22888APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
' Building Project Identification - - -
Building Address::
PERMIT NO.
:] n O (� O
/0615-01 e-
228188
1! � 4, V �- M 1, I �1�? • en.
erste ranea. me:✓—`—'—` '— t ' Lic.Nce. _
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BUTLDINGELECTRICAL-PLUMBINGMECHAMCAL
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CATEGORY
CO
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Architect/Engineer. Lic. No:
04QT'Y'
Y ., ELECTRIC PERMIT• � 3�. '�;� FEE II
� Jr � BUILDING PERMITi1NP0 -
i
Address:•'
PERbBTISSUANCE{I�
T6X ❑
LICENSED CONTRACfOR'S DECLARATION
thereby affirm that l am licensed under provislons of Chapter 9(rommmc-
Ingwlth Sealon700D)of Drvbion3 ofthe Businessand ProfeW..Codpand.y
E.nae lain full force and affect -
APPLIANCES -RESIDENTIAL
OB DGSCKBTION
1
PANELS
License Clam Lk.#
Q
Data Contractor
UP TO 2DO ANTS
—
201-1000 AMPS
ARCHITECTS DECLARATION '-
I understand my plans shall be usedaz public remnls.,
OVER 1000 AMPS
SQ. Fr. MOOR AREA
$/FQ.FI'.
SIGNS ELECTRICAL
Licensed Professional -
'
SI'ECIALCBiCUIT/MISC
- OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
'
TEMP, METER OR TOLE INST.
following reason. (Section 7011.5, Business and Profealons Cade: Anycity or
cmntywhich mquims a perrrdt to mmtmd, alter, improve, demolish, orrepair
'
anystmctum Perrin Its Issuance, also mqulrestheappllcant forsuch perMtto
file a signed statement that he is licensed pursuant to the provisions of the
POWpJ(DEVICES -
• `
SWIMMING POOL ELECTRIC
OUTLE1SSWlTCFIFSFlXTURES
Contractor's License Law (Chapter 9(mmmencing mI, Section 7000) of Dlvi-
alon3 of the Bushunu t nd Profealom Code$onliat he is exempt themfromand
the basis for, the alleged exemption. Any violation of Section 70315 by any
applicant for a permit subjects the a ppllcant to a civil penalty a am more than
VALUATION _
�l (1
`— l
NEWRESIDENTIALELECTR ' SQ'Fr'
five hundred dollars ($500). .Y '-
n I, as owner of the property, or my employees with wagesas theft sok
STOW PS
TYPE CONSTRUCTION
compensation, willdothe work andthe structure V not Intended or offeredfor
,
ale (Sec. 7044, Buaftum. and Profealom Code: The Contractors Llceme law
,
-
doesectapp)ytoan owner of property who Wilds or Improves thereon,and
whodoessuchworklemaelf orthrrogh hisownemployees, provided thatmch
OCC.GROUI'
RIS. UNITS
improvements are not intended oroffered(orate. If, however, thebulldingor
impmvement6wldwithinoneyearofcomplMioRlheowner-builderwill have
t"rima(p,ovmg that he did not bund or improve far parpaae of coir.).
Li L as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business and Presfeam loCode:
- •TOTA .
Q'Iy: `;•_,i, PLUMBING PERMIT I:.
-
PERMIT ISSUANCE ��
FLOOD WNE
APN r
The Contractor's Limnr Law does not apply to an owner M property who
builds or Improves thereon, and who contracts for such plejects with a
5ac1m(s) licensed pursuant to the Contractor's License Law.
I am exemptunder Sec B & P C for thio mtsse.
ALTER -DRAIN & VEM-WATER (FA)
'1i ' , g; i ' ''JEEiSUMMARY
BACK FLOW PROTECT. DEVICE
DRAINS FLOOR ROOF, AREA, COND.
FDCURES PER TRAP
SANITARY Y N
RECEIPT N
SQTOOL TAX Y_ N_
RECEIPT N
Owner Date -,
WOR KHAN COMPENSATION DECLARATION-
❑1 hereby affirm that I have a mrtlficate of contend to self -Insure, ora
380, 38000. La
Lab CJ eo(Workera'Compemationlmuranm oramrtifled copy thereof (Sec.
