19796APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Pro4ct Identification
Building Addmae: -Mw cR�
PRIMIT NO.
19796
Name: hone
o ` a
CITY OF CUPERTINO- BUILDING DIVISION
APPLICATION I PERMIT
BUILDINGEI .ECTRICALPLUMBING -MECI IANICAL
Contractorte NamTe: I �.BLic. No
�a \ cto"AQ rL� S;
CATEGORY
CONTROL
Arehltm /Engineer. Lk. No:
QTY
ELECTRIC PERMIT
FEE
BUILDING PERMIT INFO
Add..
1
PERMITISSUANCE
❑ �j ❑ ❑
LICENSED CONTR under provisions
I hemby affirm sand ofChapter
IngwRh l efullfmc, atdeffutn3o( thefluslMSeandProlesBirnsCode ,andmy
license lslns force and effect.
LI Date Clan Lk.N
Date 'Contractor
ARCHITECT'S DECLARATION
I understand my plane shall be used as public records.
Licensed Professional
OWNER - BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
following reason. (Section 7031.5, Busineesand P.f.lmx Code:Any city or
c ntywhlchrequiresapermi ttocoifmct,altep Impmve,demobsh,ormpair
anystmcture prierte, its luuance, alsorequiresthe applicantfor such permet to
(Ile a signed rtatement that he is licensed pursuant to the Enewhioru of the
Contractor's License Law(Chapter9(commencing with Section 7000) of Divl-
sion3 of the Budness and Prefestloru Code) rrthat he Is exempt theref emand
the basis (or the alleged exemption. Any violation of Section 7031.5 by any
applicant for a permit subjectsthe applicamto a civil penalty of nor room than
five hundred dollars ($SM.
❑ I, as owner of IM property, or my employees with wages as their Bole
compensation, will do the work and the structure ts not intended or offered for
sale (Sec. 7044, Buslneas and Pe fmlom Code: The Contactors License Law
does not apply to an owner of property who Wilds or improves thereon , and
who does such work himself orthrough his own employees, provided that such
improvements arc not Intended or-offered forsale. IL however, thebuilding or
Improvement usoldwithlnoneyearo fcompl&iogthe owner- bulklerw111 have
t rdenof proving that M did not build or improve for purpose of sale.).
(_f L as owner of the property, am exclusively contacting with licensed
contractors to construct the project (Sec. 7014, Business and Professions Code:
The Contactors License Law does net apply to an owner of property who
or Improvea thereon, and who contracts fee such ptajua with a
cgB(lactorts)Bcensedpursuanttothe Contrato'e License Law.
u I am exempt under Sec. B & P C for this mason
APPLIANCESRESIDENITAL
JOB
JOB DESCRIfT10N
PANES
201.1000 AMPS
OVERI000AMPS
SQ. FT. FLOOR AREA
$ /SQ. Fr.
SIGNSELECTRICAL
-
SPECIALCRCIIIT /MISC
TEMP, METER OR TOLE INST.
POWER DEVICES
SWIMhBNC ]Y30L ELECTRIC
OITILETSSWITCIIES FT%TIJRFS
-
e"e
LUADON
NEW RESIDENTIAL ELECTR E;Q'F
TYPE CONSTRUCTION
'
QTY.
TOTAL:
PLUMBING PERMIT
PERMIT ISSUANCE
ALTER -DRAIN &VENT -WATER (BA,
rUs
FEE -
.GROUP
Fo
HFS. UNITS
FLOODZONE
APN
BACK FLOW PROTECT. DEVICE
FEE $IIMMARY
DRAINS FLOOR ROOF, AREA, COND.
FIX.tURFS PER TRAP
SANITARY' Y N
RECEB'1' N
Owner Date
WORKMAN COMPENSATION DECLARATION
❑1 hereby affirm that I have o ce sumac of convent to rpytheure, (S a
3800, late o(WOrken'Comperuatlorilruuance ore certified mpythemof (Sec.
