21260APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - l"L POINT PEN ONLY
Building Project identificationPERhIIT
Building Address:
I9 qOO S Vers c�et �w� ,
NO.
21260
wners arae: ane:
A)S,,57 (% �I-G� £ �/ QQriJ� . ,
CITY OF CUPERTINO-BUILDING DIVISION
. APPLICATION / PERMIT
BUILDING-ELECTRICALPLUMBING MECHANICAL
_ UN ITTALDATE
/�sn'J
l �vw2'�
Coyntr—actor's Name/:� 4 P 7r Lia. Na:
T % i�-8_ - 1 — 6r.
CATEGORY
C
Arcnlle J/ ♦ - LIc. No:
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'O,iY - • 'ELECTRICPEBMiTt `:' •FEE.
BUILDING PERMIT�INFO .
_
Address: -
PERhIITISSUANCE
- El- ❑ ❑ xt7
�j
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter9(mmmenc-
Section 7000).Hh ision3 ofthe Busimsaand Professions Code, and my
Notese is In ful�forc},e�nd effect. ,—y p f/
Line Cis j�Llt p 7 E!�
5 -
APPRANCESRESIDENTIAT,
JOB DESCRIPTIONmi,with
-
��/ / • S yST
PANELS
Date �ii ContractorUP
TO 200AWS
201-1000 AMPS
r I " ARCHITECIPATION
I understand my plane shall be used as public records
OVER1000AMPS
SQ. FT, FLOOR AREA
$/SQ. FT,
SIGNS ELECTRICAL
Licensed Professional
/
OWNER -BOLDER DECLARATION
I herebya(flrm te
I am exempt from the Contractor's License Law for the
SPECIALCIRCUIT/MLSC \
j
TE14P.MEITRORPQ El ST.
%
��p
PO DEVICES t
following reason. (Section 7031.5, Business and Professions Code: Any city or
county which requires a permit to construct, alter, Improve, demolish, or repair
anystructure priarto its Issuance,' a isorequirestheappllcant forsuch proration
file a signed statement that he is licensed pursuant to the provisions of the
Contractor's License Law (Chapter 9(rommeneing with Section 7000) of Divi-
sion3of the Businessescad ProfessionaCceds) or that he is exempt thcrefmmand
the basis for the alleged exemption. Any violation of Section 7¢31.5 by any
Bwnt fora permit subjects thea applicant to a civil nal ofnot more than
fvP P le PP penalty
C/
S NG POOLx -ti" ECTRIC • x
O IVIT'CHFSFI ES
VALUATION
�/) '
�/ a
a -
NRW R DENTIr E TRSQ.PI'.
five Fll, ..hundred
wnar.dollars hepro
❑ I, a owner o(tM property, or my employees with wages as their sole
'
STORIES
TYPE CONSTRUCTION
compensation, will do the work and the structure is not Intended or offered for
- U
sale (Sec. 7044, Business and Professions Code: The Contractor's Licerrse Law
-
p t'
TOTAL:
does not apply to an owner of property who builds or improves thereon,and
who does such work himself orthrough his own employees, prwidedthat wch
Improvements are not intended oroffered forsale. If, however, thebuilding or
impowereentissold withinoneyearofcompledon,theowneo-buBderwill have
OCC. GROUP
RFS. UNITS
,
fh,�arden of proving that he did not build or improve for purpose of ask.).
I I L as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business and Professions Code:
QTY; PLUMBING'PERMIT " , FEE. Y
FLOOD NE
APN
PERMIT ISSUANCE
The Contractors License Law does net apply to an owner of property who
builds or Improves thereon, and who contracts for such penjeras with a
cgp((actor(s) licensed pursuant to the Comment's License Law.
LJ I am exempt under Sec. B 8, P C for this reason
ALTER -DRAIN AVENT- WATER (EA)
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
OUTS[ DE FEES.
DRAINS FLOOR, ROOF, AREA, COND.
