21652APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
a Kil i Pra'ect Identification
Building lfdreaa: (� -
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PERMIT NO.
21652
ere ane: 11hong
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CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
APPLICA FION SUBMIrFAE=
cantradora Nacre: Lie. Na:
'
BUILDING-ELFCTRICAIECHA
.PLUMBING-MNICAL
CATEGORY
CONTRBL �'�
Architect/Engineer. Llc. No:
'QTv"•; Et<BGTRIG PERIYIIT ` "FtE,�,
� _BUILDING PERMLT IONTO,
-
Address: •'
I PERMITISSUANCE
�j ❑, El ❑
I�
LICENSED CONTRACTOR'S DECLARATION
.�
I hereby affUmthat l am licensed under provisions of Chapter9(cormnenc-
InenseISemon 7W0) ofd died oftheBusineasand ProlesalonsCAdeand my
-Liters is in fol force and effect
APPLIANCESRESIDENTTAL
]08 DESCRIPTION
a�� ��
A
PANELS
Date Contractor
UP TO 200 AMPS I IST
�7 eF'e"M D'—I--
DF-L—.
AMPS
ARCHITECT'S DECLARATION
understand my platy shag be used as public records. �
Licensed Professional
R
OVER
OVER 1000 AMPS
AREA
SQ. FT. FLOOR AREA }�
$/SQ. FT.
SIGNSELDCTRICAL
OWNEReBUILDER DECLARATION
Thereby afOrtn that I exempt ERfimnDE LARATIO License law for the
04 TT
Qj_7
8t TJ
•1 .IV
2 SPECLLL CIRCUf7/MISCADD,
TEMP.METEROR POLE INST.
followingor
required permit S,Bua uct and Prone®Iona Code:Any eltyor
tywhiea rcqulrcs,an71131tocorutess ad Ponfprove, Code: h,or city
county which ir
1/�
��t .�
anystrudure priortoitslssuance, also requireatheapplicant forsuch permit to
file a signed statement that he Is licensed pursuant to the provisions, of the
Contractors License Law (Chapter 9 (comeencing with Section 7000) of Divi-
sion3 ofthe Business and Profeadmo, Code) or that he is exempt therefrom and
the basis for the alleged exemption.
at, Anyviolationtolacivi of Section 70115 by any
applies, forapermit$5018. subjects the applicant too dull pewltyo(nd more than
]'OWER DEVICES
�I
1. C
-
I(0�
�a
gWIy1,�.ING IDOL ELECTRIC
- VALUATION
L7 4.-v
OUTLETS -SWITCHES -FIXTURES Q. 4'0
NEW RESIDENTIAL ELECTR SQpT'
(Ne s ed owner pro
I, as owner of the property, or employees with wages their dole
4
STORIES
TYPE CONSTRUCTION
compensation, will ethe he
and lhestrvdure V not intended or for
ioffend
i ss and
sale (Sec. 7044, Buabuae and Professiow Cade: The Contradore Llmrue Law
,
'
-does not apply to an owner of property who builds or improves thereon, and
who does such work himself orthrough his own employees,, provided that sucmh
OCC.GROUP
RES. UNITS
Improveents are not Intended or offered for sale. If, however, the building or
Improvement is sold whhln one year ofcompletion, the owner-bullderwill have
TOTAL. O
trden of proving that he did not build or improve for purpose of sale.).
LJ 4 as owner o! the property, am exclusively contracting with licensed
contractors to ormtruct the project (Sec. 7044, Business and Profeaslona Code:
The Contrador's License Law does not apply to an owner of property, who
Wilds or improves thereon, and who contracts for such pSojeda with a
coa(Iador(a)Iiceneed pursuant to the Contractor's License Law.
LJ I r exempt under e & P C (ar this reason
Q{y," kLUbIBING PERMIT :FEE`
PERMIT ISSUANCE
ALTER -DRAIN & VENT- WATER 2A) O
FLOOD ZONE APN
„
FEESUMMARY'
''"
BACK FLOW PROTECT. DEVICE
OUTSIDETTES
FLOOR ROOF, AREA, CONTI.
