20066APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification
BuildAddress14 : 00 ST6ic7gS (2 awn
PERMIT NO.
2006
wne`c ante:
' w .
CITY OF CUPERTIN0.6UILDINC DIVISION
/ PERMIT
BU LDINGELECTRICALPLUMBING-MECHANICAL
�J=2-�'�O
cap annraName: /APPLICATION
3 a Co a `t�35 Y q
Architect glneer. Lic. No:
T -
CATEGORY
CONTROL MM,
—1
ELECTRIC
Qct ELECTRIC PERMIT. FEE
BUILDING PERMIT INFO
Addm.s:� �S D E�.� (�( A I
C� l 1
❑ ❑ ❑
PERMITTSSUANCE
ICF.NSED CONTRACTOR'S DECLARATION
I hereectionrmlhatlemsloo3edunderpreassad sof Cbapter9de,and e-
lice..h Section 7000) and offeon3ofthe Bualnessand Pro(eselonsCade, and my
license le In full f and d(eci.
License lam _ Lle.p
Date Coat der�OaV
ARCHITECT DECLARATION
I understand my plans shall Wused espublic records.
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm am exempt I aexempt from the Contractors License Law for the
lollowingreason.Gadon=.S, Business and Professions Code: Any city or
coonlywhlchrequtrt aperfttwmmtmd,alteylmpmve,demolleh,ormpalr
any structumpriortoheIssuance, also requlreslhe applicant forsuch permit to
file a signed statement that he is Bccesed pursuant to the provIsbm of the
Contractor's Liceme Law (Chapter 9(commencing with Section 7000) of Divi-
elan 3 of the Business and Professions Code)orthm he Is exempt therefrom and
the basis (or the alleged exemption. Any violation of Section 76115 by any
room for a permit subjects the applicant to a civil penalty of not rrc than
five hundred dollars ($500).
1, as owner of the property, or my employees with wages as their sole
compensation, will do the work and the structure is not intended or oftemd for
sale (Sec 7044, Beales. and Professions Cade: The Conlractot's License Law
don not apply to an owner of property who Wilda or Improves thereon and
who doeseuch work himselforlhrwgh hisown employees, provided that such
improvement are not Intended aroffered forsale. If, however, thebuilding or
improvement a sold within one yearofcompletloo, the owner-bullderwlll have
th„kurden of proving that M did not Wildorimprove lorpurposeolsals.).
LJ L as owner of the property, am exclusively contracting with Iimnsed
contractors to coratruct the project (Sec. 7044, Busineasand Professions Code:
The Contractora License law don not apply to an owner of property who
Wilds or improve thereon, and who atom for such p(ajeds with a
do a) licensed pursuant to the Contractors License Law.
LJ I am exempt under Sec. B & P C for this reason
JOB DGSCRR'fION
�.e..�\
P� 0I ' l GW
PANELS
TO 2DO ANTS
IDI-IODO AMPS (UP
OVER 1000 AMIsS
SQ. FT. FLOOR AREA
S/SQ. FT.
SIGNSELECTRICAL
SPECIAL CIRCUIT/MISC I a
TEMP MGI'Ot OR POLE INSf. �/ �•;
-
POWER DEVICES--�.v
D I
NG POOL[CCRIC,J� fl
OUTL SWI a` n FlXrUR /
-
VALUATION
Seg O, `� �. 17a
V
NEWR AL EL TR _SQ.
STOPIES
TYPE CONSTRUCT ]ON
G'
Or,,
TOTAL:
QTY, PLUMBING PERNAT FEE
-OCC.CROUia
RES UMTS
PERMIT ISSUANCE
ALTER -DRAIN &VENT- WATER ffNN
FLOODTONE
APN
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
DRAINS FLOOR ROOF, AREA, COND,
FIXTURES PER TRAP
SANITARY V_ N
RECEIPT M
Owner Date
WOR KMAN COMPENSATION DECLARATION
[:]I hereby affirm that I have a certificate of consent mself-Insure, ora
mrtiflute a! Workers'Compemation Insuranm oracertlfW mpythemof (Sec.
3800,L6 C.)
