21860APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pre'ed Identification
Be7¢81 PLV" ftwxoM WL. L-WIR i 1Ja - mi
PERMIT NO.
21860
wners ante: one:
c-, j%r-yr-JES As. 3—SOS'$
CITY OF CUPERTINO-BUILDING DIVISIONq
APPLICATION 1 PERMIT
BUILDING-EI.ECTRICALPLUMBING-MECF(ANICAL
2 '— >' Z—
Common;. Name: `., r % Lie. No:
Qt� l(- K11CHEp1S ,71LZ
Architect/Engineer. LIc. No:
CATEGORY
CONTROL#
QTY ELECTRICPERMIT
FEE
BUILDING PERMIT INFO
w
Addreea '1 Z3 44BLDG
S- ++ SDT
UE'Li
PERMITISSUANCII
Viz
LICENSED CONTRACTOR'S DECLARATION
I hereby Affirm that l am licensed under provisions ofChapler 9 (communist,
Ingwlth Secilan7000)of Dlvlslon3oftheBueimreeand ProfeWoneCede, and my
LenxlC I. full ss form and elle« . s¢'7 S ZZ
lc
Date ContntloV��a�TT �(�I�iWs.
ARCHITECPS DECLARATION
Iundentand my plans shall Wused mpublic records.
Ltomaed Professional
OWNERAR
rmBUILDER DECLARATION
[ hereby afBte A
I am exempt from the ciote License Law for the
following reason. �ectlon 78iiS, Business and Professions Code:Anycityer
county which requires a permit to constroci, alter, improve, demolish, or repair
anystrutlurc prion -to Its imuance,also requlrealheapplicant forsuch permit to
file a slgned statement that he Is licensed pursuant to the provisions of the
Contractor's License Law (Chapler9(commencing with Section 7000) of Divi.
slo.3 ofthe Business and Pmfxs imo Code)mIhat he b exempttherefromand
the basis nfor the alleged vemthe n.applicant
Anyviolationtolacivi ofSectiono nor room than
five hundred aperMt5500). ethe applicant loadvll penalty of nor mare than
Ove hundred dollars (5500).
I, act owner of the properly, or my employees with wags as their sole
compensation, will do/he work and thestmclure beet intended or offered for
sale (Sec. 704#, Busies.. and Professions Code: The Commeto's Llrerue Law
does not apply to an owner of property who builds or Improve, thereon, and
who does such work himself orlhrwgh his own employee., provided that such
Improvementsannotinlendedorefferedformle. ILhoweveglheluildingor
Improvement usoidwlthlnoneyearofcompletlon,the owner-bullderwlll have
th,Lkurdeno(pmving that he did not build or improve for purpose ofsaie.).
u L as owner of the property, am exclusively contracting with licensed
..trade. to construct the project (See 7014 Business and Professions Code:
The Contractor's Limnae law don not apply to an owner of property who
Wilda or Improves thereon, and who contntls a
for such p(ojes with a
crlp(larIs) licensed pursuant to the Conlradofs License Law•
IJ1doam exempt under See B k P C'for this on
reas
APPLIANCES -RESIDENTIAL
OB DESCRBr770N
�
�µ
s1 ,
PANELS
UP
101-IODOAMIS
OVER 1000 AMPS
SQ.FT. FLOOR AR
J
v lyC,oj
/
b
S/SQ.FT.
SIGNS ELECTRICAL
SPECIALCIRCUIT/MLSC
TEMP. METER OR POLE INST,
POWER DEVICES
SWIMMING POOL ELECTRIC
OUMETSSWITCH6FIXTURFS
VALUATION O
/y D %Fs
Q V If
NEW AESIDGNDAL ELECTR SQFf.
STORIES
TYI'ECONSTNUCTION
- TOTAL: ao•'IVD
QTY. PLUMBING PERMIT FEEF(.00DTONE
PERMIT ISSUANCE I #
.Z•QY
' ALTER -DRAIN &VENT -WATER (EA) all ��
OCC.GROUIa
RFS UNITS
APN
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
OUTSIDE HIS
DRAINS FLOOR ROOF, AREA, GOND.
FIX'NRFS PEN TRAP
1 QO
SANITARY Y N_
RECEIPT #
Owner Dale
WORKMAN COMPENSATION DECLARATION
S;JPbenby affirm that I have a arrif team of consent to self -Insure, or
certificate of Workers Compensation Insurance or a certlfled copy thereof (Sec.
