21597APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project dentificationPERMIT
Building Address:
NO.
21597
nets ams. one;
-
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
TRICALPLUMBINGMECIIAMCAL
C.ntartor.Name: Lk. No:
t LI
?BUILDINGaL
�
CATEGORY
CONTROL X
A Bel o a.
Archit glneer. Lic. Nee
Q'py "" ELECTRIC PERMIT- " '��.''�FEE
"c BUILDING PERMIT INFO '
1
Address:LICEN''] u u �1'RA
POthIITiSSUANCE
❑' ❑ ❑
DECLARATI
therebyaffirm tha�tl am lkcrocel underprwlsmuo(Chapter9(romenno,
ingwlthSectlon7W0)of Dlvldon3o(theBueineeaand ProlesslaneCgde,rand my
It ce.. Jai n toll force and effect '
License Claes Llc.p a'i�yy-1�, T
Date /3 •la-_�Contranor fa`S17]/1UP
ARCHITECT'S DECLARATION
undeatan phru ehaB4uaedyga,gpBc records.
{� Y.Gi�
Llceneseloai _rte_
OWNER -BUILDER DECLARATION -
I hereby afflrmthal I am exempt from the Contractor's License Law for the
followingreason.(Section 7031.5, Business and Professions Code: Any dty or
county which requires a permit to construct, alter, Improve, demolish, or repair
any smrctum prior to its issuance, also requires the a ppbcant for such permit to
rile a signed statement that he 13 Bmnsed pursuant to the provisions of the
Contractor's License Law (Chaptar9(commencing with Section 7000) of Divi-
Business and Professloa Code3arthat he is exempt therc(romand
the basis for the alleged exemption. Any violation of Section 7031.5 by any
applicant fora permit subject.the applicant to a civil penalty of nee more than
five hundred dollars(S5DUL
p1, as owner of the property, or my employees with wages a their sole
compensation, will do the work and the structure is not Intended or offered for
sale (Sec 7064, Busbmas and Professions, Cade: The Comeact.e. License Law
doesnotapplytoanownerofpropertywhoWildsorlmp'roves thereon, and
whodae.soehworkhlmself orthrough lonownemployees, providedlhatsuch
Improvements arc not Intended oroffered (orale. If, howwegthebuilding er
Improvement l..ld w thlnoneycarofcompleUoMtheowner-builderwill have
it e�urden of proving that he did not build or improve for purpose ofak.).
t I, ae owner of the property, am exclusively mntracting with Ilttnxd
contractors to construct the preird (Sec 7014, Bualness and Professions Code:
The Contractor's License Law does not apply to an owner of property who
Wilde or Improves thereon, and who contract. for such plajern with a
cgBt_jactor(e) licensed pursuant to tM1e Contrartor's Llcen.Law.
LU I am exempt under See. B & P C for this recon
APPLIANCESRESIDENEUL
JOB DESCRB'TION
�c
_
PANELS
TO 2DO AMPST`
701-1000 AMPS
OVER 70W AMT'S
SQ. FT. FLOOR AREA
- -
-
,
S/SQ. FT.
9CN5 ELECTRICAL
5PGCIAL CIRCUIT/MISC
TEMP. METER OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS -SWITCHES -FIXTURES'
VALUATION
'
NEW RESIDENTIAL ELECTR --SQ'Fr'
STORIES
-
-
TYPE CONSTRUCTION
OTAL:
QTy, PL $TNG PER IT FEE
OCC.GROIII'
RCS. [1NTT5
PERMIT. LSSl1A E ^ _rsl
.L.,-(/
ALTER -DRAW & - TER �1
) y(Yi
FLDDDwNE
APN
BACK PLOW T .'DEVI (
FEE SUMMARY
yL> PI'li5
D�VNS-FLOVDOFWCO
•—
SANITARY Y N
REE=MSCHOOL
Owner Date
ON
WORIAN COMP ENSATION DECLARATION
❑I hereby affirm that I have • certificate of content to self -Insure, ora
certi(lL.bC. Worken'Compeaatlon Wuance ora certified ropythereof (Sec.
