24380APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification
Building Addmas:/� ///� C /x (—
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PERMIT NO.
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CITY OF CUPERTTNO-BUILDING DIVISION
APPLICATION I PERMIT
BUILDINGELECTRICALPLUMBINCMECHAMCAL
l6T 1 `rcv"
Contractors Name: Lk. N.
CATEGORY I
CONTROL#
Architect/Engineer. Lie. No:
QTY_ ELECTRIC PERMIT PEE
BUILDING PERMIT INFO
AddressPERMITISSUANCE
1:1fV. ❑ ❑
L�
ma'
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am BLnued under proviaioas of Chapter 9(mmmenc
IngwlthSe ion7000)of DiAWon3ofthe Bud.nsand PmfosiomCode,andm
license Is In full force and effect.
License Class LLCM
Date Contractor
ARCHITECTS DECLARATION
I understand my plans shall be used a public records.
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby a(Rrrn that I am exempt from the Contrador's License Law for the
following recon.(Section 7031 S, Business and Professions Code: Any city or
c ntywhichmquiresapermitmmnstmcctalter,impmve,demollah,orrepalr
any structure prior to lie issuance, also requires the applicant for such permit to
file a signed statement that he Is licensed pursuant to the provisions of the
Contractors License Law (Chapter 9(commencing with Section 7000).( Divi-
gm3 ofthe Businemand ProfesslonsCode) orthat he h exemptthxmfromand
the basis for the alleged exemption. Any violation of Section 700IS by any
applicant for a permit.bjects the applicant tons dull penaltyof not more than
ve dreddolamf'5"0).
as owner of the property, or my employees with wages as their sole
c pereation, will do the work and lheatrecWre la twt intended or offered for
l5ee 7014, Burin. and Pmf.Imo Code: The Contractors License Law
does not apply to an owner of property who Wilds or improv, thereon, and
who does such work himself orthmugh his own employees, provided that such
Improvements arc not intended proffered forsale. If, however, the Wilding or
improvement lesold withinomyearofcomple orytheowner-bulMerw111 have
OW-Ifrrden of proving that he did not build or improve for purpose ofsale.).
u L as ..or of the property, am exclusively contracting with Licensed
contractors to mnstmct the project (Sec. 70K Business and Prefessioa Code:
The Contractor's License Taw don not apply to an owner of property who
Wilds or Improves thereon, and who mn(nds for such pQe*ds with a
Cg1Li cror(q licensed pursuant to the Contractors Llcenee Lew.
U 1 am exempt under Sec B A P C for this reawn
APPLIANCES -RESIDENTIAL
]OB DESCRB7ION
/�.-- �e.t� �a'1
1rFr_1�''—/1-LJ�" 10 AS
s✓�V„ • e �Ril
PANELS
UP TO 200 AM
201-1000 AMPS
OVERIO30AMP5
SQ. FT. FLOOR AREA
$/SQ. FT.
SIGNS ELECTRICAL
SPFCIALCIRCUIT/MSC
TEMP. METER ORIOLE INST.
BOWER DEVICES
SWIMMING POOL ELECTRIC
ETSSWITCHESHXTURES O
VALUATION
.
NEW R651DP-#TIAL ELFGTR —SQ'Fr'
STORIES
TYPE CONSTRUCTION
T4TAh AP -1
QTY, PLUMBING PERMIT FEE
OCC.CROUIs
RFS. UNITS
FM55ZONE
APN
PERMIT ISSUANCE
ALTER -DRAIN k VENT-WATER(RA)
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
DRAINS FLOOR, ROOF, ARCA, COND.
p0(gVRES PER TRAP
SANITARY Y N
RECEIPT If
Owner Date
WORKMAN COMPMSATION DECLARATION
C31 hereby affirm that I have a certificate of consent to self -Inge, ora
cedifinteof Workers'CompensationlnsunncearamnifWmpythereof(Sec.