Pol;#00 bC, M73L'Zv _ 90
SCHOOL TAX Y_ N_
RECEIPT #
GAS EA. SYSI'FM-1 INC.40UTLEIS
PARK FEE V N
RECEIPTN#
GAS EA. SYSTEM -OVER d (EA)
Com an
BUILDING DIVISION FEES
CertlflLdcopybhereby (umlehed.
�
®GeRiRed copy is filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(TMssedlen need not be completed tithe permit later.. hundred dollen
($1 BB)orlea..)
Ill not thatoy in anyhe person
ianHhewak so as to be. subjrmit ect Bothesued,
1 shall not employ any.Laws (C.1i manner at as to become sub�eci 101he
W plicae Compenution laws of Glllomh. Date
Applicant
NOTICE
ouldb co APPLICANT:e aftermaking fhbaxtion pro is Exemption,the
should become subject to the Werke.' Compensation provisions of the Labor
Code you awed forthwith .reply with such provlelotu orthb permit shell be
deemed revoked.
CONSTRUCTION LENDING AGENCY
Ihc.byafflrm thatthenbe construction lending agency for the perform-
ane of the work for which Ihb perMt Is issued (See. 3097, Cl, C.)
l.rder'.NamePLUMBING
Le.d.r.Addnss
I redlfythat I have read thbappli.tion and datethatthe above Information
bcomlin
ct. I agmxto complywlth all cityand county ovanresandstale laws
relating to building construction, and hereby autbmlu representatives o(Ihb
city to enter upon the above-mentioned property for Inspection purposes.
Me) agree to save, Indemnify an d keep harmless the City of Cupertino
against flab tics,judgments,cre.and expenses which may In anywayaceme
agalrsbal Ity in con sen. 0f the granting of this permit
�1
r
GREASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE
PAID
Date Recti tN
(7•FQ3
GRE'A'SE TRAP
SEWER -SANITARY -STORM EA. 200FT.
WATER HEATER W/VENT/ELECTR
ENERGYFEE Y N —
PAID
Date Repel tic
WATER SYSTEM/TREATING
NEW RESIDENTIAL PLMB. SQXM
TOTAL:
U IL12ING FEE
Sd
SEISMIC FEE
10.119
TornL:
(/
p • 1%Q
ELECTRIC FEE
SC
QTY. MECHANICAL PERMIT
FEE
FEE
IT- Ob
MECHANICAL FEE
PFRMITLSSUANCE
d0
FEES PAID:
HR
ALTORADDTOMECH.
p
/-VODate
RCCCI IH
AIR HANDLING UNIT CTO IO,ODOCPM)
SUBTOTAL:
'
AIRHANDUNC UNIT (OVER IO,ODOCFM)
CONSTRUCTION TAX
i tore pplkan Contras Date
HAZARDO ATERIALS DISCLOSURE
Will the applicant or future building occupant atom or handle haraidous
material as defined by the Cupertino Municipal Code, Chapter 9.1 1, and the
Heaithand Sifcty Code SWI=25532(a)?
ri�w,1+�-� No
Will the3ppliom or tum building occupant use equipment or devices
which emit haeardom air contandearda as defined by the Bay Arca Air
Quality Management District?
PhYes r
evened the
Health aely Code, Sercquirementsunder Chaple4.L95 of
theCalifornia erstantat fifth building does a tenant, that
understand than oifytlldingdoes oft a currentlyhavewhichL that it met
nsorl.iai to notify the ttto of of the nqulrcmenle which moat be met
prior tole an. a tate of pan n '
EXHAUST HOOD M/DUCT)
a
CONSTRUCTION TAX PAID:
HEATING UNIT (TO I M,000 BTU)
Date Receipt#
HEATING UNIT (OVER 100,000 BTU)
T TAL:
VENTILATION PAN (SINGLE READ)
ISS WT
nn
si' E
gma y
�1•C+1C�'$
i
ISSUEDBYt
BOILER -COMP OHP OR 100,DM BTU)
[LFR-COMP(OVER100,000 BTU)
NEW RE9UFN77AL MECH. SQFf.
rau ruagent
ed Date
TOTAL:
•�.e-R
OFFICE COPY