20666APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Protect Identification�I�r
Build ing Add cess:
Iba51 SANT,4 'fE¢T�SA A.ve .
PITM1r NO.
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wncr• a one:
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CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BUILDING-ELECTRICAL-PLUMBING-MLCHAMCAL
,
7— 3--q
Contractor'. Name: G� Lk. No:
CATEGORY CONTROL N
BUILDING PERMIT INFO
Architect/Englaer. Lk. No:
QTY ELECTRICPERMIT FEE
Address:
PHih4TIS5IlANW
❑ F-1 D
LICENSED CONTRACTOR'S DECLARATION
I hereby afflrmthatlnot licensed ftheunder Buprovland Pro Chapter9(e,andm
Inense 1.1 ian90W)o( d vfect. ofthe euslnessand ProfessiovCode, and my
license isl�I (ut�Jorppand effect. N...
License ('IjRN/_�c'j_Llc. N z la Jry Q g
Date Contractor
ARCHITECTS RA R3
(understand mypiawshallbeused aspubllcrecumis.
Licensed Professional
OWNER -BUILDER DECLARATION
I herebya(firm that I am exempt fromthe Contractor's License Law forthe
following reason. (Section 70115, Business and Professions Code: Any city or
county which requires a permit to mmlruct, alter, improve, demelish, or repair
anystmcmmpdortolbiss anc,ab mquires(heappliantforsuaperMtto
file a signed statement that he is licensd.p
eunuant to the provisions of the
Contractors License Law (Chapter 9 (commencing with Section 7000) of Divi-
slon3ofthe Buginensand Pmeago. Code)orlhat hats exempt therefmmand
the iasis for the alleged exemption. Any violation of Section 70315 by any
applicant fora permit subpRsthe applkanuoa dull pnalty o/not rtnre thin
five hundred dollars ($500).
nl, as owner of the properly, or my employees with wages as their sole
compensation,wllldo the work, and thestructure is not Intended or offered for
Bale (Sec. 7064 Business and Professions Code: The Contractor's License Law
does not apply to an owner of property who Wilda or Improves thereon, and
who does such work himself or through his own employees, provided that such
Improvements are not Intended or offered for sale. If, however, the building or
Improvement Is sold within one yearofcompletlon, the owner-bu ider willluve
t Nen of proving that he did rout Wild or Improve for purpose o/sale.).
Lj I, as owner of the property, em exclusively contracting with licensed
contractors to constmct the project (Sec. 7044, Business and Prefer dons Code:
The Contractor's License Law does not apply to an owner of property who
Wilds or Improve. thereon, and who contracts for such piajects with a
gqNN(Tactor(s) licensed pursuant to the Contradof. License Law.
e 5I am exempt under See B Is P C for this reason
APPLIANCESRF.S[DEN7IAL
JOB DFSCHI'TION
C4J v'I N F - y A t p.41 K
PANEfS
UP TO 200AL41!S
ZOI-IOOOAMPS
OVER1000AMPS
SQ. Fr. FLOOR AREA
$/SQ.FT.
SIGNS ELECTRI L
SPECLACIRCUIT ISC
gpAlp ME1ER 0 ST.
POWER DEVIC
SAM PEN C
OU1LE TC FS
NEW ftR51
an
VALUATION
STOwpS
TYPE CONSTRUCTION
PON
TOTAL:
UMBINGP FEE
ANCE
QTy.JALMINk VEM- WATER (EA]
OCC. GROUP
RFS UNRS
FLOODZLINE
APN
BACK FLOW PROTECT. DEVICE
` FEE SUMMARY
DRAINS- FTAOR ROOF, AREA, COND.
FDCnJRRS PER TRAP
SANITARY Y N
RECE117 p
Owner Date
WORKMAN COMPENSATION DECLARATION
❑1 hereby .(firm that I have a l certificate of consent a pytnemot ora
380uai,Lab o(Workere'Comp.aatlonlnsurana aracertlfled copythemof(Sec.
