24413APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Beildln Pealed ldemiflatlon
Building Address: -
1.9 *15016 s. c.% spa
PIRMIT NO
2 4 413
n1. came: one:
F R
CITY OF CUPERTINO- BUILDING DIVISION
BUILDING- LECRCAL- PLUMBING.MECHMCAL
APPLICAr5KMMMrfW=A
G� 2�Z-
co tt. came Lk. No
CATEGORY
CONTROL X
Architect /Engineer. Lk. No:
QTY
ELECTRICPERMIT
FEE
BUILDING PERMIT INFO
Address &41C W <rr
PFRMITISSUANCE
-
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter 9(commenc
Ingwith Secdon7D00of Dlvltlon3afthe Businessand ProfesionsCode,and my
lI ma,1 In full and dlM. �J�J _� —�� •�'� .�j��
Llcene C]a
Dat °7 /�) /��� y��— Contractor
ARCHITECT'S DE LA 1D
I understand my plans shall be used as public records.
Professional
OWNER - BUILDER DECLARATION -
I hereby affirm that I am exempt from the Contractor's License law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or
county which requbes a permit to construct, alter, Improve, demolish, or repair
anystrocture prior to its Issuance, also require the applicant for such permit to
file a signed statement that he Is licensed pursuant to the provision of the
Conlrectorb License Law (Chapter 9(commencing with Section 7000) of Dlvb
.ion ssi
3 ofthe Business and Profeon Code)mthat he is exempt therefromand
the Wsla for the alleged exemption. Any violation o(rattlon no maby any
apeBcemfor delta. $50subjects )the applicant toativll pensltydnat nnrelhan
five 1, asoddollarshepro
MLaaownaodothe wperty,ormy employees with
compensation, ended r ffered sole
fo
sale (Sec. pply Business property Code: The or License Law
7040 Business workfiesdo structure Is not Intended or offered Law
does who dot apply to an ims owner of pro ugh his who nempor ovided hereon, and
who doeesuch work himxBod oreugh hisowne . If, hoes, provided that such
improvements are not Intended earofred!orals.If, mner.q Uder l lI have
Improvement lssold within Onycarolcompletiogtheowner- WBdcrwlll have
tlgi,�urden of proving that he did not Wild or Improve for purpose ofsale.).
L L as owner of the property, am exclusively =trading with licensed
contractors to construct the project (Sec 7044, Bush. and Profession Code:
The Contractor's License Law does not apply to an owner of property who
Wilds or improved thereon, and who contra for such pSojects with a
c7n4a'tor(s) licensed pursuant to the Contractor's Limese Law.
L j am exempt under Sec. ' B & P C for thin reason
APPLIANCES-RESIDENTIAL
JOB DESCRIPTION
PANELS
UP TO 2DO AMPS
7014000 AMPS
OVER1000AMPS
SQ. IT. FLOOR AREA
DLicensed IN
j i
Y
S /SQ.Hr.
SIGNS ELECTRICAL
—
I • 1
,. I.,.
SPECIALCIRCUIT /MLSC
TENIP.METRORPOLEIN
POWER DEVICES
.
DATE
SWIMMING POOL ELECTRIC
OUILETSSWITCHES.FIXTURES
VALUATION
/'A
V GJi..fl
NEW RESIDENTIAL ELDCIR �'�'
STOW65
TYI'G CONS'I'RI1CT'ION
QTY,
TOTAL:
PLUMBING PERMIT,
PERMIT ISSUANCE
ALTER -DRAIN &VENT- WATER (EN '
FEE
OCC, CROUP
RES. UNITS
•
PIAODZANE
nPN
BACK FLOW PROTECT. DEVICE
'FEE SUMMARY
FEES
DRAINS FLOOR, ROOF, AREA, COND.
pD(TU(((:g PER TRAP
SANITARY Y N�
RECEIPT X
Owner Date
WORKMANCOMPUSSATIONDECLARATION
hereby affirm that I have a certlfkate of consent to self - Insure, or a
certificate o(Worken' Compensation Insurance or a certified copy thereof (See,
3XfA,Lab C.)
