20875APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project identification
Building Address; q/ b a Gt B
� S
PERMIT NO.
20875
Ia& L i Lir a13 -02S3
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
�y A rO
--q
Contractor's Name: I Lic. Ne:
79 3. -7
BUILDING -ELECTRICAL PLUMBING -MECHANICAL
CATEGORY
CONTROL If
A Itect/Engineer. LIB No:
QTY ELECTRICPERMIT FEE
BUILDING PERMIT INFO
,�4
Addrns:/3 h//Cf% cC U. f+5ci�
0 0
PFRMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am Reeneed under provisions of Chapter 9(commen
ingwlth Section 7000) of Divialon3 ofthe Business and ProtessionsCode, and my
license Is In full form and effect
APPLIANCESRESIDEINTIAL
JOB DFSCRB'DON
nal . ♦
PANELS
LlcamuCbn Lle.N
�[� !—
Date Comrador
UP TO 2DO ANTS
—
701-1000 AMPS
ARCHITECT'S DECLARATION
I understand my plans shall be used AS public records.
OVER 1000 AMPS
SQ. FT. FLOOR AREA
S/SQ. FT.
SIGNSELECTRICA
Licensed Professional
SPECIAL CIRCUIT
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
following reason. (Section 7031S, Bwlneu and Profession Code: Any city or
countywhich requires a permit tomntruct, alter, Improve, demolish, oreepair
TEMP METER OR PO Sf.
anyetmcture prior to its issuance, also requires the applicant for such permit to
(Ile a signed statement that he b licensed pursuant to the provisions of the
Contractor's License law (Chapter 9 (commencing withSection 7000) of Divi.
slon3otthe Buslneae sod Profemlona Code)orthat he b.xempt therefromand
p06VEbt D•
SWN{MIN RI
VALUATION
the basis for the alleged exemption. Any violation of Section 70313 by any
applicant for a permit subpds the applicant to a civil penalty of net rrorc than
OUTLETSSWITC ES
NEW RESIDENTI TR SQ.FT
five hundred delta. ($500).
❑l, as owner of the property, or my employees with wages as their sole
STORIES
TYPE CONSTRUCTION
compensation, will do the work and the strvcWre is not Intended or offered for
Sale (Sec. 7064, Business and Profession Code: The Cengract.e. Limns Law
does not apply to an owner of property who builds or improves t hereon,and
who doessuchwork himself orthraugh hismonemployees, provided that such
OCC.GROUP
RES. UNITS
improvements are not intended or offered for sale. If, however, the building or
improvement lssold within one yearofcomplation, the owner -builder will love
p
th,jurelen of proving that he did not build or Improve for purpose of uleJ.
Lf L as owner of the property, am exclusively contracting with licensed
contractors to convect the project (Sec. 7044, Business and Profealon Code:
QTy, P&MBING PERMIT FEE
PERMIT ISSU
t
FLOOD ZONE
APN
The Contractor's License law does oat apply to an owner of property who
builds or improve thereon, and who contracts for such pmods with a
ryD2(�ctor A) Bcoeed pursuant to the Contractor. License Law.
LJ I am ...dept under Sec. B k P C for this recon
ALTER-DRAINk VIV -WATER (FAA) '7x(pJ
BACK FLOW PROTEC. EVICC
FEE SUMMARY
DRAINS FLOOK ROOF, COND.
Ff%NRES PER TRAPficate ��
SANITARY Y N_
RECEIPT M
Owner Date
WORKMAN COMPENSATION DECLARATION
Of hereby affirm that I have a cerBof consent to self -Insure, or
cedlflateofWorkers'ComperuatlonlnuranmoraceAffiedmpythereof(Sec.
3800, Lab C.)
SCI{BOL TA% Y N
RECEIPT M
GAS PA. SYSTEM-1INCA OUTLETS
PARK FEE Y N
Com M
REC
GAS EA.SYSTEM-OVER4(EA)
Com any
DING DTX
BUILDING DIVISION FEES
MCertlBedmpy Wfikd thus id.