FIXTidRES PER TRAP
SANITARY Y_ N_
RECENT it
Owner Date
WORKMAN COMPENSATION DECLARATION
❑I hereby affirm that I have a mrtificate of consent to eal6lnsure ora
certifirateofWorkera'Compem.Honlnsumnmorac affied copythercof(Set
3800, Lab C.) '
SCHOOL TAK Y_ N
RECEErT N
GAS FA. SYSTEM -1 INC.40[TR.ETS
PARK FEE Y N
N
RFGEBxf p
GAS EA. SYSTEM -OVER 4 (EA)
Coiry
Cany :
BUILDING DIVISION FEES
�Certlfied copy is hereby (urnbhed,
Certified copy Is filed with the city inspection divWon.-
OF EKEMPTION FROM WORKERS'
.,
(This section need net be completed if the permit Is for one hundred dollars
GRFASEANDUSTRL WASTE INTERCEPTOR
PLAN CK FEE Mn
"r"CERTIFICATE
PAID -*COMPGNSATIONINSURANCE
Date
GREA'SETRAP
SEWER -SANITARY -STORM EA. 20FT.
($l0)or ftifytJ
Icertifythao in the per(orrounce afthework forwhlch this peirnit is issued,
I shall not employ any person to any runner se as to become subject to the
Workers' Compensation Lawes of California. Date
WATER HEATER W/VENT/ELECTR
ENERGY FEE Y
PAID
WATER SYSTEM/TREATING
ApplicaNOTICE ,you
NOTICE co APPLICANT: a after making thinsationCem provisions
should become subject to the Workers' such p Compensation n s orthioru of the Labor
ro is Ens of
dcamedyou =at forthwith comply with such provisions orchis permit shall be
deemed revoked.
Da Recei t#
TOTAL:
NEW RESIDENTIAL PLMB, SQ.FT:
B GFE-
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I herebyaffirm that there is a construction lending agency for the perform-
ante of the work for which this permit is issued (Sec. 3097, Civ, CJ
- .TOTAL:
ELECTRIC FEE.
Lender's Nance -
Lender's Address
I certifyflaml havereadthb applicationand etatethattheabove information
iscorrect. I agree to comply with all cityand county ordinances and nate laws
QTY: MECHANICAL_. PERMIT' " : E'
PLUMBING F
CH N
PERMIT ISSUANCE 2,
relating to building construction, and hereby authotlze representatives of this
city to enter upon the abovermationed property for Inspection purposes.
(We) agree to save, indemnify an d keep harmless the City of Cupertino
against liabilities, costs and expenses which may In anywayamue
against said City in consequence of the granting of this permit.
:FEFS,
a[e eipt#
S ALTER OR ADD TO MECH.
AIR HANDLING UNIT (TO 10,000 CFM)
SUB OTAL'
ux HANDUNc 41ngT (OVER ]o,BBocrM)
NSTRUCTIONT X
Signature of Applicant/Contractor Data
EXHAUST HOOD M/DUCT)
CONSTRUCTION TA PAID:
HAZARDOUS MATERIALS DISCLOSURE
Wllltheappllcant or future building occupant store or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.12, and the
Date RCee t# a�
HEATING UNIT (TO 10,00BTU)
- HEATING UNIT (OVER 10({00 BTU)'
TOTA.:
Health and SafetyCode ion 25532(a)Y '•
❑Yes .. 0 .-
VENTILATION FAN (SINGLE RESID)
ISSUANCE DATE
-
,
Will theapplicanto future building occupant use equipment or devices
which emit hazardous air contaminants as defined by the Bay Area Air
Qua lily Management Dist' a
Yes
haveria the haze et materials requirements undernd 2554.1 of
the Health & Safety Code, Sections 2550.5, 25533 and 2534. I
tt. BOILER-COMP(3F0'OR 100,00 BTI))gm
BOR.FR-COMP(OVER 10,00 BTU)'
NEW RESIDENTIAL MECH. 'SQ.FT.
understand
understand that i(tn uildingdoesnf curreritiy have atenanq that it is my
responsibility to not the occupant of the requirernentswhicherestbemat
q q[�Q
4C-� 12 Is990
poi t�If ate of Occupancy.
ISSUGU BIof M' lrvoirA
Ow er or autho fired agent - Data
NOTAL:
OFFICE COPY