23003APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
OFFICE COPY
Building Pro'et Identification
^1ding Addre.� 63 5 �, � P�QF
PFR.wiNO.
23003
er ameL one:
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION If PERMIT
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BUfLDINGELECTRICA4IPLUMBING-MECIfAMCAL
CATEGORY CONTROL#
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Qry ELECTRICPERMIT, FEE
BUILDING PERMIT INFO
Add.
❑ ❑
PFRMTISSUANCE
LICENSED CONTRACTOR'S DECLARATION
Iherebya(flrm that l am licensed under provisions of Chapter 9(mmmenc
ingwil of Dlvflh an foloneCode,andm
license i.1.faforce and effect.
APPLIANCESRESIDENITAL
DFSC ON
JOB DESCRIPTION
PANELS
LicenseClam Lic.p
Date ContractorUP
TO 2DE)Ah2S
OOO AMPS
q�++all Z
ie o
ARCHITECTSDEC R N
I understand my plans.hall be used as Ie- r rra I
el
Licensed Professional
OVE
OVER 1000 AMIrS
SQ. Fy. FLOOR AREA
+
5/SQ. Ff.
SIGNS ELECTRICAL
<6
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Z 1- u9
l
Ow
�Os
Q
OWNER -BUILDER DECLARATION
1 herebyafflrrn that laniama t from the Contractor's License Law for the
followingreason.(Setlon70315, Businessand Professions Code: Any city or
cauntywhlch rtqulresa permittocoatvct, alter,lmprovq demoWh, orrcpilr
anyotvaure prlorto Its Issuance,aW requlrestheappllcaut forsuch permit to
fib a signed statement that he b licensed pursuant to the provisions of the
Comact.e. License Law (Chapter 9 (commencing with Section 7000)ofDlvl-
slon3oftheBusinessand ProfmbruCode)orthat hebexempttherefromand
the basis for the alleged exemption. Any violation of Section 7631.5 by any
app0cant Ears permit subjects the applicant to a civil penaltyof not more than
SPEC7ALCIliCUIT/MISC
TEMP. METER OR POLE INS!.
POWER DEVICES
SWIMMING POOL ELECTRIC
VALUATION
1 ^ xo—�
Il• (�
OUTLETS-SWITCHFSFIXTURFB
NEW RESIDENTIAL ELECTR —SQ'FT'
GG11 $ �n
Dsole
Ove hundred dollars (9500).
❑ I, a owner of the property, or my employees with wages as their sok
compensation, will dothe work, and the stvture is not Intended or offered for
(Sec. 70K Businessaad Pmfcaa ax; Code: The Connatal. License Law
STORIES
7Y!'E CONSTRUCTION
$
does not apply to an owner of property who Wilds or Improves n hereon, and
whodoessuchworkhlmself orthrough ldsown employees, providedthat such
OCC.GROUP
RLS. UNITS
Improvements arc not intended oroffered forsale. If, however,the building or
Improvement bsald within oneyearofcomplatlon, theowner-bunderwlll have
TOTAL:
tgt*rden of proving that he did not bund or Improve for purpose of aale,L
u 1, as owner of the prop", am exclusively contracting with llcenmd
contractors to covtvct the project (Sec, 70K Buslnemand Profealom Code:PERMIT
OrY. PLUMBING PERMIT FEE
ISSUANCE
I:LODDZANE
APN
The Constar's License Law does nes apply to an owner of property who
builds or Improves thereon, and who contracts far ouch projects with a
cgR3(ator(s)licensed pursuant to the Contractor's License Law,
LII am exempt under Sec B & P C for this reason
:Owner Data
WORKMAN COMPENSATION DECLARATION
I here affirm that I have a mrtifkate of consent to aelf-
❑ hereby insure, or
ALTER -DRAIN &VENT- WATER (EA)
BACK FLOW PROTECT. DEVICE
FEE SUMMARY
FLS
DRAINS FLOOR RODE, AREA COND.
