20449APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
Building Project Identification - ,
Building Adds: G S- c-, 2, -
s
PERMIT NO.
2 0 4 4 9
r1 amt: hone:
e LQCf F% mA� f+j P
CITY
Rift
OF CUPERTINO- BUILDING DIVISION
APPLICATION / PERMIT
BUILDING-ELECnUCAL-PLUMBINC— MrCHAMCAL
A A
d', Name: - y =.N.
�7 �-1
CATEGORY
CONTROL N/
Arc itect /Engineer. Lie No:
QEY
ELECTRIC PERMIT
FEE
BUILDING PERMIT INFO
Address:
PnRMITISSUANCE
I Z idJ'
� 1:1 0
LICENSED CONTRAOR'S DECLARATION
R
I hereby affirm mlicensed provisions er 9 (daromme,
Ingwlh Secfl o7000)ofDlvslo3 ofthe Bunderssand PrrofeadorsCode, and my
license Is m ll force Mfect .ate
ce se Cb N `� o f "' Iey
e Contactor
ARCHITECTS DECLARATION
Iunderstand my plansMall be used as public records.
Licensed Prolessbral
OWNER - BUILDER DECLARATION
I hereby alfirmthat l am exempt from the Contractor's License Law (or the
following reason. (Section 70313, Business and Professions Code: Anydry or
cmntywhkh requires a per' dt tomratmd, alter, Impmve, demolsh,rrrepalr
anystmdure prior to its bustance, also requbnthe applicant for such permit to
file a signed statement that he b licensed pursuant to the provisions of the
Contractors License Law (Chapter 9 (mmmendng with Section 7000) of Dlvl-
,ion 3o(the Buttress and Professions Code) orthat he is exempt therefrom and
the basis for the alleged exemption. Any violation o(Section 7031.5 by any
applicant fore permit subjects the applicant to a civil penalty W not morethan
five hundred
owner dollars hepm
I, as owner of the property, or my employees with wages r there sole
compensation, willin.. and and the structure s not Intended or tense offered L for
vie (Sec: 7W4, Business and Professlom Code: The Contractors Llrerae Law
does not apply to an owner a property who bu lids or improves themoq .and
who doessuch work himself orthrough his own employees, provided that such
Improvements are not Intended reoffered for sale. If, however, thebuilding or
Improvement bsold within oneyearo(comprflm,theowner- flderwlll have
tfill.Ilurden of proving that he did not build or improve for purpose of sale.).
L as owner of the property, am exclusively =trading with 1lrensed
contractors to construct the Erected (Sac. 7074 Business and Professions Code:
The Contredor't Limes, Law time nest apply to an owner of property who
builds or Improves therms, and who comment for such ptojeds with a
cq➢.t�actor(s)Ilrensed punuantm the Contracori Lcense Law.
IJ I am exempt under Sec. B & P C for this reawn
MPLANCESRFSIDENI7AL
JOB DSCRIPTION
('C I C)
PANELS
UP TO 2DOAKE�i
201 -1000 AMPS
OVER 1000 AMPS
SQ. FT. FLOOR AREA
D 'I N
C
TER
$ /SQ.FT.
SIGNS ELECTRICAL
SPECIALCIRCUIT /MISC
TEMP. METER OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETSSWITCHFSFIXTIIRES
5, (M
a
VALUATION
CJG
2'V' 1 h�...w •�--�
-- +� --•CJ
NEW RESIDENTIAL ELECTR SQ.FT.
STORIES
TYPE CONSTRUCTION
_
_
QTY,
TOTAL:
PLUMBING PERMIT
'
00
FEE
OCC. CROUP
RFS.UNOTS
PERMITISUANCE
ALTER -DRAIN &VENT- WATER (EA)
FLOOD ZONE
APN
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
DRAINS FLOOR ROOF, AREA, COND.
