21712APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Bulldln Preis. td,mificatlon
Building Address: ,/
//-7?7' /j it g/InoK eT. Lo �G� 2—&/-7-2
PERMIT NO.
1712
reName: � one.
- A
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BUILDINGELECTRICAlePLUMBINC-MFCHAMCAL
L• 'AYRZ
CATEGORY
CONTROLN
Engine �/ s
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Address:
PERMITISSUANCE
LICENSEDCONTRACTOR'SDECL!A TION
I hereby aIT. that l am licensed under provisions of Chapter 9(commene.
Ingwlth Sectlon 7000)ofDivislon3ofth Bminensana Pmreaslos.Codednd my
license Is In fuB (q and died.
Date cCb®�Conr �//U Y�
Dat, Contractor
APPLIANCES -RESIDENTIAL
JOB DF NM'l kON
_
i
PANES
201-I0DOA.MPS
ARCHITECIPS DECLARATION
I understand ney plana shallbe used as public records
OVF.RIODOAMPS
SQ. FT. FLOOR AREA
$/SQ.FT.
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt fromthe Contractor'. Limns, Law for the
following reason. (Section 7m1.5, Business and Prefdaime Code: Any city or
county which requires a permit to consm
construct, alter, Improve, deolbh,or repair
SIGNSELECTRICAL
%� 2
w1
, V
SPECIAL CIRCUIT/MI5C
TEMP. METER OR POLE INST.
any stmdure prior to Bs beuance,abo mqulmtM1,appBant far such pemNt to
Ole a signed statement that he it licensed pursuant to the provisions of the
Contractors License Law (Chapter 9 (commencing with Section MM) of D1v1-
slon3 of the lhigiussand Professlmo Code).moat Feb exempt themfmmand
DOWER DEVICES
SWA99NG IVOL
VALUATION
I basis for the alleged exemption. Any violation of Section 70)15 by any
applicant fora permit subjects theappllcant toss doll penalty ofnm mom than
OOTLETSSWTTC
/ �J
/ (�
NEW RESIDFNIIAL EL
five hundred dollenhe pr).
❑ as owner of the or my employees with wage as thele sole
/
STOItIFS
TYl'ECONSTRUCTION
ewperty, in
e
mmpematim,will do not d for
ole andf oactoetended Liceree
70K B.gretheworkanethenrode Thee.s
Code The Law
LicenseI�d
not apply toanow property orimpoves
don notapplytoan ownerofhisonemporimprwntherwryuch
hisowne. provided that such
es,e,,
ementsw
OCCGROUP
RFS. DNrrS
impovwho
notIntededorough
If,ho the
Improvement am not Intendedororferedforeio If,h ew b l)der ilI have
Improvement baold wlthinoneycarofcompldiorytheownerbullderwlll have
TOTAL;
th rden of proving that he did not build or improve for purpose ofsale.).
I, as owner of the property, am exclusively contracting with licensed
mnton".n to contruct the project (Sec. 7064, Business and Peofesslon Code:
QTY, PLUMBING PERMIT FEE
PERMIT ISSUANCE
FLOOD ZONE -
AI'N
The Cont -does License law don not apply to an owner of Property who
builds or improves thereon, and who contract, for inch p(ojects with a
ryll[�ador(s) lkensed pursuant to the Contractor's License Law.
LJ I am exempt under Sec. B k P C for this reason
ALTER -DRAIN VFM-WATER (FA)
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
OUTSIDE FEES
DRAINS FLOOR ROOF, AREA, GOND.
SANITARY Y N_
RECEIPT N
Owner - Date
WORKMAN COMPENSATION DECLARATION
Ofhereby affirm that I have o certificate or consent m py thea for .
3800,ce�iflabof WorYen'Comperuallonlnsurance ora certified ropy Chemo/6ec.
