20628APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification
H. Rd Ing Add rear.
PEI TNO.
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20628
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Eon ' dor. Na. Lie. No:
3 3
Architect/Engineer. Lie. No:
CITYOFCUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BU(LDINGELECTRICALPLUMBING-MGCHAMCAL
A A
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CATEGORY
CONTROL N
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Addrcsc -
j� ❑ ❑ ❑
I�
PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION
(hereby affam that l am licensed under provisions of Chapter 9(commena-
ingwith Section 7000)ofDivlsion 3 oflhe Buslnessand PrefesslonsCode, and my
LiarsIshis force and e,itt
License Ess LIpN
APPEANCESRF.SIDENTIAL,ler—semf
]OB DGSCRBTION
ppp _
,ne—�
.�,J l`
-
PANELS
Date Contractor
`��r
201-IODO AMPS
ARCHITECTS DECLARATION,
I understand my plarushallbe used as public records.
OVER 1000 AMPS
D .� ART
$/SQ. Ff.
Licensed Professional
SIGNS ELECTRICAL
O
mWNER-BUILDER DECLARATION
Ihereby afOrthatlam exemptfrom the Contracture License Law the
C
11�
SPECIALCIRCU1T/MLSC F l
following reason. (Section 7031.5, Business and Professions Code: Any city or
muntywhlch requimsa perMttommtrun, alter, improve, demolish, or repair
TFMPMETERORPOLEINST.
N
a"NIINJ{1��,
anystaumrc Frantic, Its Issuance, also requlrntheappllont forsuch permit to
file a signed statement that he Is licensed pursuant to the provlaioro of the
Contractors License Law (Chapter 9 (commencing with Section 7000) of Divi-
sion3 of the Business and Profemloes Coci0orthat he b exempt therefromand
the basis for the alleged .xcmptmn. Any violation of Section 7031.5 by any
applicant fora permit subjects the applicant to a civil penalty o.nat more than
flue hundred dollars (SSW).
�I, as owner of the property, or my employe" with wages as t heir sole
POWER DEVICESTE
SWIMMING POOL ELECTRIC
OUTLETSSWITCHESSFIXTURES
VALUATION
OG
�� az) lee;
NEW RE ELECTR �'�'
STORIES
TYPE CONSTRUCTION
compensation, will do the work, and the smac ure b not Intended or offered for
.In (See 70K Business and Prof.].. Cade: The Contractors License Law
'
does not apply to an owner of property who builds or Improves thermry and
does such work himself orthrough his own employees, provided that such
OCC. GROl1P
RFS UNITS
improvements are not Intended oroffered forsale. If, however,the building or
improvement bsold within oneyrarofcompletim,tha owner.b.Oderwill have
TOTAL:
t4LkArden of proving that he did not Wild or Improve for purpose of.alej,
Lj L as owner of the property, am exclu hely contracting with licensed
nst
contractors to construct the project(Sm 7074, Business Prof"slons Code:
PLUMBING PERMIT FEE
QTY,
PERMIT ISSUANCE
FLOODZONE
APN
The Conmim or's License Law does not apply to an owner of property who
builds or Improvee thermp
s, and who contracts for such tojecta with a
cgWfano N) licensed pursuant to the Contractor. Lima. Law.
LJ 1 am exempt under Sec. B & P C for this reason
ALTER DRAIN &VENT WATER (EA)
FEE
BACK FLOW PROTECT. DEVICE
USUMMARY
DE FEES
DRAINS FLOOR RODF, AREA, COND.
FIXTURES PER TRAP
SANITARY Y N
RECEIPT N
Owner Date
WORKMAN COMPENSATION DECLARATION
711 hereby affirm that I have a certificate of consent to .elf -Insure, or a
certifiote of Workers Compcv tion buuranm ora cedlfled mpythemof (See.
3800, lab C.)
