19421APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE SALL POINT PEN ONLY
Building Project Identification
Budding Address: ti
PERMIT NO.
^3
19421
weer. ante. Phone:
T673Cl99rM—AU =A
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BtZLDING- ETECTRICALPLUMBING.MECHAMCAL
�-' ' `6
Contra . /�C— LIc.Np:
��
CATEGORY
CO OLp
Architect gineer. Lie. No:
QTY
ELECTRICPERMIT
FEE
BUILDING PERMIT INFO
T
Addrev1,0/,& �Sj
PERh4TISSUANCE
❑ ❑
❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirmlhat lam licensed under provldonso (Chapter9(commene
Ingwith Section7111ID)ot Division 3ofthe Businenand ProfessionsCode, and my
licensebIns (arm deflect.
Licanse Class C-Lk. M
Dale /i L 1 Conra or
ARCHI ECLA TION
I understand my plans shag and as public records.
APPUANCESRESIDENTIIAL
JOB DESCRITION
/� t
N `Y \s
PAN[IS
301- IOWAMPS
OVER 1000 AMPS -
SQ. FT. FLOOR AREA
/SQ. Fr.
SIGNS ELECTRICAL
Licensed Perfoashmal
OWNER - BUILDER DECLARATION
I hereby affirm that I am exempt fromthe Contractor's License law fmthe
SPECIALCItCULT /MISC '
.
TIIdPMEITRORI'OLE INST.
followkgrcaeon.e3ectlon7mi5, Budncesand Profenbru Code:Anycity Or
countywhich requires a permit to construct, alter, improve, demolbh,orrepair
-
anyslmemrepriortoitsIssuance, also requires the applicant for such permit to
file a signed statement that he b licensed pursuant to the provbbnt of the
Contractors Lkerem Law(Chapter 9(commencing with Section 7000) of DWI.
sion3oflhe Bushnessand Professions Code) orlhat he b exempt therefeamand
the basis for the alleged exemption. Any violation of Se tlon 7031.5 by any
applicant fora permit subjects the appllcaotto a civil penalty of not more than
five I, as'odneroft epro
� as owner of the propemly, or my employes with wages there dole
-
POW.ER DEVICES
SWIMMING POOL ELECTRIC
OUTLETSSWITCHFSFI%711RE5
- VALUATION
NEW RESIDENTIAL ELECTS SQFr.
Sl'OWES
TYPE CONSTRUCTION
c mpensa
e woe
pr offered for will
r
etmte:
0K B.dinelhe
oak ( &c 70M, ainow and red.l.e The C ntract r
Code: The thereon law
to f grope ty or impcors
.does not apply hlso nee orms, Pro idedt at and
whodoes hlsormi.
OCC. GROUP
RES. UNITS
amet amrktionen edorough
If,hoes,providedth irtgor
Improvementsarc cam Intended earodco (Oink.I( however, Oder ill have
improvement Iswldwlthlnoneyearo( rompldlon ,thepwner- bu0derwlllhove
TOTAL:
tlili_�turden of proving that he did not build or improve for purpose of sale.).
u 7, as Owner of the property, am exclusively contracting with licensed
contradoes to comlrud the project (Sec. 7044, Business and Professions Code:
QTY..^
PLUMBING PERMIT'
PERMIT ISSUANCE
FE'
FLODD ZDNE
APN
The Contrador's License ]aw does not apply to an owner of property who
Wilds or Ins prove thereon, and who contracts for such n in,je with a
cgp(Tador(s) licensed pursuant to the Contractor's License Law.
LJ I am exempt under Sec. B & P C for this reason
ALTER -DRAIN &VENT- WATER (EA)L
/5
BACK FLOW PROT T. I
EE SUMMARY
/
DRAINSFLOORR
FTCTURES PER
F,AREA,COND.
