21396APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project identification -
Building Address: 5•x,6 $- LI `t--1 -
PERMIT NO.
� 21396
nep�xa-a—S Press:
.LYwNails
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION I PERMIT
BUILDING-ELECTMCAL-PLUMBING-MECH LAICAL
IIS/ bO
[
Cont a o'e Name: Lie. No:
7US ��• C1 TT1�(.b S
CATEGORY
-
COMROIIIL��,
Architect/Engines. Lie. Nex
QT'Y. ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Address:
PORMITISSUANCE IZ.
® ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I herebyafflrmthat l amlicensedunderprovlalonsof Chapter9(rommenc-
of/heBminessand larofesslonsCodeLand my
ingweh5edonfices and
Incense b I. eefol 0B and offset p
License CWv_ Lle.11t ii?Z
l Contractor
ARCHITECT'S DECLARATION
I undereta ad my plane shall be used as public records.
Llacnsed Professional
OWNER -BUILDER DECLARATION
I hereby afi rrnthal I am exempt from the Contractor's Liconse Law for the
following remon.(Section 70315, Business and Professions Code: Any city or
countywhichrequires.apermitwo mtmct,alter,improve,demolish,orrepair
any structure prlorto its baciance,alsurequlresthe applicant for such permit o
file a signed statement that he b Bmnaetl pursuant to the provisions of the
Contractor's License Law (Chapter 9(commencing with Stolon 7000) of Dlvi-
slon3 of the Businessand Professions Code)orthat he b exempt therefrom and
the basis for the alleged exemption. Any violation of Section 7MIS by any
applicant for a permit subjects the applicant to civil penalty of not more than
five hundred dollars (S500).
1, as owner of the property, or my employees with wages as their sale
C] 1,
compensation, will dothe work andthe•tructure is not intended or offered for
sale (Sec 7W4, Business and Professions Code: The Contractor• License Law
does not apply to an owner a property who Wilda or improves thereon, and
whodoessuchworkhim ssif orthruugh hisownemployees, provided that such
Improvementsarenotlntendedoroffeyed for sale. Ithowevepthebulldingor
improvementls oldwithinoneyearofcompleilon,theowner-buBderwlllhave
Irdenofpswingthathedid notbuudorimproveforpurpossofsale.).
L as owner of the property, am exclusively contracting with licensedt.on to construct the project (Sec 7011, Buainessend Professors Code:
The Contractors License Law don our apply to an owner of property who
build• or Improves thereon, and who contracts for such pWj is with a
ryR��actor(s)licensed pursuant to the Contractor's Llcvnse Law.
L•J I am exempt order Sec B k P C for this rectors
APPLIANCES -RESIDENTIAL
JOB DESCRIPTION
� � ^ —•
��-
PANELS
201-1000 AMPS
OVFRIONIAMPS
SQ. Fr. FLOOR AREA
$/SQ. FT.
1
` SIGNSELECTRICAL IISO
SPECIAL Cl2CUIT/MLSC
TEMP METER OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
^
L_� OU7LETSSWHCHESFIXTURES t�t�V
VALUATION
�(�� �1Q'r„ys 00
NEW RESIDENTIAL ELEC]R
STORIES
TYPE CONS'172UCTION'
TOTA :
QTY, PLUMBING PERMIT FEE
OCC. GROUT' -
RIS. UNI'1
PERMIT ISSUANCE
FLOOD ZONE
APN
AIX
PROTFGT.DEVICE t J
FEE SUMMARY
S1 DE FEES
rI
RAI &FLOOR ROOF, AREA, ND.
-
, PER 71tAI'
—_
SANITARY Y N
RECENT p
'. Owner Date
WORKMANCOMPENSATIONDECIARATION
❑I hereby affbm that I have a certificate of conxnt to self-Inmre, ora
certificate of Workets Compensation Insurance ora cedted copy therein me.
3800, Lab C.)
Pol
SCIi/XIL TAX Y_ N_
RECEIPT
pA
PARK FEE Y N
CAS EA. 5YSTEM-OVRR4 MAI
Com any -
BUILDINGDIVISION FEES
Certified copy is heed with the city
❑ Certifid copy is flied with the city Inspection divisors.
CERTIFICATE OF E(LMPTION FROM WORKERS'
COMPENSATION INSURANCE
u
(fhlection need net be completed If the permlt b for one hundred dollars
(8100)orlea.I -
certifythat in the performance ofthework forwhich this pemdt b loud,
shall not employ any person in any manner •o as to become subject to theWATER
Compensation Laws ofCalifornia. Date Applicant
TO APPLICANT: If, after making this Certi(lateofExemption,youshould become subject to the Workers' Compensation provisions of the Labor
you must forthwith comply with such provsions or this pemdt shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
hereby afRrm that there is a corawction leadingagency for the perform-
ance of the work for which that permit Is baud (See. 3097, Civ. C.)
LenderaAddresa
1 cedifythatl have read thisappliationard state that 1M1eabove Information
Jammed. I agree to comply with all cttyand county ordinances and mate laws
relating to building construction, and hereby authorize representatives ofthis
city to enter upon the above-mentioned property for inspection purport.
(We) agree to save, indemnify an d keep harmless the City of Cupertino
es,' gments, costs and expenses which may In anywayacame
againsti t consequence of the granting of this permit.
GREASE/INDUSTRL WASTE INTERCEPTER
PLANCHECK FEE
PAID
Date Recei
03
t
GREASE TRAP
SEWER-SANITARYEA 200FF
WATER HEATER W/VFNf/F1.GCIR
—I
ecel t*NOTICE
SYSITM/TREATINGWorkers'
WRESIDENTIALPLMB, SQ.FT.
*FEEY'NI
OTAL:Code,
s,31
s (JI
rornl:
QTY. MECHANICAL PERMIT FEE
^
PERMIT ISSUANCE 14Cz
MECHANICAL FEE
��
FEES PAID:
ALTERORADDIEMECH. ,t17
Date4TAX
AIR HANDLING UNIT QO IBpW CFM)
AIRHANDLING UNIT (OVER 10,000CrM)
CONSTRUCTI
/Cos. r
HAZA OUS MATERIALS DISCLOSURE.plicant or tore buildingompant sore or handle hazardous
Cupertino Municipal Code, Chapter 9.12, and thef eS Non 25532(ap
*�cNo
Will the a ppliant or future building occupant use equipment or d evices
which emit hamrdous air contaminants as defined by the Bay Area Air
Quality Management District?
4Yes ❑❑ No
have read thehazardausmatedals requiremcrou nder Chapter 6.95 of
the California Health&Safety Code, Sections 25505, 25533and2S534.1
understand that lithe building does not currently have a tenant, that it is my
responsibility to notify the occupant of the requirements which must be met
prior to issuance ofa Certificate of Occupancy.
EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX ID:
HEATING UMT('IO 10(1,000 BTV)Date
Recei ticinedb
HEATING UNIT(OVER 103," BTU
TOTAL•'
lM
VENTILATION FAN (SINGLE RESID)
ISSUANCE DATE
N
ly
Nov t
ISSUED BV:
BOILER -COMP OEm OR 100,000 BTU)
BOILER-COMP(OVER 100,000 BTU)
M
NEW RFSIDE7ALMECH. S'Q.FT.
Owner or authorized agent Date 7
TOTAL: CLW
OFFICE COPY
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