19878APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification
Building Address:
PERMIT NO.
AVC72oVF- DRIVE. CUPER71 ND
19878
/9E4/p5 Phase:
4`/V
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
q
l C
Ccom.d.e. Name: Lic. o:
1l
�I Architett/EngitRer. Lk. N.
BUILDINGELECTRICAL-aU\IBINGMECHANICAL
CATEGORY
CONTROL N
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Addresx
PERh4TISSUANCE
jj
X ❑ El
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am beensed under provisions ofChapter9(commenc-
inense is in fun force and died. tthe Businessand ProfmlvesCodc,and my
license b in soli force and effect.
APPLIANCESRESIDENTIAL
JOB DESCRBsIION
C t L
PANELS
License Class Lk.p
Date Contractor
ARCHITECT'S DECLARATION
I understand my plana shall be used as public records.
201-1000AMPS
OVER)WO AMPS
SQ. FT. FLOOR AREA
$/SQ.FT.
SIGNS ELECTRICAL
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors License Law for the
SPECIAL CIRCUIT/MISC
TRMp METIR OR EINSf.
following reason.(Section 7031.5, Business and Professions Code: Any city or
countywhkhrequlrvsapemdttocontrud,alter,Wprove,dem lKh,orrepair
anystmc mprlortoitslssuance,aLxrcgWrestheappkeantforsuchper tto
file a signed statement that he Is licensed pursuant to the provisions of the
Contractor's License Law (Chapter 9(mmmencing with Section 7000) of Divi-
slon3 of the Business and Profession Code) or that he Is exempt therefmmand
the basis for the alleged exemption. Any violation of Section 70)1.5 by any
applicant for a permit subjects the applicant to a civil penalty of not morethan
fi undred dollars (%500).
t, as owner of the property, or my employees with wages as their sok
pOyygRDEVICES
SWIMMING POOL FLE
OUILE'ISSWITCHIS • ES
VALUATION
0 Q
NEW ENTIAL WI)FhfQFC
STORI
TYPE CONSIRUCTION
c mpensation, will do the work and the structure 6 not intended or offered for
sale 4Sec. 70441. Business and Profession Code: The Contractor. Llceme taw
does not apply to an owner of property who Wild. or improves thereon, and
whodmsuchwarkhtm Uorthwghhis wnemploym,providedthatsoch
OCC.GROUIs
fI]ES NITS
Improvements arena Intended oroffered forsale. K however thebullding or
Improvement issold withinoneyearofcompletion,the owner-budderw111 have
tlAJIurden of provingthat he did not Wild orimprove for purpose ofsaleJ.
LJ L as owner of the Property, am exclusively contracting with licensed
contractors to mnlruct the project (Sec. 7044, Business and Professions Code:
OTAL:
QTy, UMB G MIT FEE
PERMIT ANCE
FLOOD 7pNE
APN
The Contractor's Limese law dons not apply to an owner of property who
W Ills or improve thmon, and who contracts far such projects with a
I dor(s) licensed pursuant to the Contractors License Law.
LII am exempt under Sec. B & P C for this reason
ALTER -DRAIN & VENT TER ffN
BACK FLOW PROT
CE
FEE SUMMARY
QLITSIDF FITS
Owns pa
WORE AN CO ENSATION DD LAKA 'N
QI h affirm that I have a certificate of consent to self -insure, ore
cedificaleof Worker'Compenationlnunnmmawdifiedmpythemcf(Sec.
3800, lab C.)
Policy R
DRAINSFLOORR
CONp,
SANRARY Y_ N_
RECEIPT R
pT%'NRES PER TRAP
SCIi00L TAX Y N_
RECEET p
S W
GAEA SYSfEM1 C.40I1TLET5
-
PARK FFE y N
RECEIPT p
Cnm any
Certified copy is herebydwithhecitfurnished.
Certified ropy V filed with the city inspection division.
