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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Buildin Project Identification
BuOdleg Address:
PER.MITNO.
12
854
O
22709
OwoRt. one.
STCoes LC•FcUGa-
CITY OF CUPERTINOBUILDINGDIVISION
APPLICATION I PERMIT
A
O I
Contractor's Nanc: Lk. No;
^ s+
'' 11 ����
i) A N A. N.4 wI l fa Q S75% 8
BUTLDING—aECTRICA PLUMBINC-MFOIIANICAL
CAT BY
CONTROL e
Architect/Fnglneer. Lk. No:
QTY ELECTRIC PERMIT 'FEE
BUILDING PERMIT INFO
Address 'q
PERMIT ISSUANCE
❑ ❑ ❑
LICENSED CONTRACTOR'S DEC TION
thereby a f(irmthatlamficensedunderprov sof Chapter9(commenc
hSeMon 7fllD)ofd&slon3o(theBusineaaandl'rofeaelonsCode,and my
ingwit le Infic It..fo endeffect. S
11...
Limnse Cl.. Loc.#
APPLIANCESRESIDENHAL
JOB DESCRIPTION
PANELS
Date Contractor AG
ARCHITECTSD q(J
I undyalerei my player shall be �Ic rnelBs.
>_
201-1000AMPS
OVER IODO AMPS
Fi. G
�� '
t/SQ. Fi.
SIGNSELECTRICAL
SPECIAL CIRCNT/MIST "COMPUTER
ensed Pro`@�f (eso...'� 1 'e
OWNER -BUILDER DECLARATION
I herebyaffirm that I sortexempt tram the Contractors Uceme law for the
following meson.(Secion 7031.5, Business and Professions Code: Any city or
mit
county which requiresa pertocinstrun, alter, Improve, demolish, orrepalr
TEMP METER OR POLE INSf.
any structure pdortolts Issuance, abon mquimslheappllant forsuch permit to
file a signed statement that he is licensed pursuant to the proWioa of the
Contractors License Law (Chapter 9 (commencing with Section 7000) of Dlvi-
Mena of the Business and Profrssro i.Code).,that he is exempt therefrom and
the basis for the alleged exemption. Any violation of Section 70315 by any
applicant fora permit subjects the applicant to a civil penalty of not more than
tows 1, as demodollarthe Pr).
1, ae owner o! the property, .r my employee with wages as their ole
POWERDEVICES
SWIMMING POOL ELECTRIC
OUTLETSSWITCFtESE%TI1R[S
VALUATION_
C� YNR
`
NEW RESIDENTIAL ELECTR �'�'
STOWFS
TYI'C CONSTRUCTION
componeation, will do the work and the structure 1, not Intended or offered for
sole (Sec. 700 Business and Professions Code: The Contractors License Gov
does not apply to an owner of property who builder improves thereon, and
who does such work himself or through hisown employees, provided that such
OCC. GROW
RIS. UNITS
Improvements am not Intended oroffered f.rsals. If, however, thebuilding or
Improvement bsold wothononeyearofcomptelon,theawner-buBderwill have
TOTAL:
tlyn�urdeo of proving that he dm nor Wed or Improve for purpose ofeale.).
u L as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7014, Business and Professions Code:
QTy. PLUMBING PERMIT FEE
PERMIT ISSUANCE
FLOOD ZONE
APN
The Connector's License Law does not apply to an owner of property who
Wada or Improves contcontractsthereon, and who contracts for such pipjects with a
contractor(s) licensed pursuant to the Contomm's License Law.
0I am exempt under Sec. B k P C for this reason
ALTER -DRAW kVENT- VENT -WATER (FA)
FEE SUMMARY
BAIX FLOW PROTECT. DEVICE.
OUTSIDE FITS
DRAINS FLOOR ROOF, AREA, CONE.
pp(IUppg PER TRAP
SANITARY Y N—
RECEIPT M
Owner Date
WORKMAN COMPENSATION DECLARATION
I hereby afilrthat I have a rtificete o! consent to self -Imre, or
C31m cem
SCHOOLTAX Y N
cenlflateofWorken'Co Nmatoonlmumnmoraudifledmpythereof(Sec.
