20660APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification C /�`�t'1 , `\C LL �1 r_ Fl (")
Ouilding Address: C� V K� W ti 1 , 1 TF.•
l4/�-o0 5:�, a- s�,-te �o0
PERMITNO.
20660
amc: one
w ' /444aI_
4&C-6'rV.AY Cfl yy�i{ t//6S
CITY OP CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BUILDING-ELECTMCAI.MUMBING-MFiCHAMCAL
A
���
Cormactorn Name: Lie. Nee
CATEGORY
CONTROL N/'
6O�(�
Architect/Fsgineer. Lk. No:
hM P G-�2/�
p1Y ELECTRIC PERMIT
FEE
BUILDING PERMIT INFO
/01 6'T/tU OAt . Nf Tt SO
Address; f;^,),/ Tp5 G.1 , Yl^//p
PERMITISSUANCE
`jam /I ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that lam licensed under provisions of Chapter 9(mmmenc
Section 7000)of Divlslon3ofthe Busimmandl'mfnslonsCode,and my
license is In full force and effect,
Limnse Clan Lich
Date Contractor
ARCHITECTS DECLARATION201-IMO
Iupd is re fans shotused as ublit
LIrenCCseaF Prdesskl �-'—"�-'—"9
OWNER -BUILDER DECLARATION
I hereby afficon that I. exempt from the Contractor's License law for the
following reason.(Section 7M IS, Businme and Professions Code: Any city or
rounlywhkhrequiresapermittommtrud,altaylmprove,dem lWh,orrepair
anystructure priorto its issuance, also requlrestheappilcant fornuch permit to
file a signed statement that he Is licensed pursuant to the provisions of the
C.etrador. License law(Chapter 9(commencing with Section 7000) of Dlvl-
t e basis fo the alleand exemption. Any)violation f exempt 70313 by
the basis for the alleged exemption. Any violation of Section 70015 by enylIs
appUant(orapermitsubjedstheappgcanttoadvilpealtyofnm..thin
five hundred as
rowner of the pro UI
❑ I, as owner of the property, or my employees with wagon r thele so
compensation,willflothe Business and q,andthes Code: Th not Intended proffered
sale (Sec. 7044, Business and Professions Code: The Contractors Licersc law
don not apply to an owner of property who builds or Improves the reoq and
who doessuchwork hiorthrough hlsownemployees, providal thatch
m Ist
Improvements are not Intended oroffered(orsale. If, however,thebuildingor
Impmvemcnt is sold within oneyearo(complMion, the owner-bu Ilderwill have
it LIturden of pmving that he did net build or 4nprove for purpose ofaale.).''
L j L as owner of the property, am exclusively contracting with licensed
mntractms to construct the project (Sec. 7014, Business and Professions Code:
The Contractors License Law does net apply to an owner of property who
builds or Improves thereon, and who contracts for such projects with a
o t dor(s) licensed pursuant to the Contractors License Law.
LII am exempt under Sec. B & P C for this mason
APPUANCESRESIDEMTAL
JOB DESCRIPTIONingwith
T
PANELS
UP TO 200 ANTS zN�
AMPS A"
OVER I(pO AMPS •(i'
SQ. R[. FLOOR AREA
GS �'
'
S/Sp. FT.
S7GNS ELFCMCAL f
SPECIAL CIRCUIT/MIST
TEMP. METER ORI'OEE7N5�."f
{{ \�
POWP.RDEVICES')4
t
S W UIMINGtPDOL ELECTRIC
-
OUTLETSSWITCFIFSH%TLR
VALUATION
NEWRESIDENTLALELI:CTR Sp
STORIES
TYPECONSIRUMION'
ry
�y' . �'
/
TOTAL:
TY, PLUMBING* MIT
FEE
OCC. CROUP
RIS.
PERMIT ISSUANCE
ALTER -DRAIN &VENT. WATER (EA)
•• ••
F'LODDZDNE
APN
FEE SUMMARY
BAFLOW P„ TGCT. DEVICE
OUTSIDF FF
DRAINS ROO$AREA, COND.
p�.�P
SANITARY Y N_
RECEIPT N
Avner Date
WORKMAN COMPENSATION DECLARATION
❑I hereby affirm that I have a certlBeate of consent to self -Insure, ora
certiflated Workere CompereatlonIreurance orecertifkd copytherco((Sec.
