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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
building Project Identification
Building Address: -
PDLWT NO.
'/ O C A
4
! g07:oo S- 'EV046, G�2EEK
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sera aces: one.
ALUAIL
C res5 Ic C ✓TIES
CITY
3
OF CUPERTWO- BUILDING DIVISION
APPLICATION / PERMIT
BUILD INr— MECTRICAI PLTIMMNC.MMHAMCAL
can dor'sName: Lk. No
E / {SOL.4 /Z- CON D, 45CIS
CATEGORY
CONTROLS
A Itect/F gamer. Lie No:
.Ttatde=
SQTY
="�s�l*?"t
tr BPON4,1C� RMiI , 4
.,,w,;�BUiLDING "PERMIT"INFO
PERMIT ISSUANCE
Address:
1-1 1:1 ❑ IK
I�
LICENSED CONTRACTOR'S DECLARATION
hembyalfirmthat I am Bernard under
APPI.IANCESRESIDENML
]08 DESCRIPTION
PANEI9
Ingwlt is or fDlaffect fthe BualmsamdProlmlonsCode, and my
license b In fail joryt�nd died.
Limn lse GIB L1cN �!
� /`
_43
Dale Contndor
' ARCHITECT`S ECLARATION
I understand my plans slugb used aspubll <records
�./
000DOAM
OVE
OVER IfDO AMPS
SQ. FT. FLOOR AREA
f /SQ. FT.
9IGNSEL
Licensed Professional
CItCUIT /M
OWNER - BUILDER DECLARATION
Iberebya(AmthatIamexemptfromthe Contractor's Lh meI for the
TEMP O 1
following reason. (Section 70115, Business and Professions Code: My ally or
eauntywhlehrequbna pemdtwmmWct atter,bnprove,demoliakorrepalr
myatrudumpror Wiftimance ,alsorequimtheappaontforsuchp.n tw
We a signed statement that he is licensed pursuant to the provisions of the
POWERD
-
.
SWINIMI C
Contractor's License Law (Chapter 9(commencing with Section 7DOD) of Dlvl-
don3o(the Buatn rod Profmi nmCode)orthathebexempttherefromasad
VALUATION
the bah for the alleged exemption: Any Violation of Section 70115 by my
appBnnt fora permit subjects the applicant to a dvil penalty dint morcthan
0UILETS8WI
-
Rvundred ddlan (SM. ,.: -. •-
I, as owner of the property, or my employees with wages m shah role
NEWRFSUEN1TALELECIR
STORIES
TYPE CONSTRUCTION
tmpensatce, will do the work and thesmazure is not Wended or offered for
sale (see 7616, Business and Professiona Code: Tb Cmdeactoes idceme Law
don not apply to an owner of property who builds or)mprovn thereon, and
who dooasch work himself orthrwgh Msown employee, provided that such
OCC. GROUP
RES. UNITS
Improvements are not intended oroffered forsab. 14 however,thebulWing or
TOTAL:
imp it nentbsddw hinomyearo fcompletiorylheowner- bulldcrwiR have
tl)fkurden of proving that he did sea build or improve for purpose of eels.).
u L m owner of the property, am exclusively mntract)ng wah --
contrectors b corutruct the project (see 7014, Businm and Prdmh,m Cade:
r
QTY3
' yPLUMBING;:BRMIT
:y, FEES;,
FLOOD ZONE
MN
PERMIT ISSUANCE
The Cndrsctor'a License Taw don not apply to an owner of property who
bu0da or im roves thmxr and who coM'acb for such with a
gyp¢ +ek 1ploeemd pursuant to the Commence. License Law
LJ I sm nemp,urder See' B 4 P C !or fhb reason
ALTER-DRAIN&VENT -WATER OW
BACK FIDW PROTECT. DEVICE
DRAINS FLOOR ROOF, AREA, OOND.
SANITARY Y_ N-
N
Owner
Owner Dm
WORKMAN COMPENSATION DECLARATION
QI hereby affirm that I have a certdnte of consent In self- iname, or a
38TH,iL,bQ ken'CarrtperuaHanlnaunnceora certlfled copythereo((Sn.
