22442APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification
Building Address: _
PERMIT NO.
GG44^ 2 A A 2
wno m
jy/ �S�(j —°^e !)
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BUILDING-ELECTRICALPLUMBING-MECFf LAICAL
A A A
C
C. ra ' ^<: pt
Arc n/&�Ineer: Lk. N :
CATEGORY
COIsVkOjv YE��]
Ip ' CJ D
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
�/I —
-
Address:
PERMIT ISSUANCEtr�la,EL�
��_j�—
LICENSED CONTRACTOR'S DECLARATION
Ihembyafflrmthat lamlcenselunder provisions ofChapter9(rommm
3o(tFegmine'and ProfeesioreCode,and my
inenveI I. ollfmm and
license b In®I roe and elect.
LkenseC Lie.
Dated Cantrador
APPLIANCESRESIDENHAL
JOB DESCRII'7'ION
1(-/--C—
PANELS
I L�eC/
1 7_J
201-1000AMPS
ARCHITECT'S DECLARATION
To nderstand my plans shall be used'Cubhe mrords:
as
OVER ]ODO AMPS
SQ. FT. FLOOR AREA
FT.
SIGNSE
Licensed Professional
3
'$/SQ.
�y 41
OWNER -BUILDER DECLARATION
l hereby affirrnthat l am exempt lmmthe Contractors License Lawforthe
following mason. (Section 7031.5, Business and Professions Code: Any city or
countywhlchrequmaper ttomrutmMalter, pmve.demolbh,orrepair
anystmeture prior to its issuance,alsorequirestheappllcant forsuch pernatto
file a signed statement that he is licensed pursuant to the provisions of the
Contractor's License law(Chapter 9(rommencing with Section 7000) of Divi-
sion°n3 of the Business and Professions Code) or that he exempt therefrom and
Ne basisfor the alleged exemption. Any violation Of Section 70315 by any
rm
applicant for a peit subjects theapplkant to a civil penalty of not momth.O
five hundred dollars (8500).
I, as owner of the property, or my employees with wages as their sole
compensation, will do the work and the stmenum is not intended or offered for
�' y
9'ECIAL C MI$C
3g '(33;16
(/:LN
Wil ti, 600
`— c
.gyp MRA I)SLI.
POWER DEV
SWIMMING IDOL EZnW—
/B VALUATION
OUT LETSSWITCHESFIXTURES
NEW RFSIDENTIALELECTR FT.
SQ
STOW
TYPE CONSTRUCTION
sale (Sce. 7044, Business and Professions Code: The Contractor's License Law
TOTAL:^ 1 4
QTy. PLUMBING PERMIT FEE
pFRMR ISSUANCE
6
��-DRAIN & VENT -WATER (EA)
does not apply to an owner of property who builds or improves t hereon,and
who doussuch work hirrselforthro igh his own employees, provided that such
improvements am not Intended oroffered for axle. If, however, thebuilding or
improvement Lsseldwithlomeyearo(completion•the owner-bullderwlll have
t rden of proving ose that he did not build or improve for purpcfsale.).
�L as owner of the property, am exclusively contracting with licensed
Wild. contractors to centimes the project (Sec. 7044, Business and Professbns Cade:
Tho Contractor's License Law does not apply to an owner of property who
d. or Improves thereon, and who contracts fee such p(oj da with a
o5act°r(s) licensed pursuant to the Contractor's License Law.
LJ 1 am exempt under Sec B & P C for this reason
OCC. GROUP
RFS. UNITS
FLOODZONE
ApN
BAIX FLOW PROTECT. DEVICE
FEE SUMMARY
OUTSIDE FETS_
Owner Date
NS FT.DGR ROOF,AREA,CONU._WIF
SANITARY Y N
RECEIPT X
WORKMAN COMPENSATION DECLARATION
1 emby affirm that I have a mitlllcats of consent to self -Insure or a
teofWorkere Compereatlonl'uranceoracertif4d copythereo(l5ec.