MOO, Lab C.)
RECEIPT
GAS, EA SYSTEMI INCA OUTLETS
PARK FRE Y N_
PolicyN
REC
GAS EA.SYSTEM-OVER4(FA)
BUILDING DIVISION FEE
C [Red copy is herebyth the city
Certified ropy is filed with the city Inspection division.
CREASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECIC FEE
CREASE TRM
CERTIFICATE OP EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Rhos secllon need not be completed Bthe pemdt V (Drone hundred dollars
thato the person
Ill not employ
1 shall not employ an/ Uwe In any manner so en to become subject 1. the
�in an tmannerhow.rk so as tobec this pesubjecft 1. 4o the
Workcra'Compenwtion Uwe of California. Date
PAID
Date Recei t#
SEWER -SANITARY -STORM FA. WEPT.
WATER HEATER W/VENT/E.ECTR
ENERGYFEE Y N
— —
PAID
WATER SYSTEM/TREATING
ApplicaNOTICnt
NOTICE co APPLICANT: a after rs'Co this oationlprovisions of .(Exempt eLyou
should become fbjettmthe ply with
ns orchis permit s lab be
Code, you must forthwith comply with such provisions .,this permit shall be
such
dpemzd revoked.
Date Recei t#
NEW RESIDENTIAL PLMB.__SQI•T.
TOTAL:
BUILDING FEE
TOTAL:
SEISMIC FEE
ELECTRIC FEE
CONSTRUCTION LENDING AGENCY
• Ihereby affirm that there is a construciion lending agency for the perform,
once of the work for which this permit is busied
ed(Sm. 3097, Ch'. C.)
Icnderb Name
L4,dcreAdd..,
1 certtfythatl have read this appBationand statethat theaWve information
-
QTY. MECHANICAL PERMIT ' -FEE
PLUMBING FEE
MECHANICAL FEE
FEES PAID:
Escorted. Iagreeto complywlth all ety.ed county oniinances and state laws
PERMITISSUANCE
retailing to building construction, and hereby authorize exp seentatives of this
city to enter upon the above-mentioned property for inspection purposes.
(We) agree to sive, Indemnify an d keep harmless the City of Cupertino
against liabilities, Ndgment,cost... d expm. which may on any way amore
against said City in consequence of the grant thla pe
ALTER OR ADD TO MECH,
AIR RANDLING UNITED 10,000 CFM)
Date Recei t#
P
SUBTOTAL:
AIR HANDLING UNIT (OVER IO,000CFM)
CONSTRUCTION TAX
o—
S naW of Applicant/ ontracl.r Data —
DUTAUSTHOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (TO 100,800 BTU)
WIItI capplIcent cefutom building occupant store or handle hazardous
terial as defined by the Cupertino Municipal Code, Chapter 9.12, and the
F althand Safety Code Sealon25532(a)7
Ya 1�1 No
Date Recei t#
HEATING UMT(OVER 100,000 BTU)
_
TOTAL:
VENTILATION FAN (SINGLE RESID)
ISSUANCE DATE
— tl�
I•'
I'��`. �3 a
a7
Will the applicant or futumbullding occupant use equipment ordevices
which error hazardous air rontamhtents as defined by the Bay Arca Air
Quality Management District?
4 Ya � No
haveread the hua ous metals requirements under Chapter 6.95 of
the
ersta dt Flealth if the building afety Code, Sec ions currently have a tenad, that[534. ]
thatIt is my
understand thatntheteoccupant
not the
responsibility notifytheic ofthe requlrctmnlswhkh must be trot
meats which
BOMER-COMP OtI'OR 100,IX0 BTU,
BOJLER.COMP(OVER 100,000 BTU)
NEW RESIDENTIAL METH. SQ.FT.
heuato
teof
prior to Issuanre of Certificate of Occupancy.
ISSUED B
Owner or authorized agent Uate
TOTAL:
OFFICE COPY