FDOURES PER TRAP
SANITARY Y_ N_
RFCTIPI' N
Owner Date
WORKMAN COMPENSATION DECLARATION
❑l herby affirm that I have o =erttkate of consent d spythsure, (S a
certifkab of Workers Comperuatlon lraunnre ors certlfkd ropythereof (Sec.
poliyab CJ
SCI100L TAX Y_ N
RECEIPT N
GAS F.A. SYSTEM -1 INCA OUTLETS
PARKFEF. Y_ N
RECEIPT M
CAS FA. SYS2M -OVER d (EA)
Co a
C°n' ^Y
BUILDING DIVISION FEES
copy is hereby furnished.
❑ Certilled ropy b (fled with the dry inspection division.
CERTIFICATE OF IXLMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thlesectim neM not be completed lithe permit Is forms hundred dollars
(SIM)mIess.)
I mrti(ylhat to the performance of thework forwhich this permit is Boxed,
I shall not employ any person in any manner ro u to become subject to the
Workers'Compensation Laws of California. Date
NOTICE
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you
should become subject to the Workers' Compensation provisions of the Labor
Code, you must (on hwith comply with such provisions or this permit Mail be
deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affim that there is e construction lending agency for the perform-
ante of the work for which this permit b issued ( &c. 3097, Civ. G
Lmdera Name
lender's Address
I certifythat I haveread this appliatlon and Pate thattheabove Information
scored. la greet. complywithallcitya ^dcountyordl ^a ^cesandetalelaws
relating to building construction, and hereby aulhorbe representatives of this
city to enter upon the above- menHosed property for Inspection purposes.
(We) agree to save, indemnify an d keep harmless the City of Cupertino
against liabilities, judgments, mtlsand expenses which may In anywayaccnm
agalm CI com of the grantIng of this permit.
GREASE. /INDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE
PAID
Date Recei Ik
GREASE TRAP
SEWER - SANITARY -STORM EA 200FT
WATER HFATQt W /V[NT /ELFOTR
ENERGY FEE Y N
PAID
Date Recei tit
WATER SYSTEM /TREATfNG
NEW RESIDENTIAL PLMB. SQ.Fr.
TOTAL:
BUILDING •E
0
,
SEISMIC FEE
�d�
,vCD
TOTAL:
ELECTRIC FEE
1�Q0
QTY.
-
MECHANICAL PERMIT
FEE
PLUMBING FEE
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID:
ALTFRORADDTOMECH.
AIR HANDLING UNIT (TO 10,000 CFM)
Date Receipt#
SUBTOTAL:
AIR HANDLING UNTT(OVER 10,000CFM)
CONSTRUCTION TAX
g tureof AppHmnt Contractor mt.
f1AZARDOUS MATERIALS DISCLOSURE
Ill the a pplicant or future building occupant store or hand le havrdous
material as defined by the Cuperd no MuNdpal Code, Chapter 9.12, and the
I With and Safety Code Section 25532(e)?
11 Yea M No
Will the applicant or future building ormpant use equipment ordevicns
which emit havardous air contanneents as defined by the Bay Area Air
Quality Management District?
Yes g No
hzveread the hau'3ous nuterias requirements under Chapter6.95 of
the Cxll(nmrt4iealth & Safety Code, Secttom 25505, 25533 and 25534. I
understand{{ hat if the building does not currently have a tenant that it is my
prior to Ls Bfyto rf a theoate of o!therequirements which must be reset
prior to L55uanre o(a Certificate of Occupancy.
EXEfAUS'r HOOD(W /DUCT)
CONSTRUCTION TAX PAID:
�♦
HEATING UNIT CM 100,000 BTU)
Date RCCeI td
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
VEMILATIONFAN(SINGLERESIDI
ISSUANCE DATE
.y'�
ISSUED OY: � P "_ 4a)=k"�
BOMER-COMP(RIPOR 100,0(IO BTU)
BOILER- COMP (OVER 100,000 BTU)
NEWRESIDENTIALMECH. - SQ.FT,
Owner or authortaed agent Date
TOTAL:
-
OFFICE COPY