Policy X_
Coco any
MCertlfled copy ere hthe city
�CertlRed copy V (Ikd with the city Inspection division.
CERTIFICATE OF FXFMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thin.ealon need sat W completed I([he pertNt In !Drone hundred dollars
(S]W)orfy,th
Icenot thatoy an performance
panne vinany annex lorwhlcbeco become subject Baud,
I shall not employ any person In any manner m as to became subject to the
Applicant s' Compensetlen Laws of California. Date
NOTICE
co es bit&I.t a If, aftermakingpar Certificate prteof.na f the Labor should becomes forth ith co Workers suchpnaHOnpmvbionofthsGWr
Code, you =at forthwith comply with each provision or this permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the perforrry
ance olthe work for which this permit la Issued (Sec. 3097, Civ. C,)
I<ndce. Name
Lenders Address -
I cerUfythat I havereadthb appliationand aatethattheabove Information
lacomect. l agree to comply with all cityand county ordinances and state laws
relating to building construction, and hereby authorize representatives of the
city to enter upon the above- menttored property for inspection purposes.
(We) agree to save, Indemnify an d keep harmless the City of Cupertino
against liabilities, pdgments, costs and expenses which may In any wayaccme
against said City In consequence of the granting of this permit.
SCIiOOL TAX Y— N_
te, X
GAS EA. SYSTEM- ]INC.4OUTLETS
PARK FEE Y N
RECEIPT M
GAS EA. SYSTEM -OVER 4 (EA)
BUILDING DIVISION FEES
CREASEANDUSTRL WASTE INTERCEPTOR
PLANCHECKFEE .ZX�
4
PAID
Date Recei tM
`'S
GREASE TRAP
SEWER- SANITARY - STORM EA. 700FT.
WATER HEATER W /VENT /ELECTR
ENERGY FEE Y N —
PAID
Date Revel tlif
WATER SYSTI M /TRFATING
NEWRESIDENTIALPLMB. SQ.FT.
TOTAL:
13VILDING ••E.
SEISMIC FEE
TOTAL:
ELECTRIC FEE
QTY.
MECHANICAL PERMIT
FEE
PLUMBING FEE
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID:
ALTERORADDTOMRCH.
AIR HANDLING UNIT (TO 10,000 Cr M)
Date - Recej tq
P
SUBTOTAL:
'
AIR HANDLING UNIT (OVER 10,000 CiM)
CONSTRUCTION TAX
Signature of Appliant /Contractor Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle harandIDUS
material as defined by the Cupertino Municipal Code, Chapter 9.17, and the
health and Safely cedryScplon 75537(a)i
FI Yea o
Will the applicant or lurebuildingoccupant useequipment ordevices
which emit harardous air contaminants as defined by the Bay Area Me
Quality Management Dlstri
4 Yes o
have read the hazy ous maledab requirements under Chapter 6.95 of
the CalifomU Health &Safety Code, Sections 75505, 25533 and 75534.1
understand that lithe Wilding does not currently haves tcnant,lhat itls my
responsibility to notify the ompart of the requirements which at be met
prior to less cedes rUf tcofOmtpancy.
�+
Owner or authorized agent
EXHAUST HOOD(W /DUCT)
CONSTRUCTION TAX PAID:
HEATING UNIT (TO 100,000 BTU)
Date RCCeI
HEATING UNIT (OVER 100,000 BTU)
TOT
VENTILATION FAN(SINGLE RESID)
ISSUANCE DATE
p.� p I D
Y P9
OCT 30 ���
G 2
Cl IT Vr uurc
ISSUED BY _
BOILER- COMPOHPOR100,0(UBTU)
BOILER-COMP (OVER 100,000 BTU)
NEW RESIDENTIAL MCCH. SQ.IT.
F
IOTA L:
OFFICE COPY