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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Proed Identification
Building Address:
PERMHNO.
21506
Wner9 aIM:
fi1y0r1� 2,f2 S
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION/ PERMIT
_ A
'�— r D
C cter- Lie. No:
BUILDINC-ELECTRICALPLUMBINC-MECHANICAL
CATkORY
_
CONTROL it
Architect/Englneen Lk. No:
�'• � ''4s
Q?i' ' .,ELECTRIC PERMIT
� FEE
�• -'".,'BUILDING, PERMIT INFO
"
•
Addresm
PERMITISSUANCE
❑ ❑ ❑
LICENSED
- -
amCONTRACTOR'Scensed underDECLARATION"
Ihereby affirm action70tO)mDi Bi.3.funderpxvsand ProCsionB odeanenc-
3ngwith&Klan force (it affect. ofthe BuelnessandPro(esalonsCode,and my
BcenscClassIn 0force and died.
License CWmLie
Dale - _—Contractor
APPLIANCESRESIDENTIAL
)OB DESCRIPTION
_
PANES
'
201-1000 AMPS
' ARCHITECTS DECLARATION
I understand my plans shall be used as Public records.
"
OVER 1000 AMPS
SQ. FT. FLOOR AREA -
$/SQ. FT.
SIGNSELECTRICAL
-
Licensed Profeasiocal
-
SPFDIALCIRCU[T/MISC
. -OWNER-BUILDER DECLARATION
I hereby afflrenthat I am exempt fromthe Contractor's License Law for the
,
TEMP, METER OR POLE )NST.
following reason. (Section 7031.5, Business and Professions Code: Any city or
county which requires a permit to romtmct, alter, improve, demolish, or repair
-
any structure prior to its issuance, also requires the applicant for such permit to
file a signed statement that he Is licensed Pursuant to the provisions of the
POWER DEVICES
"
SWIMMING POOL ELECTRIC
OUTLETSSW[TCHFSPUC['[IRFS
Conlracior's License Law (Chapter 9(commencing with Section 7000) of Divi-
pion 3 of the Business and Professions, Code) or that he is exempt therefromand
the basis for the alleged exemption. Any violation of Section 703 L5 by any
applicant for permit sub' the applicant to a civil nal of net moons than
PP Pe subjects PP penalty
VALUATI'N
/ a{ D r J! ,
NEW RESIDENTIAL ELECTR FT.
�'
I! ve undyed dollars ($500).
I, as owner of the property, or my employees with wages as their sole
-
STORIES
TYPE CONSTRUCTION
compeneation,wOldo the work and the structure ls not intended or offered for
sale (Sec 7044 Business and Profession Code: The Contractors License Law
does not apply to an owner of property who builds or improves thereon, and
who does such work himselforthreugh his own employees, provided that such
"
OCG GROUIs -
RES. UNITS
Improvements are not intended or offered for sale. If, however the building or
Improvement is sold within one year ofcompletion, the owner-bullderwlll have
TOT
tb,�urden of proving that he did net build or improve for purpose of sale.).
L1 6 as owner of the property, am exclusively contracting with licensed
contenctore to construd the project (Sec. 7044, Business and Professions Code:
Qpy, •' ', OLUM "PERMIT
PERMIT ISSUANCE
FTpODZDNE
APN
The Contractors License Law does not apply to an owner of property who
builds or improves thereon, and who contracts for such Ix jeda with a
ogBtjador(s)llrensed pursuant to the Contractor's Llcenee Law,
LJ I am exempt under Sec. B & P C for this reawn
TEt DRAT VENT )
'
FEE SUMMARY
BA FLOW PR TD E,
n
D S. FLOOR CO
SANITARY Y_ N
RECEIPT # "
Owner DaHt
te
R IAN CO SA ON ECLAR Tp
MI hereby affirm that I e a certificate of consent to tell -insure, ora
certlRcateof Worlusa'Com suationlnsumnesoracertlfled capythereof(Sec'
3800, Lab C.)