3800 �b CJ
FD(TURE4 PER TRAP
SCI OOLTAX Y_ N_
RECEIPT N
GAS EA. SYSTEM -1 INCA OUTLETS
PARR FEE Y N
+
I'o11ry N
N
GAS FA. SYSrEMOVER 4 (EA)
Com any U
DING Df
BUILDING DIVISION FEES
❑ptertified copy t hereby with nished.
f-ACertificd copy b filed with the city W pection division.
GREASE/INDUSIRL WASTE INTERCEPTOR
PLANCHECK FEE
GREASE TRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(rhls.ectign need not be complied lithe permit b (oro�undred dollen
PAID
Date ReceI t#
SEWE,RANITARY-STORM E.A. 20OFr.
Will cemleeed
I artily that o the pmum in of hew.rkmanner so as tobthis permit c iso the
I shag not employ any prawn in any manner so u to become subject to the
Wwkciu Compensation Iaws of Uilfornla. Dat,
WATER HEATER W/VENT/ELECTR
ENERGYFEE Y_ N
PAID
WATER SYSTEM/TREATINC
AppllcNOTICnt 1
NOTICEea A, subjeAM:IL cher makingthisationkro is Ememptbn, you
sowedbecameforth to the Workers' Compensationprovisionsofthe Labor
Code, you must forthwith comply with such provisions or this permit shall he
decreed re.•gkea.
Date RCOeI t#
NEW RESIDENTIAL PLMB. SOFT.
TOTAL:
BUILDING FEE
-
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
IherebyafBrmthat thertbamrutroctlon lendingagenry forthe pedomm
anm of the work for which this perrrpt b band Geo W97, Clv. C.I
TOTAL:
ELECTRIC FEE'
Lender's Name t 1 n
lendersAddreee EdTi3
Icertifythatl have read this app tionand Maethatthe above Information
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
MECHANICAL FEE
. S
PERMIT ISSUANCE
FE'SD:
FAD: y
iscorrect. I agree to complywlth all city and county ordlnanmsand state laws
relating to building construdlon, and hereby authorize representatives of this
city to enter upon the abavcmentloned property for bupectlon purposes.
(Wel agree to save, lnderrmlty an d keep harmless the City of Cupertino
ALTFRORADDTOMECH.
Date Receipt#
SUBTOTAL:
."lost liabllltln,}idgments,nms and expenses which may In anyway accrue
agalnst saki City in consequence of the granting of this permit.
cal � IAj
AIRHANDLING UNIT (TO 10,0000IM)
AIR HANDLING UNIT 10,=CFM7
CONSTRUCTION TAX
Signatumof AR Timm/Contracind ate
E(HAUS'r HOOD(W/DUCT)
CO T UCTION TAX PAID:
HA7A R DOLS MATERIALS DISCL05 RE
�'Y 9, �"Xr To
HEATING UNIT (TO I MODO BTM
-
Will the applla ext orfuture bu llding omu pant store or ha rd is havrdous
meertal as defined by the Cupertino Mu nicipai Code, Chapter 9.1 2, and the
1trait h and Safety Code Section 75532(x)?
❑ Yes M No
Date ROcel t#
HEATING UNIT (OVER tOQ000 BTU)
TOTAL:
VENTILATION FAN 6INGLE RESID)
�•E DATE
Wlletheappliant orfutumbuildingoccupantuseequlpment ordevices
which emit hamnimis air contaminants as defined by the Bay Area Air
BOILER -COMP OTB' OR 700,000 BTU)
Qaaloy Management District?
4Yrs ❑(�jNo
ifereaathe under C .95 of
FED 4 jWj
BO LER COMProVERt00,000BN)
th&SafuyCode,brequlremenb
the CaliforniaaIinith & Safety Code, Sections 2x505, 8533 and 75539.1
25534.
✓44V
NEW RESIDENTIAL MEI{. SQ.FT.
understand that if the building does not currently have a tenant, that it is my
rnpansibiluy, to notify the ..p.m of the requlrementa which must be met
prior to issuance of m
a Certificate ofOrpanry.
C
M�9 � , •asst'
ISSUED (-J'JAv f't;
A9
Owner or authdrimd agent 1` 1 tales
VVV
TOTAL I
OFFICE COPY