3800, lab CJ
p
SC1IOOLTAK, Y_ N_
RECEIPT N
GAS EA. SYSTEM -1 INCA OUTLETS
PARKFEE Y N
M
RECEGAS
EA. SYSTEM -OVER 4 (EA)
Coilcy
Cany
DING DT
BUILDING DI VISION FE ES
arefte�CAdificd ropy 1s hereby with the city
Sqa�` ertl/led copy b (bed with the city inspea[Ion division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not PENS TI NI permit le/occas hundred dollars
(f100)or less.)
I certify (hat N the performance of the work for which this permit Is issued,
I shall not employ any person In any manner An as to become subject 1. the
Workers' Compensation Laws of California. Date
Applicant
NOTICE TOAPPLICANThe after makingthis ationlpro is Exemption, you
should becamesubjecttothe plyk t Compensationprovisionofthe Labor
CodGyouvoet forthwith comply witheuch proWionsorlhbpermit shallW
deemed revoked. '
CONSTRUCTION LENDING AGENCY
I hereby affirm that there A a construction lending agency for the perform-
once of the work for which this permit b Lsmed (Sec. 3097, Civ. C.)
Lender's Name
Lendce.Addm.
I certify that I have read this application and pate that the above Information
is correct. I agree to comply with all city and county ordinances and state laws
relating Wbullding construction, and hereby authorize representatives of this
city to enterupon the above�meatoaad property for inspection purposes.
(We) agree to save, Indemnify d
denify an keep harmless the City of Cupertino
against liabilities, judgment., rosband expenses which may in anywayamme
Against said City N con Bore fthegnnting fthlspe It.
CREASEANDUSIRL WASTER INTERCEPTOR
PLANCHECK FEE
PAID
Date Recti t#
GREASE TRAP
SEWER-SANTTARYSIORM EA 20017
WATER HEATER W/VENT/ELECTR
ENERGY FEE Y N
PAID
Date Recel t#
WATER SYSTEM/TREATING
NEW RESIDENTIAL PLATE. SQ7T.
TOTAL:
BUILDING �
-�
SEISMIC FEE
a
TOTAL:
ELECTRIC FEE
QTY. I MECHANICAL PERMIT FEE
PLUMBINGFEE
MECHANICALFEE
PERMIT ISSUANCE
FEES PAID:
ALTERORADDTOMECH.
AIR HANDLING UNIT (TO 10,000CFM)
DRte _ RfCfl t#
F
SUBTOTAL:
AIRHANDWNG UNIT (OVER locisIC[M)
CONSTRUCTION TAX
Slgnsture of Applicant/Colitractor Data
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupantstore or handle hazardous
malertalaadeBand by the Cupertino Municipal Cod, Chapter 9.1 Z, and the
Heaeh.od SafetyCode Section75532W?
❑ Yea fffo
Will the applicant of future building occupant use equipment or devices
which cent hazardous air contaminants as defined by the Bay Area Air
Quality Management District?
4 Yes W14.q
have read the hazy mmaterlab requirements under Chapter 6.95 of
the California I9alth k Safety Code, Sections 75505,15533 and 25534. I
and erstand that it the building does not currently have a tenant, that it V my
responsibility to notify the occupant of the requirements which =at be me(
prior to Issuance of rtif-k{atA o(O panty.
r7-15-9
E%HAus'r HOOD(W/DUCT
CONSTRUCTION TAX PAID:
HEATING UNIT (TO 100,000 BTU)
Date Recei t#
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
,rQ
VENTILATION FAN (SINGLE RESID)
ISSLF I
y 1✓ 7
W
City. /s
of, {linin .4, {IRQ
_ rI r
ISSUED BY: V x �(� �(f
BOILER-COMP(3FIP OR I00,000 BTU)
BOILER -COMP (OVER 100,000 BTU)
NEW RFSIDFNTIALMECH. SQ.FT'.
Owner or authorized agent Date
'
TOTAL:
OFFICE COPY