Poli3800, Lab CJ -
It
TAX Y_ N
RECETT N .
G
STEM- IN AO
PARK FEE Y_ N_
G
YS-OVER4
Comry
ray
BUILDINRECG DIVISION ON FEES
Certified copyE hereby tarnished.
ertified copy V (ihd with the city Inspection division.,
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not W completed if the permit is for one hundred dollars
($100)oify that the work for s to bec is permit is head,
I cenot that In any pehe rson in any
I shall not employ any person In any manner . a to berome subject to the
Laws of California. Date
Applicant
NO IICEt
NOTICE oo APPLIGto the after making this ationk ro of Exemption,aLabor
peofthn Lab or
should Wcoma fortect hwith co ply with
Code, you most forthwith comply with each provieloa or this permit shell be
Cuch provisions
deemed revoked.
CONSTRUCTION LENDING AGENCY
Iherebya(firmthatthemis construction lending agency for the perform
aatter'.Nthe work for which h bound tree. 3897, ch'. C.)
Lenders Name
LendelsAddmss
Icertifythat I have readthisapplicationand statethatthe above information
Iscormet.I agree tocomply with all cityand county ordinances and date laws
relating to bullding roatroction, and hereby authorise rcpre.npurpos o(thb
city (We)aenter upon the
ve, Indereadlyand propertyharm inspection purposes.
(We) agree to ave, Indemnify and keep harmless the City of Cupertino
all tsabllltlea, jrdgmenb, mass and expenses which may In anyway accrue
rag teal C�1 n race of the granting of this permit
Slgna , o pp /Contractor Data
R DOUS MATERIALS DISCLOSURE
Willt appll of orfuture building occupant store or handle hazardous
materhla defined by the Cupertino Municipal Code, Chapter 9.17, and the
I kalth and Safety Code Section 25532(a)7
r-1Yeau No
Will the applicant orfutumbuilding occupant use equipment ordevices
which emit hazardous air contaminant. a. defined by the Bay Area Air
Quality Management Listed?
n Yea No
ave read the but ,r o. rtatedahrequimr nhunderChapter6.95of
the California Health & SafetyCuda, Sections 75505, 25533 and 75536. 1
understand that lithe building does not currently have a tenant, that It is my
responsibility to nosily the occupant of the requirements which most be met
prior to Issuance ofd Certificate of Occupancy.
C SE/INDUSIAL WA EPTOR
PLANCHECK FEE
PAID
Da[e Remi tiF
GREASE TRAP A
SEWER -SA Y -S RM EA. 700FT.
WATER HRA W/VENT/ELECTR
ENERGY FEE Y N
PAID
Date Recd tk
WATER /TREATING
NEW RE9 ENTIAL PLM B. SQ.FT.
TOTAL:
ILDIN
SEISMIC FEE
TOTAL: '
ELECTRIC FEE
-
QTY. MECHANICAL,PERMIT "FEE
PLUMBING FEE
(4,•{m
PERMITISSUANCE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT (170 10,000 CFM)
-
MECHANICAL FEE
FEES PAID:
pate ReceI tk
P
SUBTOTAL:
AIRHANDLINGI1MT(OVER10,000CFM) 'CONSTRUCTION
TAX
EXHAUST HOOD(W/DUCD
CONSTRUCTION TAX PAID:
HEATINGUNTTC1010),000BTU)
Date ROCCI tN
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
VENTILATION FAN (SINGLE RESID)
ISSUANCE DATE
b.,, es ,t I}�i�N
LUEDBY. W
BOILER -COMP O}R'OR 100,00) BTU)
11011,13R -COMP (OVER 100,00) BTU)
NEW RESIDENTIAL MECH. SQ.}T.S!!4
Owner or authorized agent Date
TOTAL:
OFFICE COPY