It
5CIi00L TA% Y_ N
RECEIPT M
GAS PA. SYSTEM -1 INCA OUTLETS
PAIU FEE Y N_
GAS EA. SYSTEM-0VER4(EA)
Com any
BUILOf C nIVI510N FE ES
the cid.
IRCenilied copy ls filed famished
K] Certified ropy t hereby fa the city impaction dlvlslon,
W CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(fhlasection need not W completed If the permit ls for one hundred dollars
($1(0) or leas.)
I certily that in the psr(mmam. of thewmk forwhlch this permit is blued,
I shall noemploy any pesmIn any mnner o ss to bcomubjcto the
Workers` Compensationlaof California.ate
Applicant
NOTICE TO AI'PLICANT:IL after making this Certlflcate of Exemption, you
should become subject lathe Workers'Comperuatlon provisions of the Labor
Code, you moat forthwith comply with Mich pruvlsloas orthis pemdt shall be
dmmed revoked.
CONSTRUCTION LENDING AGENCY
Iherebyaffirm thatthereisa construction leadingagenry for the perform
ante of the work for which this pmmlt Is Issued (Sec. 3097, Civ. C.)
]aiald'.Nanta -
Iaadara Address
I car lythaH have readthisapplicationand statethAtheabavel.formation
lsmriect. I agree to comply withal)dtyand county ordinances and state laws
relating to building construction, antl hereby authorise representatives of this
city to enter upon the above-mentiorsed property for bupeetion purposes.
(We) agree to save, Indemnify an d keep harmless the City of Cupertino
agahstliabllitln' dgmenI coshandex meswhicherayle.eywayacerue
ag sold n nsequenm t ming dthls permit.
igoa of Appll / a or Dae
AZARDOUS MATERIALS DISCLOSURE
Willtheapp leant or future building occupant atom or handle haaardous
rwtertl as defined by the Cupertino Municipal Code, Chapter 9.17, and the
Ficalthand Safety Code Sedivn 25532('.)7
❑ Yes i9Na
Will the applicant or future building occupant use equipment ordevices
which card hanrdous air con M
nnsab as defined by the Bay Area Air
Quality Management District?
Yes No
have read the harajKus materials requirement under Cha pier 6.95 of
the California Health & Safety Code,Sacdom 25505,25533 and 75534, I
understand that lithe building does not currently have a tenant, that It is my
responsibility to notify the oaupant of the requirements which at be rnet
prio otss o aCsAificat- O /jury.
nc rauthod Ise`
GREASE/INDUSIRL WASTE INTERCEPTOR
PLANCHECKFEE
PAID -3 -IQ -96 �
Date Reml tH
Q
I (^7s7Q
GREASE TRAP
SEINER-SAINMEARY-STORM 200FT
WATER HEATER W/VENT/ELECTR
ENERGY FEE Y N
PAID'SISGCO
Date Remi tit
73 /^
C�Cb
WATER SYSTEM/TREATING
NEW RESIDENTIAL PIMB. SQRT.
TOTAL:
BUILDING ITEaJJ
SEISMIC FEE
l
1_
TOTAL
ELECTRIC FEE
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID:
ALTERORADDTOMECH.
AIR HANDLING UNIT CTO 10,000 CFM)
Date Reeei tN
P
SUBTOTAL:
AIR HANDLING UNIT(OVFR 10,000 CFM)
CONSTRUCTIONTAX
EXHAUST HOOD(W/DI1C7)
CONSTRUCTION TAX PAID:
BEATING UNIT (TO 1 00,W0 BTU)
Date RCCCI tk
HEATING UNIT (OVER IM,000 BTI 0
TOTAL:'
t,
I t]
VENTILATION FAN (SINGLE RF.SID)p/SR
UANCE DATE
zv
UL U7 ygg,�
�he asL /1u ,-a_
city of 4 mR
ISSUED BY: �U1/ITl\1.JICA.1as-e[L
BOILER -COMP QHP OR 100,0(10 BTU)
BOILER -COMP (OVER 100,000 BTT.
NEW RMDFN HAL MECH. SQFT.
70'fAL:
OFFICE COPY