21085APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification
Building Address:
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PERMITNO.
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CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT01,00
BUILDING ELECTRICALPLUMBING-MECHAMCAL
C�Jf
CrntrachasName: Lic.N.:
M 7
CATEGORY
CONTROL M
Architect/Engineer. LM. No:
QTY ELECTRIC PERMIT II
BUILDING PERMIT INFO
Address:
1'FRhIITISSUANCE
tFJ
1:1 ❑ ElLICF.NS
ED CONTRACTORS DECLARATION
Ihereby Scdk,irmlhafDIv Bcensedunder provisions ol Chapter9de,and a
Ingwe sInfull force it died. o(the Buslrmuand Prolesslona Code,and my
license Is In Tali force and effect
Claes Lin. B
Doth
Date Contndor
ARCHITECT'S DECLARATION
]understand myplamshallbeused aspubhcremrda:
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt fromthe Contractors License Law for the
following reason. (Section 7071.5, Bustess and Professions Code: Any city or
cmntywhich requims a permit to mmtrod, alter Improve, demolth,ormpair
anystrudurepdortolttsuancgaLa mqur theappBantforsuchperMtto
file a signed statement that bet licensed pursuant to the provisions of the
Contractor'sLicense Law (Chapter 9(commencing with Section 7000) of Diel-
slon 3 ofthe Budoessand ProfeadoruCode) orthat bels exempt themfromand
the basis for the alleged exemption. Any violation of Section 7THS by any
applicant for a permit subjects the applicant to a civil penalty of not anrethan
five 1, as ed dollars owner pr).
❑ 1, as owner of the property, or rtry employees with wages a their sole
compensatlon,wlll do Ne work and thestructure is not intended or offered for
xle (Sec. 7064, Business and Profemlons Code: The Contractors License Law
does net apply to an owner of property who builds or Improves therms,and
whodaessuch work himself orthrwgh his own employees, provided thatsuch
Improvement are not intended reoffered for sale. If, however thebulldl h8 a
Improvement tawldwithin oneyearofcompleioM therwner-buBderwlll have
the of proving that he did net build or improve for purpose oft ).
L as owner of the property, am exclusively contracting with Been
contractors to mnstmet the project (See 7044, Business and Professions Cade:
His Contractors License law dews not apply to an owner of property who
or Improves thereon, and who contracts for such pWjects with s
,yNTTactorW licensed pursuant to the Contractors License Law.
W I am exempt under Sec. B k P C for this reaaon
APPLIANCFSRESIDENTIAL
JOB DESCRExnON
GIS I `
••�\ ��
PANELS
UP TO 2DO AMPq
XII -1000 AMI"'
OV ER ]OOOAM]'S
SQ. FT. FLOOR AREA
$/SQ. FT.
SIGNS ELECTRICA4,
SPECIALCBtCUIT/
TEMP. METER OR ['D I ST.
POWER DEV1
SWlMM]NCPO0L\M\U
O�E.� .�
VALUATIW
D D a (v1
NE ISIDENTIA TR
STORIES
TYPE CONSTRUCTION
L:
QTY. PLU BIN MIT FEE
OCC.GRON'
RFS. I11V1'1'S
PERMIT] CE
ALTER -DRAIN kVENT- WATER (FA)builds
FLOODZONE
APN
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
DRAINS. FLOOR ROOF, ARRA, COND.
F0(IQ)RES PER TRA
SANITARY Y_ N
8
Owner Date
WORKMAN COMPENSATION DECLARATION
E31 hereby affirm that I have a cortffieste of consent to self -Insure, or a
M00'lateTab C.) rfWorkera'Compenaatlon lruurance rracerti(ied copy thereof Ree.
3800,
Policy8
SCHOOL TAX Y N
RECEIPT N
GAS FA SYSTEM -1 INCA OUTLETS
PARK TIE Y N
RECEIPT If
GAS EA. SYSTEM-OVER4(EA)
BUILDING DIVISION FRES
ECy
ertified copy 6 hercbyturnecity
❑Certified copy t Bled with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thisics,) need notMcompleted lithe permit t(Drone hundreddollars
(Si 00)orlese,)
Icertlly that in the performance olthe work for which this permit is Ensued,
I shall not employ any person In any manner so as to become eub)ed to the
Workeri Compensation laws of Callfomt. Date
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you
should become subject to the Workers' Compensation provisions of the Labor
Code, you must forthwith comply with such provisions or this permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
Ihembyaflen that there t co
a nstmdion lending agency for the perform
ansa of the work for which this permit t Issued (Sec. 3097, Civ. C.)
Iendere Na me
Ienderb Address
I reit ify that have read this application and nate that the above information
Is correct. I agree to comply with all city and county ordinances and pate laws
relating to bu lldleg construction, and hereby debenture representatives of this
citytoenterupontheabove-mentioned property for Inspection purposes.
(We) agree to save, IndemNty an d keep haemic. the City of Cupertino
agairutllab 1 N nle ta, Messrs whlchmayleanywayaccem
.gains d s uses (the gr Ing of this Permit.
'
GREASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECKFEE
PAID
Date Recel t#
GREASETRAP
SEWER -SANITARY -STORM EA. X10171.
WATER HEATER W/VENT/ELECTR
ENERGYFEE Y N —
PAID
[Tate— Recei t#
WA1PR SYSTEM/TREATING
NEW RESIDENTIAL PLMB. —�'FT'
TOTAL:
BUILDING
EE
SEISMISEISMIC FFEE
TOTAL:
QTY. MECHANICAL PERMIT ITE
PLUMBING FEE
MECHANICAL FEE
PERMITISSUANCE
FEES PAID:
-
ALTERORADDTOMECH.
Date Receipt#
AIRHANDLING UNIT (TO I0,000CFM)
SUBTOTAL:
AIR HANDLING UNIT (OVER 10,000 CIM)
CONSTRUCTION TAX
Signa o(Applic nt/Cmameter Da
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfuture building occupant store or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.1 2, and the
Hea lth and Safety CodS,^,adlon 75S32(a)7 -
❑ Yes , etTTuj No
Willtheappilcanta to re building occupant use equipment or devices
which emit havarduue air contaminants as defined by the Bay Area Air
Quality Maiugemcnl Dis��hyy7
4 Yes Pr—N.
havemia the Heath zarrr33�fctymatrlals cctk,m25S05,under Chapter 6.95 of
the Califrrnla Health&Sof Cade, SectlOv 15505, 25533 and 7SSld.1
understand that if the building dews net currently have a tenant, that it Is my
IMPOroibllity to notify the occupant of the requirements which moat be met
prior to Issuance of a Certificate of Occupancy. '
101JAD
EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HEATING UNIT (TO 100,000 BTU)
Date RCCCI t#
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
_
VENTILATION FAN (SINGLE REBID)
ISSUANCE DATE
P�
^^T j WO
MY Qllj
co at C"aft
ISSUED OY: C i1V
BOILER -COMP DHP OR I000W KIM
BOILER-COMP(OVER 100,0008'N)
NEW RESIDENTIAL MECH. SQ.Fr
Owner or author red agent IDate�
TOTAL:
OFFICE COPY