23072APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE SALL POINT PEN ONLY
Building project Identification
BuOding Address:
Nu
PERMIT NO.
^{ 7
(j �J O 1 Z
corset aces: one:
Ib —
CITY OF CUPERTINO-BUILDING DIVISION
/ PERMIT
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c°ntra luar�e:
V C
UIAPPLICATION
BLDING-ELECTRICALPLUMBINGMECHANTCAL
CATEGORY
CONTROL N
Architect/Engineer.Lk. No:
QTY ELECTRIC PERMIT FEg
BUILDING PERMIT INFO
Address:
PERM TISSUANCE ��"
❑ �r O ❑
L�1
LICENSED CONTRACFOR'S DECLARATION
thereby.I arnkensedunder provlsionsof Chapmr9(ournmeno
l'ngwithSeelon700D)of Divisien3oftha Bu•Inemand I miaslon.Ccde,and my
icense is in (uB torte and effect.
Licen Lk. p
APPLIANCES -RESIDENTIAL
JOB DFSC
V
PANELS
Data ContactorUP
ARCHITECT'S DECLARATION
I understand my plane shall he used as; public records
TO 200 MAPS
^ GR
201'1 WO AMT'SPt
OVER 1000 AMPS
SQ. .FLOOR AREA $/SQ. FT.
9GNS ELECTRICAL
Licensed Profession al -
SPECIAL CIRCUIT/MISC 1
OWNER -BUILDER DECLARATION
(wing affirmthallam31.5,Bexerept lroessa dProfctoion.Co e; Law firths
fogowingmaxim. chmqui saperction Qittocoslness andr,impr Profession. Code:Mycttyor
countywhich requires a permit to corstruct,alter, improve, demellsh, or repair
A L E D 14
M P U T E
TEMP. METER OR POLE INST.
anystacture prkrto itslssuance, also requlrestheappllcanl forsuch permit to
file a signed statement that he is; licensed pursuant to the provbiors of the
Contractor's License Low (Chapter 9(commencing with Section 7000)of Divi-
of the Bu sines and Professions Code) or that he is exempt therefromand
the bvis for the alleged exemption. Any violation of Section 7MIS by any
applicant fora permit subjects the applicant to a civil penalty of not more tban
POWER DEVICES
TE
SWIMMING POOL ELECTRICskm3
OUTLE7SSWITCHESFIXT'URES
VALUATION
NEW REST AL ELECTR SQ'Fr'
five, hundred dollars ($500).
�I, as owner of the properly, or my employee with wages as their sole
S70WFS
TYPECONSTRUCHON
compensation, willdo the work and thestructure ls not Intended or offered for
-
sale (Sec. 7064, Business and Prof ca om Code: The Contractors License Law
r'
docs not apply toanowner of property, who Wilds or lmprwn thereo,and
who doasuch work himself or through his own employees, provided that such
OCC. GROUP
RES. UNITS
improvements arc not Intended reoffered for sale. If, however, the building or
improvement issold within one year ofcomplellon, the owner-bullderwlll have
t"nica of proving that M did not Wild or improve for purpose of ale.).
Lj 4 as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7D44, Business and Professions Code:
TOT s.-�
QTy. PLUMBING PERMIT FEE
PERMIT ISSUANCE
[.7.00DZDNF.
APN
The Contractor's License Law don net apply to an owner of property who
Wilds or Improves thereon, and who contracts for such pto)ects with a
licensed pursuant to the Contractor's Lkense Law.
Lj I am exempt under Sec B A P C for this mason
off,
ALTER -DRAM & VENT WATER eEn)
BACK FLOW PROTECT. DEVICE.
FEE SUMMARY
DRAINS. FLOOR, ROOF, AREA, COND.
FD('IURE". PER TRAP
SANITARY Y N_
RECEB'T N
Owner Date
WORKMAN COMPENSATION DECLARATION
❑I hereby affirm that I have a cortiBnte of consent to self-Insum, or a
SCHOOL TAX Y_ N_
certificate of Worken'Compensation Insurance or a certified copy thereof (Sec.
