21007APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro'ed Identificatio11bn
Building Add mus: V O
PERMIT NO.
1 0 0 7
21007
G
nte
a: one:
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION I PERMIT
p
re tact ten/Engl LGLT%D iJ �O J/
nth ser e. No:
Li
BUILDING-MECTWCA4PLUMBINr—MECHANICAL
CATEGORY
CO (O [ 1
QTY ELECTRICPERMIT FEE
BUILDING PERMIT INFO
PERMITISSUANCE I t�
n4as((((//as((
Addte(_ v2JY�y d.
rQ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions o(Chapter 9 (commem,
Ingwith force of Dlvfect. (the Business and ProfesslomCode,and my
license la In fug fonts and d(M. a�// ,S/
APPLIANCESRESIDENTIAL
J00 DFSCRETION
PANELS
Llmnee dam LIe. Mntractaa�" Bi
DakCoor
ARCHITECTS DECLARATION
1
101-1000 AMPS
OVER 1000 AMPS
SQ, Fr. FLOOR AREA
l Y��
S/SQ. FT.
"�.O
I understand my plans shag be used u public records.
Licensed Professional
SIGNS ELECTRICAL(\
SPECIAL CIRCUIT/k$C
OWNER -BUILDER DECLARATION
I hereby afOrm that I am exempt from the Contractor's License Law for the
P
METER ORPOLE] )
I
POA DEVICES M r
following Mason.(SMIon7031.5, Businessand Profeeirm.Code: Anycttyor
courywhich requima permUtoconstruct, alter, improve, demnlleh,orrepair
anystrecure prlortolts Issuance, also requlresthe appllcantforsuch peroutto
file a signed statement that he is licensed pursuant to the provisions of the
Contractor's License Law (Chapter 9 (mmmenmg with Section 7000) of Divi -11
slon3 of the Business and Professions Code) or that he Is exempt therefromand
the basis for the alleged exemption. Any violation of Section 7031.5 by any1�
applicant fora permit sub"theapplicant to a civil penalty of net room than
gmAiC I ECTBIC u
OU77-E HESF7 ES
VALUATION
—L
�%
NEW RFSI AL Ili .FT.
11 hundred dolhm (5500).
1, as owner of the property, or my employees with wages as their sole
STORIES
TYPE CONS7l2I1C'I'ION
compensation, wlllciothe work andthe simmers Is not Intended or offered for
sale (Sec. 7061, Business and Professlom Code: The Contractors License Law
OTAL:
does not apply to anowner of property who builds or Improv,thereon,and
hlmselfwth.gh hlsownempioyees, provided thalsuch
improvements am not Intended proffered for sale. If, however, thebuliding or
Improvement Issold within owyearofcompImlorytheowner-bugderwlll have
OCC.GROIIP
RFS. UNITS
tmen of Proving that he did not build or improve forpurpouofule3.
4 an owner of the property, am excluldwly mn.....a g with —nsed
cont, to construct the project (Sec. 7074, Business a nd Profesdome Code:
QTY PG BING PERMIT FEE
PERMIT ISSUANCE
FIOODZONE
APN
The C otractore License law don no apply to an owner of property who
Wilde r Improv,m
therm., and who contnm for such pkojem with a
r(s) licensed pursuant to the Contmemes License Law.
c exempt under Sec B k P C for this reason
pL W k VENT - WATER (EA)
FEE SUMMARY
BA WI'IIOTFOT. DEVICE
OUTSIDE FLES
DRAI S FLOOR ROOF, AREA, COND.
SANITARY Y_ N_
RECEIPT #
Owner Detc
WORKMAN COMPENSATION DECLARATION
01 hereby affirm that I have a mrtlOwte of consent to self-Insum, w a
card(icateofWorkem''Compenutlonlr mnmwacedifiedmpythercofakc.
3500,1ab C.)
