20470APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification
Building 2 1, �,�;,�-
PERMITNO.
2 0 4 7 0
Phone:
S'�' �6
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
AL I A
/ / ( p
n
c°nraor'sNa Lin.Na
2 0-2 3
Archlt ct/Gglneer. Llc. No:
BUILDING-ELECTRICA4PLUMBING-MECHANICAL
CATEGORY
CONTROL M
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
O
Address:
'• a Sr
MI
PERTISSUANCE
❑ ❑
❑LICENSEP
CONTRAClfOR'§ DECLARATION
I hereby affirm that l am licensed under provisions of Chapter 9(mmmmc-
'ngwith Section 7000of Divlslon3ofthe Bugnessand PmfmionnCde and my
license is in fu8 force and off -'a
License Clasac-3G Lie.p U M
Date %I L Contraaor z
ARCHITECTSD O I
I understand my plain shag W used n pubbc rem s,
APPLIANCES -RESIDENTIAL
JOB ESCRD'UON
A
/�
PANELS
201-1000AhiPS
OVER 1000 AMPS
SQ. FT. FLOOR AREA
S/SQ. FT.
SIGNS ELECTRICAL
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby saloon m
that I aexempt from the Contractor's License law for the
D '
SPECIALCIRCUIT/MISC
county hichrequiren perneL5,BusinessandProfessionCode:Anycityor
countywhichon.(Sc apemdttomntrogalter,improve, demolish, orrepalr
T�(p,METE2ORIXJLEINS
anysmacWre priorto its issuance,alsonclumatheappllcant forouch perMtto
file a signal statement that he 6 licensed pursuant to the provision of the
Contractors Lkense Law (Chapter9(mmneecing with Seaton 7000) of Owl-
slon3 of the Business and Profession Code) or that he is exempt therefrom and
Section basis for the alleged exemption. Any violation of Sion 7071.5 by any
applicant for a permit subjects the applicant to a civil penalty of not morethan
five hundred dollars ($500).
I, as owner of the property, or my employees with wages as their sok
POWER DEVICES uivirld
T E R
SWIMMING POOL ELECTRIC
LIP 'A
OUTLETSSWITCHFSFIXTUIRFS
VALUATION
NEW RESIDENTIAL ELECTR FT.
SQ'
STORIES
TYPE CONSTRUC'T'ION
compensation, will do the work and the structure 6 not intended or offered for
sale eia, 7044, Business and Proauslon Code: The Contraaors License Law
does not apply to an owner of property who Wilda or improves thermR and
who does such work himseRorthrough his own employee, provided that such
Improvements arenot intended proffered forsale. IL howevey thebuliding er
impmven'ent6eoldwithinone3earofcomplabn,theowner buBderwillMve
TOTAL:
OCC.GROUP
RE'S.UNTI5
the-I,anden ofproving that he did notbulld or improve forpurposeofsak,),
Las owner of the property, am exclusively contracting with licensed
contractors to mnW a the pmjen (Sec. 70K Business and Professions Code:
The Contractor's License Law don not apply to an owner of property who
Wilds or Improves thereon, and who contracts for such pwirets with a
cgat{aaor(s)BmnedpumuanttotheCmtranorb Licene Law.
LII am exempt under Sec. B & P C for this reason
QTY. PLUMBING PERMIT FEE
PERMITISSUANCE
ALTER -DRAIN &VENT'- WATER (EA)
FLOOD ZONE
APN
BACK FLOW PROTECT. DEVICE
FEE SUMMARY
I _
Owner Date
DRAINS FLOOR ROOF, AREA, CONT.
SANITARY Y NOUTS
RFLEQ'f Y
WORKMAN COMPENSATION DECLARATION
�1 hereby a(llrm that I have a certl0cate of consent to ulf-Inwre, m a
ceM,Lab ofWorkeri Compenatlon Wuranceoracertllled ropythertrof (Sec.
