22581APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification
Building 40dress: t
Y.fI I PIC fi Prr
PERMIT NO.
2 2 5 81
nere ame:sone:
Meg 'i nnu w»aC 946-x489
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BUILDINr—ME TRICAL-PLUMBING-MFLHAMCAL
Con aRso-rwaNa LIc.N.
G 6-be.3 A
CATEGORY
CONTROA
Architect/Engineer. Lk. No:
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Add.
PERMITISSUANCE
❑ ❑ ❑
DECLARATION
LICF.NS EDCONTR under provisions
I hereby
ereaction mthat l iv silicensed3fth. erp essandaof Chaptemionsr9 (comment,
o[the Bustnmand Pro/mlansCode,nd my
]Iran.h 1.full force and effect.
Ileense is in full force end .Ia
Limn CW `s Llc.p-�
Dale Contractor
ARCHITECPSDECLARAT70Ns
Iundemlandmy
mphes.hal a public remrda
Llmosed Pmflooal i 11111
OWNER -BUILDER DECLARATION
m
Iherebyaflrthat l am exempt fromthe Contractors License Law for the
(oaowing reason.(Section 7071.5, Business and Pmfmlons Code: Any city or
countywhich requires a permit to construct, alter, improve, demolish, orrepair
any structure prior to its hunts nee, also requires the applicant for such permit to
at
file a signed statement that he licensed pursuant to the provisions of the
Contractors License Law (Chapter 9 (commencing with Section 7000)of Divi.
s1on3 o(the Buslneesand ProfenlmoCoie)orthm he is exempt therefromand
the basis forthe alleged exemption. Any violation of Section 7HIS by any
applicant fora permit subjects the applicant to a dv11 penalty of not morethan
five hundred dollars (S500),
I, an owner of the property, or my employees with wages as their sole
compensation, will do the work, and the structure is emt intended or offered for
vie (Sec. 7044, Bush. and Pro(enlom Code: The Contractors License Izw
does not apply to an owner of property who build& or Improves thereon, and
who doessuchworkhlmselforthmugh hlsownemployen, providedthat such
Improvements an not Intended oroffered forvle. If, however, thebullding or
improvementiceoldwlthin oneyeamfcomple im,the owne,builderwlll have
tfa.4urden of proving that hedid nathuildorimprove forpurposeo(sale.).
L j L as owner of the property, am exclusively contracting with licensed
orM actns to construct the project (Sec 7074, Businm and Profe cion Code:
The Contractors License Law don cad apply to an owner of property who
Wild. or Impmen thereon, and who contracts for such p(ojects with a
cgng.ctor(.)Bcensed pursuant to the Contractors License Law.
L j I am exempt under Sea B k P C for that reason
API'LIANCESRFSIDENMLIngwit
J R DESCRI'CfON
n ^
Y`/ M✓:J".`F:'n�Y J\
V9f )
s�
FAM7R l Wv
201 1000 AMP"'
OVERIODOAMPS
SQ. FT. FLOOR AREA f/SQ. FT.
,q L E D IN
M P U T E
,e.
�L ,aa �s®� D
E V �7 i
SIGNSELECTRICAL
SPECIAL CIItCUl7'/M1SC
TEMP METIER OR POLE INS(.
POWER DEVICES
SWIMMING POOL ELECTRIC I
OUTLETSSW TCIiESFIXTURES ' Qa
VALUATION
NEW RESIDENTIAL ELECTR _SQFI'.
STORIES
TYPECONSTRUCTION
,
TOTAL: t
QTY. PLUMBING PERMIT FEE
OCC.CROUP
RES. UNITS
PERMIT ISSUANCE
ALTER-DRAINA VENT-WATER(EA)
FLCODZONE
APN
FEE SUMMARY
BACKFLOW PROTECT. DEVICE
•
DRAINS FLOOR ROOF, AREA, COND.
FIXTURES PER TRAP
SANITARY Y_ N
RECEIPT p
Owner Data
WORKMAN IO
reCOMPENSATN DECLARATION
❑I heby aM. that I have a certificate of consent to self-Inmre, or
cenlflcamofWorkers Compeesatln lecomm s ora certlfled ropy thereof(Sec.
