22349APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification -
B"Rd og Address:
PERMIT NO.
/970/ S -teT evq C e C� VO4
22349
wners ams: s:
p ,
jV-"kN`ILjr
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BUILDING-ELFCTRICALPLUMBINGMECFIANICAL
6 LSCS L
C .no'aN� NL Lc. No:
CATEGORY
CONTIj7
It7
A ItM grocer. Lic. No:
/Sorra `/o� tYnn Ami" PI, Zv7 [
�jy ELECTRICPERMIT FEE
BUILDING PERMIT INFO
Addms:Lr I Wf It Cj '
PERMITISSUANCE
❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter 9 (commune,
with Section Wee) of Division 3 ofthe Buslnessand ProfessionsCode, and my
I icense lsln full to and effect.
LlmneeCie«N�
APPLIANCE&RESIDENIAL
JOB DESCRIPTIONIng
PANELS
I
Date Contractor �,
PS
201-1000 AMIs5
OVER 1000 AMPS dFkj
ARCHITECTS DECLA ATION
I understand my plane shag be used as public records.
&QCKFAAW I V/SQ. Fr.
SIGNSELECTRICAL
Licensed Prafeskonal
�7 U T E
SPECIALCIRCUIT/MISC
OWNER -BUILDER DECLARATION
I herebya(finnthat I am exempt from the Contractors License Law for the
following reason.(5ection 7031.5, Business and Professbns Code: Any city or
muntywhleh requlma pemdttocomtmct, alter, Unpmve, demolish, orrepair
anystmc mpdmmlts Uasance,alcorequbstheappBmntforsuchper tto
III. a signed statement that he Is licensed pursuant to the provblom of the
Contractor's License Law (Chapter 9(mmmencing with Section 7000)of Divi-
of the Bu green and Professions Code) orthat he Is exempt Nerefrom and
f
TE
/
TEMP, METER OR POLE INSG
POWER DEVICES
SWATMING POOL ELECTRICah.3
VALOATI
the last/ for the alleged exemption. Any violation of Section 7031.5 by any
applicant fora permit subjects the applicant to a civil penalty of not more than
O A
ONLETSSWITCHESHXTURES V
`D O�
U
NEW RESIDENTIAL ELLCTR SQ'Fr'
five hundred dollars ($500).
I, as owner of the property, or my employees wBh wages as their Bale
STORIES
TYPE CONSTRUCTION
compensation, will do the work and the structure Is not Intended or offered for
'
.In (Sec. 7044, Business and Pre essimut Code: The Contractor's License Law
TOTAL: 1
does not apply to an owner of property who builds or improves therron.and
docasuch work himself or through his own employees, provided that such
Improvements are not intended oroffered forsels. If, however, the building or
improvement i,"dwithln oneyearofcmnplelion,the vomer-budderwill have
OCC. GROUT'
065. UNITS
tl)4,Iurden of proving that he did not build or improve for purpose of sals.).
LI I, as owner of the property, am exclusively contracting with licensed
contractors to meslruct the project (Sec. 7044, Business and Professions Code:
QTY, PLUMBING PERMIT FEE
PERMIT ISSUANCE
FLOOD ZONE
APN
The Contractors License law does not apply to an owner of property who
builds or Improves thereon, and who contracts for such p(olects with e
c}LIjactor(s) licensed pursuant to the Contractor's License Law.
LJ I am exempt under Sec. B & P C for this mason
ALTII4ARAM&VENT-WATER (Ess)
FEE SUMMARY
BACK FLOW PROTECT, DEVICE
..
DRAINS FLOOR ROOF, AREA, COND.
FD(TURES PER TRAP _
SANITARY Y_ NRECEIPT N
Owner Date
WORKMAN COMPENSATION DECLARATION
❑1 hereby affirm that I have of consent to
SCHOOL TAX Y_ N_
rlum o Insurance opf-tnwre, (Sa
certificate of Worken'Compereatlon lreurance ora ttrtlfled copy thennf(Sec.
