23763APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification
PERMITNO.
Building Address:
le33 , -Io (es
23763
ante: on .
^Irly've-bi,-QSOk
A
376-20(
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION 1 PERMIT
BUILDING-ELECTRICAI..PLUMBINC MECHANICAL
p
l�
estn//r. Na Lic.No:
u 4 . GC 4 LC ki'l d N
CATEGORY
.CONTROL N
A tM/Enginm Lk. No:
QTY i" ,ELECTRIC PERMIT, 1: ';"FEC
','Ili L#BUILDING PERMITINFO "•'
Address: -
PERMITISSUANCE
LICENSED CONTRACIOA'S DECLARATION
Iherebyafftr thatlamllcrosedunderprovlslons6tChapter9(mmmm
Been h5ect vielon 3o(the Buslneaeand Pmfeaelona Codq and my
BeenIs In (uB d effM.
LIcN .?iS zZI
APPLIANCE&RESIDENIAL
- JOB DF9CRE'170N
fi_
PANELS
Date Contractor QCOuUP
Data
ARCHITECTS DECLARATION
fundentandmyp6nsshall beused upubecmmrds
TO 200AMPSYTL
-
OVER00AMI's
OVER 1000 AMP5
SQ. FT. FLOOR AREA
S/"JQ. FT.. ,
SIGNS ELECTRICAL
Licensed Professional
SPECIAtCIRCUIT/MLSC
OWNER -BUILDER DECLARATION
I hereby affirm that l am exempt from the Contractor's License Law for the
TEMP. OR POLE ]NST.
.
_
following maaon.(Seaton 70313, Business a nd Professions Cade: Any city or
countywhich requires apermW
ittocom uct, alts, Improve, demolish, repair
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any structure prior to lb isms nee, also requires the applicant for such permit to
file a" ed statement that he is licensed pursuant to the provisions of the
POWER DEVICES
_
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SWISIMING POOL ELECTRIC
_
Cmu=r'eLicense Law (Chapter 9(commencing with Section 7000) of Owl.
slon3 olthe Business and Profesiona Code)orthat he 6 exempt theretromand
VALUAUQjI):
the basis for the alleged exemption. Any violation of Section 7001.5 by any
applicant for a permit subjects the applicant to a civil penalty of not more than
OV7IETSBWITCIiFSFf%'NRES
asses a�� sy/
{.W
NEW RESIDENTIAL ELECTR SQ. T•
five hundred dollars ($500).
❑ I, as owner of the property, or my employees with wage as their sole
STORIES
TYPE CONSTRUCTION
' compensaflon, will do the work and the structure is not Intended or offered for
sale(ac.704y Buaon and Profesios Code:The Contractor's LIce®e Law
does not apply to an owner of property who builds or improves thereon, and
who does such work himself or through his own employees, provided that such
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OCCGROUP
.
RFS.[MCfS
'
Improvements arc not Intended proffered forsale. If, however, thebuilding or
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Improvement 6 sold within oneyearofcomplatory the owner-bullderwlll have
ft,t,rrden of proving that he did not build or Improve for purpose ofsale.).
U I, as owner of the property, am exclusively contracting with I& C aed
to construct the project (Sec. appy Business and Professions Code:
QTY, `
', i PLB
UMING PERMIT";
FLOOD ZONE
APN
PFRMITISSUANCE --
The Cotoe
License
Limner Law doe not apply to an owner of property, who
The Coor Improves
Wilds t r Improvss thereon, and who contracts for such ptajects with a
cgat.(actor(sexemptlicensed
un6r ecnt to the Contractor's License PLaw'
1� I am exempt under &e B & P C for this rcaaon
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ALTER -DRAIN& VENT- WATER (EA)
FEE SUMMARY
i
BACK FLOW PROTECT. DEVICE
-FEES
DRAINS FLOOR ROOF, AREA, COND. . -
FIX'I'URFS IBR TRA]' -
SANITARY Y N
RECEIPT#
Owner Data
WORKMANCOMPENSATIONDECLARATION
❑I hereby affirm that 1 have a certificate of consent to self -insure or a
cenifirete of WorYsrs'Comperuadun Insurance or a renifkd mpythereof (Sec.