❑Cedlfled copy ls filed with tM cityInpectbn divlelon.
CItPASEANDUSIRL WASTE INTERCEPTOR
PLANCHECICFEE
CREASE TRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(I) need net Fx complded If the permit lsfwrgne hundr d dollars
PAID
Date Re J ted
SEWER -SANITARY -STORM EA. 7(IOFr.
w ledian
($I IA)orfy that
Imnotrtify thato the personerformance
I shall not employ any.Lawn In any manner m a to become subject to the
tnornerhe work for tobehich hers,is suitblso the
W ns
Compeation laws o(CalRornh. Date
WATER HEATER W/VENT/ELECTR
ENERGY FEE Y N
PAID
WATER SYSTEM/TREATING
Applicant
NOTICETOAPPLICANT: a orkfter makingthis peonation Certificate Of mottle Lyou
mistedto the Workers' such prvisinsrovlsionofthe liber
Code,Shoulyou
Codgyoumlood. forthwith comply with each provision orthls permit shall be
deemed revoked.
Date Remi ted
NEW RESIDENTIAL PLMB. SQ.Fr.
TOTAL:
BUILDING '
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hembyaffirm that there is a construction lending agency for the perform-
ante of the work for which this permit ls laved (Sec. 3097, Cie. C.)
TOTAL
ELECTRIC FEE
I<nder's Name
Leader'.Addrea
I mrtitytbrt I have readywith allcity n d countyrdabove information
ismingt building complywo,all ordinancesgate laws
QTY. MECHANICAL PERMIT FEE
PLUMBINCFEE
apQ
MECHANICAL FEE
REKNIT ISSUANCE
FEES PAID:
relating to building construction, and hereby authorize rc ctio ntauvea o(thls
ndhereb auntyfie representatives
m ify aned propertyfor Inspection of Cuaes.
city to (WA) agree to Sae , indemnify
(We) aimti to save, IndemNty and keep harmless the City Cupertino
ALTER OR ADD'10 MECH.
Date Revel t#
P
SUBTOTAL:
agalwtllabllitln,judgments, cede end eapensea which may In anywayamme
y
gal tald Gtysryue of gra mg of a IL
A'+O
AIR 7iANDWNC UMT(TO 10,000 CPM)
AIRHANDLINGUNIT(OVER10,000CFM)
CONSTRUCTION TAX
Signed fAppiant/Contractor ate
D(HAus r HOOD(W/DUC'IT
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DI SCLOSUR
HEATING UNIT (T0100,000 BTT)
Will the applica to or future building occupant atom or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.12 and the
I lealth and Safety Code dign7S537(a)?
❑ Yea No
Will the applla or rebuilding occupantuseequlpmentordevices
Date RCCeI ted
HEATING UNIT 100,000 BTU)
TOTAL:
tail
boams s/
VENTILATION FAN (SINGLE RESID)
ISSMAIMIATE
which emit hazardous air contaminants as defined by the Bay Area Air
BOILER -COMP OHPOR 100,000 BTU)
Qua llty Management Di rid?
4Yrs o
have mad the lt ar ods materials tions 25505,25533
the Hnith & Siletydin Code, Sections 55 5, 2553 Band2S5Chapter 8.95 of
sad i
nand
nj' Q 1990
1 s v Lei
,
BOILE&COME (OVER 100,000 BN)
NEW RISIDEN77AL MECH. SQ.FT.
er
t have a tenant, that i
understand that if the theongdant not .require encs whichthat b met
responsibility to polity the occupant of the requirements which most be met
Ply Of Ptloprfln O
rior toissua faCedi m.fomv ancy
Owncr0iu. a ate
ISSUED BY: �1 CJiiV'f v'+ "'u4+ l
f
TOTAL:S.—
OFFICE COPY