3800, LebC i
POoGtS3o3 A-
RECEIPT N
GAS P.A. SYSTEM -1 INCA OUTLETS
PARK EF£ Y_ N—
TN
GAS EA, SYSTEh1-0VERd(EA)
Com
DING
BUILDING DIVISION FEES
r �
Certified mpy is filed w th the city
Certified mpybflled with the city lrepectlon division,
CERTIFICATE OF EXEMPTION FROM WORKERS'
CREASE/INDUSTRL WASTE INTERCEPTOR ,
PLANCHECK FEE
PAID �: ( C
GREASE TRAP
COMPENSATION INSURANCE
(Thlseemon need not becompleted If the permit infor one hundred dollars
($11 mftifyth work
of theearner so to to becomh this e
permit is Issued,the
Inot employ any person
I shall not employ any person In any manner so ss m become mbfect to the
Compeneatlon Laws of Dote
Date Recei til
SEWER-SANrTARY-S1ORMEA.200FT.
WATER HEATER W/VENT./EI.ECTR
ENERGYFEE Y N—
PAID
WATER SYSTEM/TREATING
Appiloi
NOnCaot
NOTICEm APPLIesubJe Atotheattermaking this Certificateis Exemption,you
Code, become mrth to the Workers' CompensationproWlmaofthe Labor
Code, you most forthwith comply with such provisions .,this permit shall be
deemed revoked.
Date Retti t#
NEW RESIDENTIAL PLMB, S,Ff.
` �
TOTAL:
BU INC �'E
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby -!lire, that there is a construction lending agency for the perform
ance of the work for which this permit is Issued (Sec. 3097, Civ. C.)
L:
ELECTRIC FEE
Leader'.Name
Ixodes Address
I mdlfy that I have read this application a nd state that the above N(orrtutlon
Iscorrect. I agreetocomplywlth allcityand countyordinancesand state laws
relating to building construction, and hereby authorize representatives of this--`�=�6
-
QTY. MECHANICAL PER IT FEE
PLUMBING FEE
MECHANICAL I•TE
PERMITISSUANCE
FECES
city to enter upon the above-mentioned property for impm ion purposes.
(We) agree to save, Indemnify an d keep harmless the City of Cu pertlno
ALTER OR ADD TO MUCH.
Dale ReCel t#
P
SUBTOTAL:
against llabilltlen,judgments, mks and expenses which mayinenyw.y..ru.
agobutui itylncouneq�u 7 (the g naves of this permit.
A 1( Cern a.�.vvw, 1?
AIR HANDLING UNIT (TO 10,Bfo CFM)
-
AIR HANDLING UNH (OVER I0,000CFM)
CONSTRUCTION TAX
�)4%
Signa reof Applicant/Contractor / Dass
EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (M 100,000 BM
-
Will the applicant or future building occupantgme or handle haaardcus
material as defined by the Cupertino Municipal Code, Chapter 9.1Z and the
Date Recel [#
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
Health and Safety Cade Satlon 25532(.)7
❑ Yes 6 No
VENTILATION FAN(SINGLE RESID)
ISSUANCE DATE
Wllltheapplicant or(ture building occupant use equipment or devicce
which emit hazardous air contaminants as defined by the Bay Area Air
BOILPR-COMP OI-B'OR 100,000 BTU)
Quality Management District?
Yea 1� No
I?
HOMER-COMP(OVIN 100,000 BTU)
have read the hazer us materials requircmentsunderChapter6.95 of
the Czlifomia Health & SafetyCode, Semens 25505, 25533 and 25534. 1
NEW RESIDENTIAL MECTL SQ.IT
understand that if thebuilding done not currently have a tenant, that It E my
responsibility to notify the occupant of the requirements which most be met
Prior to Lasuanc ofa Certificate of OCmpanry.
PAID
ISSUHDBY:
�Dwner or th dud agent Date
TOTAL:
r Eyyill
OFFICE COPY city
0l Cumfin®