.. t
-
GAS EA. SYSTEM -1 INC OUTLETS
PARKFEE Y ,N .
RECEIPT # .
GAS EA. SYSTEM -OVER -
Com any -
Cff.
BUILDING DIVISION PEES _
C
Certlfled copy is hereby filed the ed.
CertNed espy is filed with the Illy inspection division.
GREASEANDUSTRL WASTE INTERCEPTOR
PLANCHECK PEE -'
-.
.GREASE TRAP '
CERTIFICATE OF EXEM PTION FROM WORK ERS'
PAID
SEWER -SANITARY -STORM EA 2(01"1.
COMPENSATION INSURANCE
(Thiasectlon need notedcompleted lithe permit isfor one hundred dollars
WATERHEATTRW/VENT/FJ.FCTR LSP
EY N_
-
P I '
(8100)orlea.) '.
I certify that in the performance of thework for which this permit I. Issued,
I shall not employ any person In any manner so as to became subject to the
Workem'Compenealion Lawsof California. Date
WATER SYSIFM/TREATING
_
Appllcant -
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you
should become subject to the Workere Compensation provision ofthe Labor
a Rece1 t#
NEW RESIDENTIAL PCMB. SQFT.
I- TOTAL:
Code,you =at forthwith complywlth such provisions orthis permit shall he
deemed revoked.
B ILD NG '
-
SEISMIC FEE I-
CONSTRUCTION LENDING AGENCY
Iherebyaffirmmatthereisammtructionlendingagencyfrrtheperform-
ane, of the work for which this permit is fasted (Sec. 3097, Cly. C.)
Landcr'.Name
Lender's Address -
I certify mall have read t his application and state that above lnformaHon
rormct.I agree to comply with all city and county ordinances and state lawn
TOT
ELECTRIC FE R 02
QTY. ''. MECHANICAL. PERMIT ;" " ''••FEE • '
PLUMBING FE
MECHANICAL FE'
-
PERMIT ISSUANCE
FEES PAID:
raising to building construction, and hereby authorize representatives of [hts
city to enter upon the above-mentioned property fm inspection purposes.
(We) agree to ave, Indemnify an d keep harmless the City of Cupertino
agairsu s, rydgments, costs. xpenses which may In any way accrue
Imt id Cit In cccggqa ry�uen .o( tinting of hl It.
ALTER OR ADDTOMFCH.
- -
Dale Receipt#
-
AIR HANDLING[1MT(TO 10,000 CFM)
UBTOTAL:
AIR HANDLING UNIT(OVER 1g000CFM)
CONSTRUCTION TAX
Signatu of pllcant/ ontractor Date'
EXHAU5THO0D (W/DUCT)
CONSTRUCT N TAX PAID:
HAlEARDOUSMATERIALSD URE
HEATING UMT(TO 100,000 BTU)
-
Will the applicant or future building occupy sior handle hazardous
material as defined by the Cupertino Municipal e, Chapter 9.12, and the
Hcalth and SafetyCode Section 25532(a)2
M Yes M No ,.
Date Recel
NOTA
HEATING UNIT (OVER 100,000 BTU)
VPNITLATION FAN (SINGLE RESID)
-
I$$ N ATE
Will the applicant or future building occupant use equipment or devices
which craft havnlouaait meMmntsas defined by the Bay Are. Air
�ulity Management District?
L,, ye. F1 No
(have read the hazardou. materials requirements u neer Cha liter 6.95 of
the California Health & Safety Code, Sections 25585, 25533 and 25534. I -
-
t
PAID
BOILER -COMP DHPOR 100,000 BTU)
BOILER COUP (OVER 100,000 BTU)'
' NEW RESIDENTIAL MECIL SQ.I.-I'.
understand that lfthe building does not mrmntly have a tenant, that it is my
responsibility to orally the occupant of the requirements which at be met
prior to issuance of a Certificate of Occupancy.,
,
N0V•Y 19
I Q y
ISSUED BF
Owner or authorized agent Data
-
TOTAL:
OFFICE COPY
1,Y%/
Al
'41
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