SCHOOL TAX Y_ N
RECEIPT N
GAS EA. SYSTEM -1 INCA OUTLETS
PARK FEE Y_ N_
Poll p
RECEIPT#
GAS EA. SYSTPM-OVER
Com any
HUI LDING DIVISION FE ES
Certified copy Is hebhed.
Certified copy b tileded with with the city Inspection division.
GREASE/INDUSTRL WASTE INTIMCETOR
PLANCHECK FEE
GREASETRAP -
CERTIFICATE. OF FXEM PTION FROM WORK ERY
COMPENSATION INSURANCE
(Than seelon need not he completed If the permit b (Drone M1undred dollars
(f100omlyt.)
for to hich bbo theed,
(cent thatanthe personanynce of manneeworkr
I shall not employ any %Laron in any manner m"lo become mb)Ln to the
subjrmitect
Worken Compensation Law. o(GII(omla. Date
PAID
Date Recei tN
SEWER-SANTEARY-STORM EA. 200FT.
WATER HEATER W/VENT/ELECTR
ENERCYFEE Y N —
PAID
WATER SYSTEM/TREATING
Applicant
NOTICE co APPLICANT: a after making than Certificate of ons oft
a Labor should
oumus subject to the ply wit'suchim ,lalnproalImpsomits Lab or
Code you must forthwith comply with such provblora or than permit shall be
deemed revoked.
Date Retei tN
NEW RESIDENTIAL PLMB._SQ.FT.-
TOTAL:
UUILDING FEE
Cie
TOTAL:
SEISMIC FEE
ELECTRIC FEE
CONSTRUCTION LENDING AGENCY
I herebyaffirenthat them ba mnatmctlon lendingagency forthe perform-
ance of the work for which this permit is bound (Sec. 3097, Clv. CJ
I.^dere N.
I.miers Address
I certify that have read this appllratlo.. ad state that the above Information
Is correct. I agree to comply with all city and county ordinances and elate laws
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID:
'
relating to building construction, and hereby authodu repenentativn o(thb
city to enter upon the abovcmenlloned property for Inspection purposes, .
(We) agree to save, indemsdfy and keep harmleas the City of Cupertino
ALTERORADDTOMECH.
Date ReCCI [fF
P
SUBTOTAL:
agoWtllablllll",judgment, castaand expenses which may In any wayaccrue
against said City In consequence of the granting of this permit.
e
AIR HANDLING UNIT(TO I0,D00CFM)
AIR HA NDLING UNIT (OVER 10,000 CEM)
CONSTRUCTION TAX
Signature of Applicant/Contractor Date
EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
. HAZARDOUS MATERIALS DISCLOSURE
HEATING UMT(TO 100,00) BTU)
Will the appliant or future building occupant store or handle haurdous
material as defined by the Cupertino Municipal Code, Chapter 9.IZ and the
TbrAth and Safety Cade —S�ection 25532(a)7
❑ Yes rL,1 No
Mrs
Date RCeCI [N
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
p
. y
VENTILATION FAN (SINGLE RESIDE
ISSUANCE DATE
/� RD
JU
JUN 2 `r 19�u
Will the a pelletal building occupant use equipment or devices
which emit haaardous air contaminants as defined by the Bay Area Air
Quality Mawgt,.nt District?
. (-1 Y" I—I No
shave read the haze Due materlab requirements under Chapter G95 of
the Glife.i. health & SafetyCode, Sections 25505, 5533 and 25534. 1
BOILER -COMP DEEP OR IOQ000 BTU)
BOILER-COMP(OVER 100,000 BTU)
NEW RESIDENTIAL MECH. SQFE.
understand that ifthe building does net currently have a tenant, that It is my
responsibility to notify the occupant of the requirements which must be met
priorto lssuanre of a Certificate o[Occupanry.
as( N�����a{�
City of j)�. nefflip•
�Iy`r�lH
ISSUEDBY: �4 (
Owner or authorlud agent Date
TOTAL:
OFFICE COPY