SANITARY Y_ N_
RECEIPT N
OwnerDRAINS
Date .J(.,{���
I WORKMANC 4PENSATION DECLAR IOIV _
reby affirm that I have a mrtiflcate of consent to self -Insure, ora
certificate of Workers Compensation Insurance or a certified copy thereof(Sec.
3800, Lab CJ -
pp(,yURpS, pgg TRAP QO
`
SCHOOL TAX Y N_
RFGEI'f N
GAS EA. SYSTEM-11NC.40UTLECS
PARK FEE Y= N_
Policy N
RECEIPT N
CAS EA. '`Y
GREASE/IN
Com any
BUIL13ING DIVISION FEES
PLANCHECK PEE
�Cshifted copy is hereby furnished.
F-1 Certified copy le filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
CREASE ._ �. IlIage
PAID Jul ub
COMPENSATION INSURANCE
('Ihissectlon need not be complded i(the permit le forone hundred dollars
(S11U)orl
Icertl(ythythat at in performance o(thework (orwhlch this pend[ is Issued,
I shall not employ any person In any runner at as to bemire subject to the
Workers'Compensallon Laws of Cailfornla. Date
Applicant
NOTICE TO APPLICANT: If, after making this, Certl(Icete of Exemption, you
should become subject to the W.flo rs'Compensatlon provislom of the Labor
Code, you moat forthwith comply with such provisions or this permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency forthe perform-
erform
ance
ante ofthe work for which this permit le bound (Sec. 3097, Cl, C.)
- Date Recei til
,�2�
5611
SEWER -SANITARY -STORM EA. 200 .
AG
WATER HEATER W/VENT/ELECTR
ENERGYFEE Y N
� —
i -16 -RI -�ra'
AID7 (Z
Date RECei t#
.l. 0l�
WATER SYSTEM/TREATING
NEW RESIDENTIAL PLMB. FT.
.
TOTAL:
BUILDING FEE
T20,sr>
TOTAL: ``
0. Oct
SEISMIC FEE
ELEGTRIG FEE
LI
-
lendcraName
Leader'. Address
I ormlythatl have read lhisapplieatlonand datethattheabove information
is mrrect.7ag.c to complywith all cityand county ordinances and state laws
.PLUMBING
if`C,Y: FEE',
FEE
a, -OG
,,,"`;'MEGHANICAL,RERINIT"
PERMITISSUANCE
MECHANICAL FEE
FEES PAID:
relating to building construction, and hereby authorize representatives of this
city to enter upon the above-mentioned property for Inspection purposes,
(We) agree to save, indemnify an d keep harmless the City of Cupertino r• at liabilities, pediments, emtsand expenses which may In anywayaccrue
• a nst said City In on ce o t granHn of this omit
r u 3 L$
,QQ
��/s
I. ALTERORADDTOMECH. .OD
AIR HANDLING UNIT (TO 10,000 CFM)
Date RCCCI t#
SUBTOTAL:
AIR HANDLING UNIT (OVER 10,000CFM) -
CONSTRUCTION TAX
tureof Applicant/ ntrador Date
EXHAUSTHOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (TO, I Og000 BN)
Will the applicant or future building occupant store or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.1$ and the
I ealth and Safety Code Section 25532(a)7
Yea ri No
Date - Recei t#
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
VENTILATION FAN (SINGLE RESID) - �
ISSUAVCAT 6'E
a 1l�
-
MAR 2 51991
Will the applicant or future building occupant use equipment ord evices
which emit hazardous air contaminants as defined by the Bay Area Air
Qu a lity Management Dlstrid7
4 Yes', �No
have read thehaza ous materials requirements under Chapler6.95 of
BOILER -COMP QHP OR 100,0(10 BTU)
BOILER -COMP (OVER 100,000 BTU)
the California Health & Safety Code, Sections 25505, 25533 and 25534. I
NEW RESIDENTIAL MECH. SQ.Fr.
and sesta od that if the building does not currently have a tenant, that it is my
responsibility to notify the occupant of the requirements which most be met
prior to issuance of a Certificate of Occupancy.
City CI��iG1' �R�
ISSUEDBYJA til- 0 1i
Owner or authorized agent Date
- -
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TOTAL: .a V
OFFICE COPY
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