PD(.f.URE&PER TRAP
SCHOOLTAX Y_ N_
RECEIPT N
GAS EA. SYSTEM -1 WG10UTLEI'S
PARK EFF. Y N
Polley If
RECE
GAS EA. SYSIIMd OVER 4(EA)
Com any
DING IN
BUILDING DI VISION FEES
ed
Certified copy is herebyth the city
Certified copy Is filed with the dry Impaction division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thlssection need not be completed lfthe permit Is forom hundreddollan
(Slowcoleu.)
I certify that In the performance of the weak forwhich this permit is Issued,
I shall not employ any person In any manner se m to become subject to the
Workers Compensation laws of California. Date
CREASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE
/yk�I Q 1(7
PAID f 41
Date R # (O JI
GREASE TRAP
SEWER 'SA"ITN1Y'Stt1RM EA. 200FT.
WATER HEATER W/VENT/ELECTR
ENERGY FEE Y
PAID
WATER SYSTEM/TREATING
Applicant
NOTICE TO APPLICANT: If, after nuking this Certificate of Exemption, you
should bemmesubFct to the Wmrkeri Compensation provisions o(the Labor
'Code, you moat forthwith comply with such provislom orthis permit shall be
dermad revoked.
Date ReceI t# 0s
NEWRESIDFMIALPLMB. _SQFT.
rin
TOTAL:
tm
Mitt FEE
CONSTRUCTION LENDING AGENCY
Ihembyaf0rm that there Is a mmtmdimlendingagencyfortheperforrry
once of the work for which this permit b Issued (Sec. 3097, Civ. C.)
Lender's Name
Landce.Address
1 certify that I have read thlsappgcationand tlatethatthe above information
tsmrrsct.lagmlo complywithall cttyand county ordinances and tlatelaws
TOTAL:
CTRIC FEE
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
MECHANICAL FEE 00
FEES PAID:
PERMIT ISSUANCE t�x Q3
relatingtobulldingcomtmdimn,andherebyautho mpreeentativeaofthIs
city to enter upon the above-mantioned property for Inspection purposes.
(We) agree to save, indemnify an d keep harmine the City of Cupertino
agar ablllRes, to dgment.,.9. and expenses which may In any way accrue
aga t City in mmnlu a. egranti ofthtspemnit.
Date Recel t#
/ ALTER OR ADD TO MECH. 2rer'
AIR HANDLING UNIT (TO 10,0DO CFM)
SUBTOTAL:
AIR HANDLING UNIT (OVER 10,000 CFM)
OIL—
CONSTRUCTION AX
4VI
S�gmturef pplcant/Con cto to
EXI7AUSTHOOD(W/DUCT)
CONSTRUCTION X PAID:
HA4AR U ATERIALS DISCLOSURE
HEATING UNIT (TO 100,000 BTU)
Will the appgcanl or ulldingoccvpant store or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.12, and the
Health and Safety Section 25532(.)1
[] Yes ' lr/I�fuiuNo
Wgliheapplica rebuilding occupant use devlcn
Date Re t#
HEATING UNIT (OVER 100,000 HIM
TOTA 5zkos
VENTILATION FAN (SINGLE RFSID)
I DATE
hamardn a
which emithovment air contaminants as defined by the Bay Area A4
the BayequipmentArea
Quality Management
4 Y� No
have read the h us materials requlrements under Chapter 6.95 of
SEP 12 1990
BOILER -COMP OFN OR 100,0(YBTU)
BOILER-COMP(OVER 100,000 BTU)
the California I lealth h Safety Code, Sections 25505, 25533 and 25534. 1
,
NEW RESIDEM7AL MECi 7. SQFr
understandthatifthebulldingdoesnmtmrrentlyhaveatenanL,th.tltIsmy
r,po Ibllity to net Ify the occepa to of the requirements which must be met
pp.� //�s �{
City of PupeliIIII
prior arce.f.colf ofOccu nry.
alar'
ISSUEDB
Owns ora horizeda n Dateb,yx
TOTAL:
OFFICE COPY
IIA