21851T.:'
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification
Building Address: -eqq���21
PERMIT NO.
851
ner one:
ate. - .i✓�
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION I PERMIT
BUILDIt GC MECTRICALnUMBING-MECIIAMCAL
p
Coatractr'.N.meic.No:
�/ �
CATEGORY
CONTROL N
X.h ten/Engin r. Llc. No:
QTY ELECTRICPERMIT FEE
BUILDING PERMIT INFO
Address:
PER)ATISSUANCE �W
u
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter 9 (connumene.
'ng with Section 7000)rf Division 3 ofthe Buslnentand ProfeasionsCode, and my
license IS In tuLLfo and e(Iect. ,z
Ll.nse Clare k.Is
Date Contractor
ARCHITECT'S DECLARATION
I understand my plans sMBbe used as public reconls
Licensed Professional
OWNER -BUILDER DECLARATION
Iherebyof rmthatIamexempt lromthe Contract.!.LicenseLawforthe
following reason. (Section 71.1.5, Business and Professions Code: Any city ar
omatywh,ch requires a permit to construct, alter, Improve, demoll h,orrepalr
anystm=mpnortal.issuance,aI requimtheappbmnlfwauchpert tto
file a signed statement that he is licensed pursuant to the provisions of the
Contractors License Law (Chapter 9(mmmunclog with Section 7000) of Divi-
sion 3 ofthe Buslressand Protessiom Code) or(hat he Is exempt therclromand
the basis for the alleged exemption. Any violation of Section 7031.5 by any
applicant for a proat subjects the applicant to a civil penalty of not nnre than
five hundred dollars (.$500).
F11,, as owner of the property, or my employees with wages as their sale
compensation, will d o the work, and the structure is not intended or offered for
.Is (Ser- 7044, Buabus and Profession Code: The Contranore License Taw
docs not apply to an owner d property who build. or improve thereon, and
who does suchwork himself orthra tSh hisawnemplryees, provided thatwch
Improvements are not intended oroffered for sale. If, however, thebullding or
improvement b sold within one yearofcompleion, tM owner-bunderwill have
Ut,kumenofpmvingthathedk1 not build or improve for purpose of sale.).
LI L as owner of the property, am exclusively contracting with licensed
..trace. to construct the project (See 7044, Business eand Profeslow Code:
The Contractor's Li.ns Law does not apply to an owner of property who
bu
Wilds or Improves thereon, and who contracts for such Inpjects with a
cgalpdm(a) limned pursuant to the Contractor'. Llceme Law.
LJI am exempt under Sec. B & P C for this reason
APPLIANCRSRFADENTIAL
JOB DESCRIPTION
(' u
PANELS
— UP TO 2DOANTS
201 -IOW AMPS
OVER1000AMPS-
SQ.FT.FLOORAREA
$/SQ. FE
ll
y SIGNS ELECTRICAL W
$PECIALCIRCUIT/MISE
TEMP. METER OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETSSWITCHFSFIXTIIRES
VALUATION
QQ_10i/
NEW RESIDENTIAL F.LECIR SQFT
_SQ.Fr.
STORIES
TYPE CONSTRUCTION
TOTAL. ID
QTY. ', PLUMBING PERMIT -FEE
OCC.GROUP
RES UMTS
pptMITI55UANCE
pLTFR-DRAIN & VENT - WATER (EA)
17ppu ZONE
pPN
BACKFLOW PROTECT. DEVICE
FEE SUMMARY
OUTS I
DRAI NS FLOOR A, ROOF, ARECOND.
FD(TURES E'ER IRM
SANITARY Y N�
RECEBT N
Owner Date
WORKMAN COMPENSATION DECLARATION
[]I hereby affirm that I have • certificate of convent to 0:1mosure, ora
-.nlnmeofworkers'Comper donlnsuran.oraudife mpythemf6ec.