SANITARY Y— N—
REOo #
SCHOOL TAX Y N —
FIXTURES PER TRAP '�
comfime
3800,UbC.) rkea'Comperwtlon Wuancemacertl(kd copy thereof (Sec.
C.)
RECEEPT R
GAS. F.A.SYSIEM4 INCAOUTLL•TS
PARK PEE Y_ N
Policyab
Paltry M
RECEIPT #
Com anY
CAS EA. SYSTEM -OVER d (EA)
BUILDING DI VISION FEES
[�Cetified mpy b hercbyfhrnecity
❑ Certified copy b (Ikd with the city inspection division.
GREASE/INDUSIRL WASTE INTERCEPTOR'
PLANCHECKFEE
GREASE TRAP
Z
N
>
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATIONINSURANCE
Ohbvetlon need not be completed the heppermit b forone hundred dollars
fS1OO)or lea.)
I certify that in the perfomunceof the work for which this permit is issued,
I shall not employ any person In any manner an a m became subject to the
Comperatakm Lawn of California. Data
Applicant
NOTICETO APPLICANT: If, after rs'Comking a sationCemf catepro iconof s of
should become subject to the Workers' Compensation provisions of the Labor
Labor
Code you must forthwith comply with such provlalom arthb permit shall be
deemed revoked.
PAID
DRIC RCCCI [R
SEWER -SANITARY -STORM EA. 200PT.
WATER HEATER W/VENT/ELECTR
ENERGYFEE Y N —
PAID
Date Recei t#
WATER SYSTEM/TREATINGWorkers'
NEW RESIDENTIAL PLMB. FI.
—�
TOTAL:
B G —30
i�
SEISMIC FEE
ELECTRIC FEE
1 C
1 Z
Q
F
W
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction Icad Ng agency for the perform
once of the work!orwhlch this permit is Issued( Sec.3097,CIv.C.)
Lender's Name
Lender's Aadrtas sapp..
m
Itifythatlhavereadthl.adstatethattheahovelnfarmatlon
T ��
Q'TY. MECHANICAL PERMIT FE8
PLUMBING FEE
MECHANICAL PEE
FEES PAID:
It.
• W
• Z
bmmsct. I agree to comply with all cityand muntyordinanmand statelawa
relating to building construction, and hereby authorize representatives of this
city to enter upon the above-mentioned property for Inspection purposes.
(We) a no ave, Inde and keep harmiess the City of Cupertino
against) tie Nd sand expenses whlchmaymanywayaccrue
agabu I a mofthe Ai of this croon.
PERMITISSUANCE
ALTERORADDTOMECH.
Dale Re[ei [N
P
AIR HANDLING UNIT (10 10,000 CFM)
- SUBTOTAL:
AIR HANDLING UNIT(OVER 100DOCFM)
CONSTRUCTION TAX
grant a of Applicant/Contractor Date
EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (TO IOD,000 DTV)
Willtheappllant orfuture building occupant store or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.12, and the
Ileahh and Softy Cade Section 25532(a)7
[—]Ya MNo
Date Recei tic
HEATING UNIT (OVER 100,000 BTI)
TOTA
VENTILATION FAN (SINGLE RESID)
ISSUANCE DATE
Ql
&' A F D
�0� x/991
1x99
`V y/
II11VU
ISSUED BY:
Will thezpplicant or future buildingompa.t.oe equipment or devices
cndt hazardous air contaminants as defined bythe Bay Arca Air
Quality Management DlsWt7 -
4Yes (�( No
haveread the h.. ca, materialsrequirementsunder Chapter 6.95of
I!
lM California Health & SafetyCods, Sections 25505, 75533 and 75536. 1
underst that if thebulldingdoes not vrmntly have a tenant, that it b my
.¢ p f the mqum.nt which must be met
Fri!i ! pa^cy.CIUl�cutrh
JW
or alLthorbed agent Date
SOILER-COMP OILPOR 100,000 BTI)
BORER-COh1P(OVER100,000 BT)
NEW RESIDENTIAL MECH. SQ.FT.
Torn1:
OFFICE COPY