3800, 1,.b
SQi00L TAX Y_ N
�E, Y
GAS EA. SYSTEM -I INC.4 OUTLETS
PARK ME y N
RFLEBR N
Cam
Y
GAS EA. SYSTEM -OVER 4 (EA)
BUILDING DIVISION Fr. ES
ertified copy Is hereby famished,
the city
Certified copy V filed with the city inspection division.
CERTIFICATE OF ORTIPFION FROM WORKERS'
COMPENSATION INSURANCE
(0) or I Ion aced not be completed If the permit le for one hundrrtl dollars
(811D)orly that
J that employ an pery r, in any lmanner was to become pesubjec Issued, the
L shall not employ any person in any manner so as to become subject to the
W ca'CompenuHOn Gwe o /Glifornla. Date
Applicant
NOTICE TO APPLICANT: a after making this Certificate of Exemption, you
Code, becomesubjectto the ply wit Compewonprovbis permits Lab or
Code, you must forthwith comply with each provisions orthb permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirmthat there is acenstmctlon lending agency forthe perform,
ance of the work for which this permit Is Issued (Sts. 3097, Civ. C.)
Lenders Name
Lenders Address
I redimythatl have read thbapplicatlon and statethat the above Information
Iscorrert. I agree to comply with all city and county ordinances and date laws
relating tobuilding cowtrunion,and hemb authorize representativesafthls
city to enter upon the abov ntionedp pedyforiespectlonpurpoeee.
(We) agree t save, n ep harMev the City of Cupertino
against Rabllltles' d e, co a xpeneea which may In anyway accrue
ago;tuid City onto gmetingo(this ps IL �pc�
Odd 10
CREASE /BVDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE
PAID
Date Rccel t#
GREASE TRAP
SEWER- SAKETARY -SNRM EA 200F1.
HEATER W /VENT /ELECTR
ENERGY FEE Y N-
—
PAID
Date RCCeI t#
WATER SYSTEM /TRMAUNC
NEW RESIDENTIAL PLMB._SQ.Fp.
TOTAL:
BUILDING •'E
TOTAL:
SEISMIC FEE
ELECTRIC FEE
QTY.
MECHANICAL PERMIT
FEE
PLUMBING FEE
MECHAMCAL FEE
PERMIT ISSUANCE
ALTLRORADDTOMECH.
FEES PAID:
Date R0[el t#
P
AIR HANDLING IMH(T010,000 CFM)
SUBTOTAL:
AIR HANDLING UNIT (OVER 10,000 CFM)
CONSTRUCTION TAX
Signature of pB '- / r or Date
A DO SMATERIALS DISCLOSURE
Willtheapplica orfuture building occupant store or handle hazardous
materul as defined by the Cupertino Mueldpal Code, Chapter 9.18, and the
the ith and Safety Cade Sealon25532(a)?
F-1 1 Yes r] No
Will the applicant or future building occupant use equipment or devices
which rout hazrrdous air cent.oura. s as defined by the Bay Area Air
Quality Management District?
'Ph Yn No
t avcrcadthehaza�mmaterlalsrequirementsunderChapter6 .95of
the California Health & Safety Code, Sections 25505, 25533 and 25534. I
understand that if the building does no(cumently have a tenant, that it B my
responsibility to notify the occupant of the requirements which must be met
prior to Issuance of a Certificate of Occupancy.
EXHAUST HOOD(W /DUCT)
CONSTRUCTION TAX PAID:
'
HEATING UNIT (TO 100,000 BTU)
Date Re[ei t#
HEATING UNIT (OVER IOW000 BTUI
TOTAL:
t
VENTILATION FAN (SINGLE RESIW
ISSUUATE
U 2 s i99 U
City (jf r(
t- {•.r�_�l. �p�R�s {IAQ
ISSUED BY:V`-'r— 1P4 W'��
BOILER -COMP DEEP OR IOW000 BTU)
_
BOILER-COMP (OVER 100,000 BTU)
NEW RESIDENTIAL MECH. SQ.FT.
Owner or authorized agent Date
TOTAL:
OFFICE COPY