTRUCTION TAX
a
Signa— g FLAZA °ntrDS V Dat
HAlARDOUS MA ERcupsct
IXHAUST HOOD(W/DUCT)
CQIt}$:F�iUCTION X PAID:
--f/—f���
I-IL177NG UNIT (TO 100,(X)() BTU)
Wre or
Will the definedart by
material as Cupertino Municipal Code, CM1aptcr9.lZand the
theC pr hit.. mind ng Municipan ode, hapten handleh and
DatC Recel f#"
IIWTING UNIT (OVER 100,000 BTU)
TOTAL -
Health and Si/sty Code S°No LS531W7
M No
VENTILATION PAN (SINGLE RESIW
ISSUANCE DATE
1 7
FEB j•r4 �99i
Will
Wiiemt hapanlntorfutontbuilding arvpandby the equipment,Are. dcvim
whichemit air contaminants eta as dented by the Bay Arca Air
Q.ulity Management DisWct7
Yes ❑F� No
have mad the h &Safet material tions 2mrntsunder Chap534.1 of
the California Health&Safety Code, flections 25505, 5533 and 75534.1
BOILER COMP (31 0' OR ] W,IXD BTU)
IK)ILER-COMP 1DJ,o006I11)
NEW RESIDENTIAL MECH.—SQ-17.
understndthstifthe Wildingdocsnotammtlyhaveate...t, that It d my
responsibility to notify the occupant of the requlmments which most be met
-
Prior to isc f a a Certificcaate-olOccupaney.
C u cal—)c 1 \�� l ),IT I_
w•• • g� M�aw�• t(�("v� ��(\
ISSUED OY���.�V f
w
Owncrorah tlsd agent Dae
TOTAL:
OFFICE COPY