3800, Lab CJ
Policy N
SCFIOOL TAX Y_ N
RECEIPT N
GAS FA. SfF M•1 INCA OUTLETS
PARK ITE Y N
RECEIPT 0
GAS EA. SYSTEM.OVER 4(EA)
Com an Y
BUILDING DI VISION FE CS
Con ified copy h hereby filed
❑CertlBed copyhfiled with the city Inspection division.
the city
CERTIHCATE OF E(EMPTION FROM WORKERS-
COMPENSATION INSURANCE
(Thhaeo need nbe compldne etl ](the permit h(prohundred dollars
s
(Sl00)orlcs.)
Irenlfy thh at In the pedormanceo(ths work farwNch thio permit lehmed,
I shall not employ any person In any manner so as to become subject to the
Wmkers'Compen.atlon Lawn of Californh. Date
Applicant
NOTICE TO APPLICANT: If, after making this Certificate is Exemption, you
should become subjcd to the Workers' Compensation Provision ofthe Lebon
Code, you must forthwith comply with such provhlons or this permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
I herebyafRrmthat there Is a construction lendlegzgency forthe perform-
once of the work for which this permit Is Issued (Sec. 3097, Civ. C.)
Lender'sNa
Lender. Address
I certify that I have read thh application and tlate that the above In(ormatlon
Iscomed. I agree to comply with all city and county ordinances and state laws
relating to building construction, and hereby authorize representatives of this
city to enter upon the above-mentioned property far Inspection purposes.
(We) agree to save, Indemnify an d keep harnden the City of Cu pert Ino
against lla ities,^rfigments, "a and expenses which may In any way accrue
against aald ty in ronsequence of the granting of thh permit.
u Z
GREASEANDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE
-2 O p
PAID C 3�TQ'%Cf78
Date Recei t#
1
3,8.ts
GREASE TRAP
SEWER -SANITARY -STORM EA. 200FT.
WATER HEATER W/VENT/ELECTR
ENERGYFEE Y N —
�Q �s--{{ ps'-) /�
PAID+ b i\ L [S
Date Recei t#
["31'0D
WATER SYSTEM/TREATING
NEWRESIDENTIALPLMB. _SQFf.
TOTAL:
Q
-
BUILDING
SEISMIC FEE
TOTAL:
ELECTRIC FEE
QTY. MECHANICAL PERMIT
FEE
PLUMBING FEE
'
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID:
'
ALTER OR ADD TO MFCH.
AIR HANDLING UNIT 8010,000 CIM)
Date Receipt#
SUBTOTAL:
AIR HANDLING UNIT (OVER 10,OWCFM)
CONSTRUCTION TAX
Signatumof Ap rat/Contre� Date
HAZARDOUS MATERIALS DISCLOSURE
Willtheappllant or future building occupant store or handle havnlous
material a. defined by the Cupertino Municipal Cade, Chapter 9.1Z and the
Health and SafetyCade Sedlon25532(z)?
Fly. Q No
Will the applicant"Wre building part use equipment ordevices
which emit hazardous air contamlanta as defined by the Bay Area Alf
Quality Management District?
4 Yes No
have road the haaennous materials requirements underChapter 6.95 of
the California Health & Safety Code, Sections 25505, 25533 and 25534. i
understand that lithe building does not currently have a tenant, that it is my
responsibility to notify the ompant of the requirements which at be and
Pries uanceof.CertsGatoofOccupancy.
- EXHAU5r HOOD(W/DICT)
CONSTRUCTION TAX PAID:
HEATINGUMT(TO 100,0008TU)
-
Date Recei t#
HEATING UMT(OVER 100,007 BTU)
TOTAL:
p
tJ
VENTILATION FAN (SINGLE RESID)
1.
ISSU C -DATE
u 1 V
/4,�
CR�r,of4Unertino
ISSUEDBY�
BOMEILOOMP OHP OR 100,000 BTU)
BOILER -COMP (OVER 100,(100 BTU)
NEW RESIDENTIAL MECH. SQ.FT.
Owner of autQzed agent Date
TOTAL:
OFFICE COPY