3800, Lab C.)
SCIi00LTAX Y N
RECEIPT
GAS EA. SYSTEM -1 INC4 OUTLETS
PARK FEE Y N
RECGAS
EA. SYSTEM -OVER
Co.Cmppppppany
BUILDING DI VISION FEES
VINE DIM
LCenlRed copy 6 had with thehed.
Certl(led ropy at (Bed with the city inspection division.
CERTIFICATE OF EXEIFFION FROM WORKCRV
COMPENSATION INSURANCE
(Thtemctbn need not be completed lithe permit at (atone hundred dollars
(S100)orlm.)
I mrtify that in the performance of the work (or which this permit is atsued,
Ishall not employ any person In any manner eo as to become subject to the
Worken'Compensatlon Laws of CalIIornb. Date
ApplicaNOTICE
shoulNOTICEco APPLICANT: If, orkmakingthat CenniProisons oftlo Lyou
Code, becomesubjectto the Workers' CompensationProvisionspomits Labor
Code, you must forthwith comply with such provisions or this permit shall be
domed revoked.
CONSTRUCTION LENDING AGENCYSEISMIC
Iherebya((Irm that there is amestructlon lendlegagenry forthe pedonrt
ance o(the work for which that permit is issued (Sec. 3097, Civ. C.)
Lender's Name
Iender.Addrcv
I certlfythatl have read thisappllotlonard stalelhatthe above Information
incorrect. 1.8me to comply with all cityand county ordinances and Kate laws
relating to building mmlructln, and hereby aulhorlu representatives of thio
dty to enter upon the abovcmentlared property for inspection purposes.
(We) agree to save, Indemnify an d keep barred. the City of GL pardon
against BablBtles, judgment., cocasand expense. which may In any way accrue
zgaiml.al n4, esequ of granting ofthls permit.
Sigwturco Appll c t Date f
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant on future building occupant store or he cad In hazardous
moterbl as defined by the Cupertino Municipal Code, Chapter 9.12• and the
I ealth and Safety Cade Semon M2(a)2
nYen M No
Will the appllnnt or future building occupant use equipment or devices
which emit hazardous air com.nonanta as defined by the Bay Area Air
Qua Bty Management Dist rict7
4 Yea F� No
have read the cue materials requirements under Chapter 6.95 of
the Callfomia Health k Safety Code, Sections 25505,7$533 and 25534. I
understand that lithe huilding does not currently have a tenant, that It is my
rnpomibility, to notify the occupant of the requirements which at be met
prior to Issuance of a Certificate of Occopaocy.
GREASE/INDUSIRL WASTE INTERCEPTOR
PLANCHECK FEE
PAID
Date RCCeI t#
GREASETRAP
SEWEWSANRARY-STORM EA. 200FT.
WATER HEATER W/VENT./ELECTR
ENERGY FEE Y N
PAID
Date Recei t#
WATER SYSTEM /TREATING
NEW RESIDENTIAL PLMB. SQ.FT.
TOTAL:
BUILDING • •
FEE
TOTAL:
ELECTRIC FEE
a
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
MECHANICAL FEE
PERMTTISSUANCE
FEES PAID:
ALTER OR ADDTO MECH.
Date Recei I#
P
AIR HANDLING UNIT(TO 10,M0 CFM)
SUBTOTAL:
AIR HANDLING UNIT (OVER I QITO CEM)
CONSTRUC71ONTAX
IXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HEATING UNIT 00100,000 BTU)
Date RCcei t#
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
VENTILATION FAN (SINGLE RESID)
I$SUANIZE DATE
Qr7r
{��%h 1 rj
a+e o6 O /c`J
RL
VG sd.
ISSUED BY:
BOILER -NMP OHP OR 100,0M BTU)
BOILER -COMP 100,0(0 BN)
NEWRESIDENTIALMECH. SQ.FT
Owner or authorized agent Date
TOTAL:
OFFICE COPY