00,I 1, CJ
Policy X
S. PER TRAP
SCHOOLTA% Y N
REC[7PfM
GAS FA.SYS[IM-1 INC.40[IfLEfS L
PARK FEE Y N
RECEIPT X
Cam any
�Certlfled copy Is hereby furnished.
r7 Certified copy Is filed with the city Wpection division.
CERTIFICATE. OF UEM PTION FROM WOR K ERS'
COMPENSATIONWeemplINSURANCE
Qhor lemon need no becompleted If the porMt L for ane hundred dollars
($1 W)otifyth
(certify that In the performance of the work for which this permit is issued,
I shall not employ any person In any manner se as to become subject to the
Workers'C°mpensati°nlawsof California. Date
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you
=h I'dbecome subjodn"he Workers'Compenantion provisions, ofthe Labor
Code, you nwu .h.,tlro plywithsuchprovisloruolthisper tshallbe
revoked.CONSTRUCTION LENDING AGENCY
there b a construction Tendingagency for the perform
ance ofthe work for which this permit b LvvM (See. 3097, Civ. C.)TOTAL:
Lc.dce.Name
certitythatl have read this appBatbnand nthatthabovin(Ormation
I agreeto complywith all city and county ordinances and. nate laws
relating to building construction, and herebyauthorizerepmaentativesofthis city to enter upon the above-mentimed propertyforimpectlonpurposes.
tosave, Indemnify and keep harmless the City of Cupertino
against liabilities, lodgments, sande s which may In anyway.a
agaiws Cit in mss a oft a n�this permit.
GAS EA. SYSTEM-OVER4(EA)
GREASE/INDUSIRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
PLANCHECKFEE /
PAID _Z�T`�r� piZ 3
Date Recel til
GREASE TRAP
SEWERSANTTARYSTORM EA 200FT
WATER HEATERw /VENT/FJ--FLTR
ENERGY FEE Y N
tel./
PAID—Iii-Ii (=9
Date, Recei [11
e. O
J `�
WATER SYSTEM/TREATING
NEIN RE9DCN17AL IPLMB. SQFT.
MIC FIherebyafemnthat
TRIC
QTY. MECHANICAL PERMIT FEE
PFRMITISSUANCE 2.60
' ALTER OR ADDTO MECH.(We)agree
AIR HANDUNG UNIT (To 10,alle CFM)
!BUILDINGdeemed
MBINGLendersAddacas
AT
HAMI
PAI
Icziscormet.
ate
SUBTOT G
AIR HANDLING UNIT (OVER 10,0D0CFM)
CONSTRUCTION TAX
igna of Appl nt o actor to
It USMATERIALSDISCLOSU
Will the a ppBo nt orfutum bu llding occupant store or hand Is azardous
material as defined by the Cupertino Munldpa l Code, Chapter 9.1 A and the
lO Ya�d Safety Code Section 2$37(a)7
IXHAUS'C HOOD (W/DOLT)
CONSTRUCTION TAX ID:
HEATING UNIT(TO 100,000 BTU) ✓�
Date Recel 6
HEATING UNIT (OVER 100,00081'[!)
IOTA
Will the xppllcant orfulure building ocmpantuse equipment ordevices
which emit haeardous air cont.m amsas defined by the Bay Area AU
Quality Management District?
Yea ❑❑ No
Ihavercadtheha UusmatetiabrequirementsunderChapter6.95of
the California Health & SafetyCode, Section,75505, 75533 and 75534. 1
understand that lithe building does not currently have atenanL that ltbmy
rrspo'ibility to notify the Occupant of the requirements which most be met
prior to issuance Of a Certificate of Occupancy.
VFNTIIATION FAN (SINGLE RFSID)
ISSUANCE DATE
PAID
,x �p. �
" �i
BOILER -COMP QHPOR 100,000 BTU)
BOILER-COMP(OVER100,efBM)
NEW RM ENTTAL MECH. ;Q.FT.
aaa��aeeeaaa...��.
Owner or authOm cd agent Date
TOTAL:
ISSUEDBY:
OFFICE COPY