3R00,UbC.) - -
foil,# '
SCHOOL TA% Y N_
RECFR'T N
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GAS F.A. SYSTEhf-1 INCA OUTLETS
PARK FEE . Y_ N
RECEIPT
- GAS Ilk SYSTEM-OVER4(FA)
Com any
BUILDING DIVISION FF.Ii9 '
[PCeniRed copy Is hereby fumlahad.
F-1Candiedcopy is filed with the city Inspection division.
GREASE/INDUSIRL WASTE INTERCEPTOR
PLANCHECKFEE
GREASE TRAP '•
CERTIFICATE OF EXEMPT ION FR OM WOR KERS'
PAID .
SEWER-SANITARY-51ORM EA. aDOFT.
COMPENSATION INSURANCE
Qhis section need net be completed If the permit 6 for one hundred dollars
Date RCCCI I#
WATER liFAT'IBt W/VENT/Fl.LCTR -
ENERGYFEE Y N
,
(5100)or less.)+ -
I certify that in the performance of thework forwhich this permit is Issued,
WATER SYSTEM/TREATING
_
I shall not employ afiy person in any manner so as to - .ant n m the
Workeri Comp5n9atlo Gv(go(Ca lom6. D to
.
PAID
Applicant /!Bl ¢¢ K. ifY,�.�'
NOTICE TO APPLICANr'f- ftermaking Certificateof
Date RCCCI t#
NONRESIDENTIAL PLMB. �.FT.
a this Exemption, you
should become subject to the Workers' Compensation provisioro of the Labor
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TOTAL:
L NG
as'm
Code, you must forthwith comply with tach provisions or this permit shall be
deeed revoked.
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SEISMIC FEE
CONSTRUCTION LENDING AGENCY
IhembyafRrm that there Isa mmtructlon lending agency forthe perform
anmofthaworkforwMchthispermit66sued(Sec.3097,CIv.C.)
lanier.Narne
Lenders Addreaa
I certifythat l nava read thisappBratmn and statethatthe aWwe Information
Is correct. I agree to complywlth all cityand county ordinances and nate laws
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ELECTRIC FEE
,
I y
44Y. MECHANICAL PERMIT `' ^`_`,' FEET
PLUMBING FEE '
MECHANICAL FED -
PERMIT ISSUANCE
FEES PAID:.
ielating to building construction, and hereby authorize representatives of this
city to enter upon the above-mentioned property for inspection purposes.
(We) agree to save, indemnify an d keep harmless the City of Cupertino
against liabilities, judgmenb, co&eand ex ers whkh may In anywayaccrue
.gal City Inc equenre of th ng of this permit p
•2 /
ALTER OR ADD TO MECH.'
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Date $CCCIPt#
AIR HANDLING [NIT (TO IO,fJ(10 CFM)
SUBTOTAL:
PIR HANDLING UNIT (OVER 10,000 CFM)' •
CONSTRUCTION TAX
Signature of AppllcnData
IXIiAUSTfI00D(W/DIK:T)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
'
HEATING UNIT (TO 1(10,000 BTU) _
Will the applicant orthe Cupertino
material asdefiny by Co,1a eCupertino MuNcipal Cote,Chapter9.12 and the
ruin Municipanta e,Cha t, le 91hazardous the
Health and safety Code section 25531(.)7
❑ r] No
Date Receipt#
HFATNG UNIT 100,000 B s
TUI
TOTAL:
VENTILATION FAN (SINGLE RESIU)•.
ISSUANCE DATE
Will t building occupant use devices
Wlllthe applicant or
hamrousairfuturn
cont the BayequiptnintArea
eMana em nt Distmntamimnts as defined by the Ray Arca Air
Quality
Quality Management District?
4Yca No
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A. II
K 1 D
BOILER -COMP OF(I'OR 100,000 BTU)'
BOILER-COMP(OVFEIW,IXpBTU)
the 21hvcmadtheh.eRuamaterialsrequircerentsunderChapter6.95of
fornia Health & Safety Code, Sections 25505, 25533 and 25534. I
NEW RESIDENTIAL MECH. SQ.FT+
understand that if the building doea net currently have a tenant, that It is my
peortol6uaneoi.ythe.t p.f oliherequlrcmeniswhich must be met
rnprmiilityt nNi Certificate of Occupancy.
p, 1i1Q7
x792
J��11f +� /T) S/
CITi ur ®
ISSUED BY:
Owner oramhorized agent - -Date
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7YlTAL�
OFFICE COPY