GAS EA. 9YSTEM-OVER4(EA)
CREASE/WDUSTRL WASTE INTERCEPTOR
BUILDING DIVISIONFFFS
PLANCHECK FEE
CERTIFICATE OF EXLWPFION FROM WORKERS'
COMPENSATION
hisxxtion read not W completed INSURANCE RA V torose hundmM dollars
(Tlithe per
PAID
Date ReceI lit
GREASETRAP
SEWERSANII'ARYSTORM EA 200FT
(51 I0)orfy thatIn permit is Issued,
I cenotem employ
I shall not employ any person In any manner x v to become subject to the
an person in an tmannerhe work so an to become
Worknrs'Compewllon laws of Glllomla. Date
Applicant
NOTICE TO APPLICANT: If, skim making this Certificate of Exemption, you
WATER I-IEATER W/VENT/ELECTR
ENERGY FEE Y N
PAID ___Date Ri ted
ece
WATER SYSTEM/TREATING
NEW RESIDENTIAL PLMB. SQ.
}T
should become subject to the Workers'ComperoaHon proeit ofthe Labor
Code, you It fort hwlthcomply with such provision or this permit shall be
deemed revoked.
TOTAL:
BUILDING FEE
4 �• BO
TOTAL:
CONSTRUCTION LENDING AGENCY
I hereby affirm that there Is a construction lending agency for the perform-
once of the work for which this permit b bound (Sec. 3097, Clv. C.)
SEISMIC FEE
ELECTRIC FEE
/
Tender's Name
LenaerYAahatI
Ice in formative
andll
stacounty
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
MECHANICALFEE
-IdatIhavereadywfth aliatlon
city dc rdi .above
recorrect. building comouctioh andhereyauhorbernanmand state lam
ordinances
of this
relating to building a abov ctloq and heldby property fee
city Woenter Inspection
ectonaeabovo- ailyaned Propeharml Wpe Cit purposes.
(We) aim to save, IndemN(y an d keep harmless the City of Cupertino
against said CAY,buwnsvnb, consand expenses which may In anywryaccrue
against said City In onsxryet)ct!j•f the granting o(thle permit
[sQiMTI1S5UANCE
ALTER OR ADDTO MECH.
AIR IBANDUNG UNIT (TO 10,000 CFM)
FEE$PA]D:
Date RCCCjIs[M
SUBTOTAL'
AIR HANDING UNIT (OVER I0,000CFM)
CONSTRUCTION TAX
_
of ppLont/Contractor ( Dine/9-0
Sig(ot3(re oel
��VJJ HAZA R DOUS MATER IAL$ DI SCLOSU RE
MIAUSTHOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HEATINGUNIT(TO100,000BTU)
Will the applicant orfuture building occupant store or handle havardous
serial as defined by the Cupertino Munfdpal Code Chapter 9.12, and the
.t�aI h and Safety Code Section 75532(.)7
]'Yes
'p] Yes No
Date RCCCI Ni
HEATING UNIT (OVER 100,OW BTU)
TOTAL:
S,
the applicant or future building occupant use equipment or devices
which emit haurdous air contaminants as defined by the Bay Area Air
Qa Iityhl tnngement District?
4Yes ❑❑ No
haveread the haardommaterials requirements under Chapter 6.95of
the C' Boris Health & Safety Code, Sect ion 25505,25533 and 25534. I
u ad erstand that it the building does not currently have a tenant, that it is my
n xponibility to notify the occupant of the requirements which must be met
prior to issuance of a Certificate of Occupancy.
VENA LATION FAN(SINGLE RFSID)
I$$U DATE
p
C
r �A(Ifl
COX atCIT""
BOILER-COMP(3FW OR IOQOM BTI)
BOILER COMP(OVER 100,000BT1)
NEW RESIDENTIAL MECH. sQ.FT.
V% -l 7 Lc V S G -
ISSUED BY4 4V%- D
Owner or authorized agent Date
TOTAL:
OFFICE COPY