3500yab CJ
Policy Y
FIXTURES PER.T.RAP
SCHOOL TAX Y N_
RECEIPT X
GAS FA. SYSTEM -t INC.40UILETS
PARK FEE Y N —
" any
Certified copy b hereby—f..1,1,1
Certified ropy 6 filed with the sty inspection division.
GAS EA. SYSTTM-OVER 4(EA)
GREASE/INDUSIRL WASTE INTERCEPTOR
BUILDINGI VISION FEES
PLANCHECK FEE
GREASETRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
UAisseaion neat net Wcompleted lithe permit 6forunhundred dollars
PAID
Date ReCCi til
SEWER-SAMTARY-STORM EA. 200FT.
(SI 1(catifesh)
(certify that o the person In an mannerh, work fortowhich corn emtit c tuvat,
I shall not employ any person In any manner ro n to become subject to the
Workcrs'Compcnatlon Tawe of California. Date
Applicant
NOTICETO Exemption, you
after makingpe
WATER HEATER W/VENT/ELECTR
ENERGY FEE Y N —
PAID
Date Repel t#
WATER SYSTEM/TREATING
NEW RESIDENTIAL PLMB. SQ}T,
crum subject tothe, cationCertificate
shouldou=a sforth to the ply wit gash provialmprovhionofthe Labor
peavis
Code, you must forthwith comply with ouch provision orth6 pemdl Nall be
deemed revoked.
TOTAL:
BUILDING FF •
CONSTRUCTION LENDING AGENCY
Ihcrcbyalfikfo'rwhat ichthhem tier tr6al ed nding agency for the perform
ce perform -
the work for which this permit 6 issued (Sec. 3097, Civ. C.)
Lender'.
I<ndera Name
wae
Lenaere rcae
I certl(ythatl have rcadeh6 appBcatmnand gatethm theabove Inforrrvtion
bmrnet Iagratocomplywith all atyand comayonlinances and gate laws
relating to building contraction, and hereby authorize representatives of thio
city to enter upon the above-mentioned property for inspection purposes.
(We) agree to save, Indemnify an d keep harmless the City of Cupertino
against liabilities, Judgments, coat sand expenses which may In any way accrue
-9.mtsldCa in consequence of the granting of this permit
` �
'nJ5 y(/. ;;!r �
TOTAL: '3 eL [Yj
P
SEISMIC FEE
ELECTRIC FEE
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
t 00
PERMIT ISSUANCE
ALTERORADDTOMECH.
AIR HANDLING UNIT (TO 10,000 CFM)
MECHANICAL FEE
FEES PAID:
Date Recciptil
SUBTOTAL:
-
3 -
AIRHANDLING UNTT(OVER 10,000CFM)
CONSTRUCTION TAX
sign rare of APPBn�ontractor Date
HAZARDOUS MATERIALS DISCLOSURE
EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PA ID:
HEATING UNIT (TO 100,0DO BTU)
Will the applicant orfuture building occupant store or handle haardous
material as defined by the Cupertino Municipal Code, Chapter 9.1Z and the
Tic❑althand Safety Code a(.S�Sectiin 25532(a)7
Date Recel tat
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
3- Q7
Willtheapplicim olfuture building occupant use equipment or devices
which emra
it hardous air centaminamsas defined by the Bay Arca AU
Quality Management Disct7
1 Yea No
havemla read the haza pus materlab requirements under Cha pier 6.95 of
the Wllfehealth&Safety Code, Sections 25505,25533 and 25534. 1
VENRLATION FAN (SINGLE RESID)
1$ SijiDATE
�i -+.
��®
1 y
' 1990
BOILER -COMP (311' OR 100,000 BTU
BOILER-COMP(OVER 100,000 BTU)
understand that if the building does not currently haves tenant that it is my
responsibility to not By the occupant of the requirements which must be met
P'2 to La uan rtifotc o(Ompanry. )
�p7 [/J r-- /(��— 9)
O
Oki of Auaaee{in
Oki 04J {i Frra ecrr'
ISSUEDBY: ✓C
NEW RESIDENTIAL MECH, eJj, .R.
Owner or authonced agent Date!
TOTAL:
OFFICE COPY