^L
�7
L
SANTFA N
FLEBrf p
Owner Date
❑ ORKMAN COMPENSATION DECLARATION
I here affirm that I have a cartlficate of consent m self -lnarc, or a
LT N_
3800nLb o(Workern' Compensation Wurance or a certified Copy themof (Sec.
F.CFRrr M
GAS G.SYSfFM•1
INC.40[�7,Ft T5-
`
. •
p N,
Cnmyan
ECEIT M
CAS EA.SYSTEM -INEft
4 (FA)
Y
BUILDING DIVISION FEES
Certified ropy b heed with tecity
�Ccrtified copy b /lied with the city ImpeNOn divislan.
CREASE /WDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE
GREASE TRAP
CERTIFICATE OF UEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(fhb sedlon need not be completed If the permit b forom hundred dollars
PAID
Date Reoei D
t#
SEWER- SAMTARY -STORM EA. XIOFT.
(SIEB mIcid.)
I certify that In the pedarmanceof the work for wMch tN mi
d pert ht ion ed,
I shall not employ any person In any manner an m to become satiated to the
Workem' Compensation Laws of California. Date
wATEft EffAr04 w /vENr /ELFCTR
ENERGY FEE Y N
1 a AID
WATER SYSTLM /TRGTING
Applicant
NOTICE TO MPLICANT: E, after naking this Cnrtlflale of Exemption, you
should become subjm to the Workers' Compensation provisions of the Labor
Code, you must forthwith comply with such provisions or this permit shall be
deemed revoked, t
Date Recel
t#
NEW RESIDENTIAL PLMB. SQ.FT.
TOTAL:
UIL G ^'E
—'
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that there b a comtmction lending agency for the perform
once of the work for which this permit b headed (Sec. 3097, Civ. C.)
TOTAL:
ELECTRIC FEE
L cr der° Name
Tender's Addreao
s Icertlfythatl have read thisappBcationand state thattheabovelnformanno
bcorred. Iagmetocomply with all city and county ordinanm and statelaws
'relating to building construction, and hereby authorize representatives ofthb
QTY.
MECHANICAL PERMIT
PERMIT ISSUANCE
FEE
PLUMBING FEE
MECHANICAL FGE .
FEEL Sj�AID _ _ _I
Z (0
city to enter upon the above- mentioned property or inspection purposes.
(We) agree to sues, Indemnify an d krep h en the Clty of Cupertino
agalnslllab es,Judgments, costs and ex pen' whin maylnanywxyaccrue
aga BY In rondequenc, O It, g of permit.
2 z�
ALTERORADDTOMECH.
AIR HANDLING UNIT(TO 10,000 CFM)
Date Receipt#
SUBTOTAL:
AIR HANDLNG UNTT(OVER IU,ODOCFM)
CONSTRUCTIONTAX -.
_
core of Ap rani /Contractor Date
EXHAUST HOOD(W /DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT(TO 100,000 BTU)
Will the applicant Or future building occupant store or hand le hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.17, and the
Fkalth and Safety Cock Section=(a)7
0 Yes No
Date Revel I#
HEATING UNIT(OVER 100,000 BTU)
TOTAL:
/
VENTILATION FAN(SINGLE RFSID)
ISSUANCE DATE
QV atlnrr�� n
J1O I�
Will the applicant or Marc building Occupant use equipment or devices
which emit hazardous air rontaMeantsas defined by the Bay Area Air
Qulity Management District?
4Yn ojNo
havereadthehazadouseuterial srequirementsunderChapler6.95of
BOILER- COMP(3FB' OR 100,000 BTU)
BOILER- COMP(OVTR100,000 BTU)
the California Health &Safety Code, Sections 35505, 25533 and 75534, 1
NEW RESIDENTIAL MECH, SQ.FT.
understand that if the building dcesnolcurrerglyhave a tenant, that ll limy
responsibility to notify the occvpaetofthe re. be cab which must be met
prior to nee of a Certlficamof Occup Illy
�Ll�
or aulhorl gent Dale
ISSUED BY:
TOTAL:
21
OFFICE COPY
u