Labe "' - -
1'D(TlIRE41aEIt TRAP '
SCHOOL TAX Y_ N_
RECEIPT N
GASpA.SYSIMA -1 INC60UTT.EI5
PARK FEE Y N3800,
RECEIPTS
Policy
Co,�roPany
GAS.Ep.sYSfFM- OVERI(PA)
BUILDING DIVISION FEES
"Certified copy is hereby fuMshed.
njCaitme copy b filed with the city Inspection division.
GREASE /INDUSITiL WASTE INTERCEPTOR
PLANCHECK FEE
CREAM TRAP
i, CERTIFICATE OF EXEMPTION FROM WORKERS'
PAID
COMPENSATION INSURANCE
(rhissection need not be completed li r
the permit isforone hundred dollars
SEWER - SANITARY- 5T17RMIA. MO[, -p
Date React) t#
WATER HEATER W /VENT /ELECTR
ENERGYFEE Y N
(S100)arleas3
I certify that N the pedomunne of the work for which this penNt is based,
WATEtSYS1EM /TREATING
I shall not employ my person In any nomner w m to become subject to the
Workers Compensation laws of California. Date
PAID
NEWRE'IDENTIALPLMR. SQ.FI.
Applicant
Date Recei t#
NOTICE TO APPLICANT: H, after making this Certificate of Exemption, yen
should become subject to the Workers' Cempemethm pnwi'1=of the Labor
TOTAL:
BUILDING ME
Code, you amat forthwith comply wlthsach provisions orthb permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
SEISMIC FEE
Iherebyalirrn that there is. M
a construction leingagency for the perform-
men of the work forwhich thin permit Is named (Sec 3097, CIv.C.)
,Imd.e. Nana
1ander's Address
` I mdifythatlbvereadthbapplicatlon andsbtethatlheabovelnfomution
Is corred. I agreeto complywlth all cltyand county ordinances and state law.
TOTAL:
ELECTRIC FEE
PLUMBING FEE
o.,
Qhf
!
, . .. ,.,.... -=_• ..,
; i A'IECFIA/JICAL ",PERMIT t`;'. «+"
-
PERMITI.SSUANCE
tV "FEE,.,
(%
MECHANICAL FEE
FEES PAID:
relating to building construction, and hereby authorize representatives of this
dtytoenterupon the above- mentioned property for Inspection purposes.I
(We) R. to rove, Indemnily an d keep hamdm the City of Cupertino
against lbbWthis, judgments,cortsand expenses which may in anywayacoue
ALTER OR ADD TO MECH.
q.DD
Date Receipt#
AIR HANDLING UNIT (170 10,000 CFM)
SUBTOTAL:
a Wt mid City tssu � granting of this permit.
AIR HANDLING UNIT (OVER IO,ODOCFM)
CONSTRUCTION TAX
SI nstureof Apphcent Contractor Data
EXHAUST HOOD M' /DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERI LS DISCLOSURE
HEATING UNIT (TO 100,000 BTU)
Date Recel t#
WOltheappficant orfuturebuadlegoccupant storcor handle hazardous
feral as defined by the Cupertino Municipal Code, Chapter 9.17, and the
Health and Safety Code Section 75537(a)7
MYes MN.
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
VENTILATION FAN (SINGLE RESID)
ISSUANCE DATE
Will the applicant or future building occupant use equipment or devices
which emit hazardous air contaminants as defined by the Bay Area A4
Quality Management District?
M Yea ❑No
f haE V
BOILER-COMP OHP OR 100,000 BTU)
BOTLER-COMP(OVER 100,000 BTU)
LI have read the b.zerdous materials requirements under Chapter 6.95 of
e California Health & Safety Code, Sections 75505,25533 and 75534. 1
'understand that lithe building don not currently have a tenant, that It is my
[! I�(TO
AUG 11 JJ
NEW RESIDENTIAL MECH. SQFT.
enpo sibiity to not lfy the occupant of the requirements which must be met
prior to beam. of a Certificate of Occcups ney. '
City Cf mn?rtinn
ISSUED
Owner or authorized agent Date
TOTAL:
q
V
OFFICE COPY f