3800, Lab C.)
Policy #
SCHOOL TAX Y_ N_
RECEIPT M
GAS EA.SYSTFAf-1 INCAOUTLETS
PARK FEE Y N
RECEIPT #
GAS EA. SYSTEM -OVER 4 (EA)
Com any.
B UI LOING DI VISION FEES
Certified copy is hereby te
Certified ropy V filed withh the city
ry Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(TMssedlon need not be completed If the permit b for.. hundred della.
(81Icrify that
]certify thatln the person in
se as tobthis permit blao the
L shall not employ any person in any manner w u to become subject to the
Wnriners'Compersation laws o(Cell(prnla. Date
Applicant
NOTICE 7'0APPLICANT:attohe after making pe Certificate of Exempt a Labor
provisions of the Labor
shmld become subject no the Workan' such
Cod,youeat voked. rthwith comply with such pmvblans or this permit shall be
deemed revoked.
CONSTRUCTION LENDING AGINCY
I hereby affirm that there is a construction lending agency forthe perform
Lace of the work (or which this permit Is 6eued (Sec. 3097, Clv. CJ
lender's Name
Lenders Addmse
I ceditythmIhavemply with
all catiandcurand tyardthm nheabo and
r rornat building mratruwith anll dInneb muhorize inancee and eesoftwa
tam
or in representatives of this
relatingtobuilding ronsW,men andhereby property
city to)aenter
eeupon to the, indemnify aned property ls.pe Cit purpose.
(We) agree to cave, Indemnity an d keep harmless the City o(Cupertlno
against Wbilllies,judgments, mrts and expenses which may In any way acerur
against said City in ron.ryuence oft egranning of hls It,
Or O I aN�L�
-�
GREASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECIC FEE
PAID
Date RCCCI [N
CREASE TRAP
MWER,SANITARY-STORM EA. 200•T.
WATER HEATER W/VENT/ELFCTR
ENERGY FEE Y N
PAID
Date Recei tic
WATLRSYSTEM/TREATING
NEW RESIDENTIAL PLMB._SQ.FT.
TOTAL:
BUILDING FE
SEISMIC FEE
s TOTAL:
ELECTRIC FEE
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID.
ALTER OR ADD TOMECH.
Date Recei to
AIR HANDLING UNIT (TO 10,000 CFM)
SUBTOTAL:
AIR HANDLING UNIT (OVER 10,000 CFM)
CONSTRUCTION TAX
EXHAUSTHOOD (W/DUCT)
CONSTRUCTION TAX PAID:
sig aa_ to
HA RDOUS MATERIALS DISCLOSURE
I'he applleant or future building occupant store or handle hazardous
mat al asdeflned by the Cupertino Munldpal Code Chapter 9.12, and the
Health and Safety Cade Section 25532(a)?
❑ Yea No
WBl the ipplieant or Nre building occupant use equipment or devices
which emit hazardous air mntapd.nD as defined by /he Bay Area Air
Quality Management District?
Yes readthehaz❑❑ No
Ihave ardousmaterials requirements under Cha pter6.95of
the California Health k Safety Code, Sed lo. 25505,75533 and 25534. I
unde.ta fid than if the building does not currently have a tenant, that it is my
r.a
podulity to notify the occupant of the requirements which must be met
prier to Issuance Of a Certificate of Occupancy.
HFATINGUNIT(TO100,o00BTU)
Date RL'cef t
HEAUNG UNIT (OVER 100,000 BTU)
TOT
VENTILATION FAN (SINGLE RFSID)
ISSUANCE DATE
PAID
OCT/ {�00 {]
V
ISSUED BY: V(•.
BOILER -COMP OFR' OR 100,000 BTU)
BOILER -COMP (OVER IW,DWBTU)
NEW RESIDENTIAL MECH. SQ.FT.
Owner or authorized agent Date
TOTAL:
OFFICE COPY