Policy #
pD( SP
SCHOOL TAX Y_ N_
RECEIPTN#
CAS EA -I INC 5
PARK FEE Y N
RECEIPT #
Company
GAS EA YSTCM-OV )
BUILDING DIV] SION FEES
I� Certified copy is herebyfurnished.the cid'
Certified copy b filedhere with the city inspection division.
CREASE/IND L STE INTERCEPTOR
PLANCHECK PEE
"
GREASE TRAP
CERTIF]CATEOFEIK MPFION1ROMWORKERS'
COMPENSATION INSURANCE
(I'hissedion need net be completed If the permit is for one hundred dollars
PAID
Date Remi t#
SEWER -SANITARY -STORM E4.200FT.
(8100)orleth permitls Issued,
Illnot emplat oy an person nce of
I shall not employ any Person In any manner w u to berorrn subject to the
numner wato become
Workers' Laws of California. Date
WATER HEATER W/VENT/ELECTR
ENERGYFEE Y N
PAID
'
WATER SYSTEM/TREATING
plicaCompensatlon
Applicant
OAPPLICt APPLICANT. mkxrs'fter klmnpe.ng this Cer.. pro icons aft
Nould be..Labor
eLabo
Workers' Cuch
Date Recei f#
-
NEW RESIDENTIAL PLMB. SQ.FT.
TOTAL:
_
Code, you=a forth ith co
Code, =at forthwith comply with such proWslons orthls permit shall be
pre islns orthionsrmit s
deemed revoked.
BUILDING
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
Iherebyaffrm that there ls a construction lending agency for the perform-
ce of the work for which this permit b issued (Sec. 3097, Civ. CJ
Le.dara
TOTAL:
ELECTRIC FEE -
Name -PLUMBING
Lenders Address
QTY.: ". '1,14
'M +
';'•;:'FEE `
FEE
I certify thatl have madthisapplicationand statethatthe above Information
1,emeaci.]a8rec to comply with all city and county ordinances and state laws
PERMIT ISSUANCE
MECHANICAL FEE
FEES PAID:
relating to building construction, and hereby authorize representatives of this
-
citytoenterupontheabove-men]loned property for inspection purposes.
(We) agree to save, Indemnify an d keep harmlem the City of Cupertino
ALTER OR ADD TO MECH.
Date Rete( f#
P
SUBTOTAL:
against liabilities, }udgmenta,costa and1ape sea which may In any way amus
against a id Cityin cons yuence ftFe gra Ing of this pe It.
�
AIR HANDLING UMT(T010,000 CFM)
AIR HANDLING UNIT (OVER 10,000 CFM)
CONSTRUCTION TAX
SignaturcoI Applcant/Contracts Date
allAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS VATERIALS DISCLOSURE
"
HEATING UNIT (TO 100,000 BTU)
-
WllltheappEra at or future building occupantstore or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.12, and the
Date Retel f#
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
Iicalth and Safety Code Section 25532(a)2
r-1 Yes b No
VENTILATION FAN (SINGLE RESOD)
ISSUANCE DATE
� 'D
A
J d tletM
Will the applicant or future building occupant use equipment or devices
which coot hamedous air contaminants as defined by the Bay Area Air
Quality Management Diatnd7
Yea No
4 have maous materials requirements under Chapter 6.95 of
the California Health&Safety Code, Sedlons 25505,25533 and 25534. I
understand that if the building does not currently have tenangthatitbray
BOILER -COMP (311P OR 100,000 BTU)
BOILER-COMP(OVER 100,000 BTU)
NEW RESIDENTIAL MECH. SQ,FT.
responsibility to notify the oaupant the requirementswhkh mu at be met
psi to taco nce of a CerS{#rate pancy. n
//
ISSUED BY: C.,
Owner or authorlred agent to
TOTAL:
OFFICE COPY