3800, Lab C.) �j ����11) yN�r 8
Policy# j / �40'�
SCHOOLTAX Y N
RECEIPT
GAS EA, SYSTEM -1 INCAOUTLEfS
PARKFEE Y N
RECEIPT If
GAS EA.SYSTCM-0VER4(Fia)
Co������mppppppaaaa�ray T
_
BUILDING DIVISION FEES
Certified copy la hercbyth the cityed.
/1��ECertifled ropy k hike with IM city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSUfa ram hundred delta.
ctlon need n. becompleted BIM pemut
(ITlssedt V far..
Ol00)orlcsJ
Lnot thatlotany perhe son
lmwtobeca eesub)emit e0o the
I shall not employ any perws f any manner so u to become subject to the
Applicant Workers' Compensation Laws of California. Date
Applicant
NOTICE 7u APPLICANT: a after nuking perhis at[on pro is Exemption, you
Could you =a subject to the Works=' Compematlon provisions of the Labor
dawned emke forthwith comply with such provisions or this penNtshall o
deemed revoked.
CONSTRUCTION LENDING AGENCY
I hembyafnrmthat there Is a construction lending agency forthe perform-
once of the work for which this permit Is Issued (ser. 3097, Clv. C.)
[oder'. Name
Lender's Address �
I.rtBythatl cave reads reapplication and state that theatxwe Information
is correct. I agree to comply wlthall dtyand county mdlnanresand Mate laws
relating to building wrutrudion, and hereby authorlee representatives of thio
city to enter upon the above-mentlomdi property for inspection purposes.
(We) agree to save, Indemnify an at keep harmles the City of Cupertino
against liabilities,judgmenta, main and expenses which may In any wayaccrue
ag.imt Bald City In consequenes of the granting of this penult.
GRFASE/INDUSTRL WASTE INTERCEPTOR
PLANGHEGIC FEE
PAID
Date Remi 1#
GRFASETRAP
SEWER -SANITARY -STORM FA. 2X1111'.
WATER HEATER W/VENT/PLEC.I.R
ENERGYFEE Y N
PAID
Date Reml t#
WATER SYSTEM/TREATING
NEW RESIDENTIAL PLMB._SQFf.
TOTAL:
BU IN
SEISMIC FEE
TOTAL:
_
ELECTRIC FEE
-
QTY. MECHANICAL PERMIT,' FEE
PLUMBING FEE
MECHANICAL FEE
PERMITMSUANCE
FEES PAID
Dale Receipt#
ALTERORADDTOMECH.
AIR HANDLING UNIT (TO 10,000 CFM)
-..SUBTOTAL:
AIR HANDLING UNIT (OVER 10000CFM)
CONSTRUCTIONTAX
Signature of Applleint/Contractor Dae
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous
material as defined by the Cupertino MuoldpaI Code, Chapter 93 Z and the
Health and Safety Code Section 25537(a)7
❑ Yea No
Will the zpplican ,foto. building occupant use equipment or d evices
which emit haeardous air.ntamimn. as defined by the Bay Area Air
Quality Management District7
Yes �1�y No
have read the haYardous materials requirements underChapter6.95 of
the California Health & Safety Code, Sections 25505, 75533 and 75534. I
unde.tandthatill bulldingdoesnot arrcntly have a tenant, that It k my
prix toibllea to Ify .occupant of he.qunementa which musiMmet
mp to are Ilaaa parry.
EKHAUSTHOOD(W/DUCT)
CONSTRUCTION TAX PAID:
Date Recel 1#
HEATING UNIT (TO 100,000 BTT.
-
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
VENTILATION PAN (SINGLE RESID)
ISSL�j�DATE
FAn
n } 'j
a• Trp V
p-
JU
ISSUIiU BY: V IVa
BOIL IM -COMP OHP OR 100,000 BTU)
BOILER-OCMP(OVER 100,000 BTU)
NEW RESIDENTIAL MECH. SQ'FT
ner or au oriAd.gents Data I
TOTAL:
OFFICE COPY