3800, Lab C.)
RECEIPT N
GAS EA. SYSTEM -1 INCA OUTLETS
PARK FEE Y_ IN -
Policy
1N
S EA.
GASYSTEM-OVER
Coan Y
BUILC.ffIIDING INC 0DI VISION FEES
Certified ropy is hereby cifamished.
❑Certified ropy Is filed withhthe
e city inspection division.
CREASE/INDUSTRLWASTEIN=- EPTOR
PLANCHECKFEE
CREASE TRAP
CERTIFICATE OFEXEMPHON FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed If the permit ls forces hundred dollars
($100)or less')
I certify that N the penformanceofthe work forwhich this pemdt is Issued,
Ishall not employ any person I. any manner m as to become subject to the
Workers' Compensation laws of California. Date
PAID
Date Reed t#
SEWER-SANTTARYSIORM EA 200FT
WATER HEATER W/VPNT/ELCCTR
ENERGY FEE Y N
PAID
WATER SYSTEM/TREA7TNG
Applicant
NOTICE TO MPLICANT: I(, after making this Certificate of Exemption, you
should become sub)nct to the Workers' Compensation provisions of the Labor
Code, you moat forthwith comply with such providers or thin permit shall be
deemed revoked.
Date Recei t#
NEW REST DENTIAL PLMB.SQ.FT.
TOTAL:
-BUILDING
CONSTRUCTION LENDING AGENCY
Ihereby affirm that there is construction lending agency for the perform,
ance of the work for which this permit Is dsuad (Sec 3097, Civ. C.)
TOTAL:
SEISMIC FEE
ELECTRIC FEE
�•
Lender. Narre
Landes Aaarea
I certifythat [ luveread thls appllctlonand statethat theabove Infomution
-
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
MECHANICAL FEB
FEES PAID:
incorrect. lagreeto comply with all cityand county°rdinance• and state laws
PERMRISSUANCE
relating to building construction, and hereby authorize representatives olthia
-
eBylo enter upon the abovementioned property for Inspection purposes.
(We) agree to save, indemnify an d keep baroness the City of Cupertino
age Inst Bab011ies,judgments,costsand expenses which may In any way aceme,
against said Cl conr�aI�(are��l/I�I� fthe grantin�gJ of this permit.
'CiLa..-�/2-6-9�
ALTERORADDTOMECH.
AIR HANDLING UNIT (TO 10,000 CFM)
Date, ReCel t#
P
SUBTOTAL:
AIR HANDLING UNIT (OVER IO,OWCFM)
CONSTRUCTION TAX
E)HAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
Signature ppgont odn�o'r"�"�'� Data
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (TO 10%000 BTU)
Will the applicant orfutum building occupant store or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.17, and the
Health and Safety Code/. �Stolon 75537(a)?
[7Yrs L_I No
Date RCCCI t#
HEATING UNIT (OVER 10%000 BTT!)
VENTILATION FAN (SINGLE RESID)
ISSUANCE DATE
f
PAID
r
Willthe applicant orfutumbullding occupantuse equipment ordevices
which emit haardous air cortamiruntsan defined by the Bay Area Air
Quality Management District?
4Y" No
have read the ban ous materials requirements underChspier 6.95 of
BOILER -COMP OHP OR 100,000 BTUI
BOILER -COMP (OVER IOO,WO BTU)
the California Health&Safety Code, Sections 25505,25533and 75534. 1
understand that if the building does not currently have a tenant, that it is my
responsibility to not By the occupant of the requirements which must be met
_
®EC 6 a1�1 99
NEW RESIDENTIAL MECH. SQ.Foccupant.
prior to issuance of a Certificate of Occupa ncy.
Y ur Durr ..
ISSUED BY:
Owner or authodud agent Data
TOTAL:
OFFICE COPY