21547APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project identification - '
Building Address:
PERMIT NO.
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wnere ante: one:
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APPLICA11ON SUHM11-1ALA
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BUILDING.ELECTTCCAL-PLUMBING-MECHAMCAL
rL�
cono-ador's Noma:: Lic. No:
12
CATEGORY CONTROL If ,
Archlted/Engineer. - Ge No:
'1 -' .T 3• I ''3''-
IQTY';,r `_:'ELECTRIC PERMITS 3 .t 3 . { ITC �{
- r' ",IBUILDING:PERMITINFO-
_... . .. .. . .. ...... .. . .. '.'
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-Address: •
EJ ❑ _ ❑
PERMITISSUANCE
LICENSED CONTRACTOR'S DT:CLARATION
I hereby affirm that l am licensed under provbiensof Chapter 9(commenc
ingwith Sedion7000)of Dlvislon3otthe Bustnemand ProtessionsCode,and my
license lslns fora dna Affect
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LI«nse Class LIGX CJ_r-7UP
Date Contactor '—�:--(
Amshail eusedA public ori J
(understand my phmelu06e ueedupublk recxuds '
APPLIANCESRESIDENTIAL
)OR DESCKR'ITON
.���' `��
F
- PANELS
TO 200 AWS
701-1000AMP5
OVERI"AM
' SQ. FT. FLOOR AREA -
S/SQ.FE
;' SIGNSELECTRI
Licensed Professional •
_
SPECIALIRCUIT
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contrador'e Li... law for the
`fallowing
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Tp�yP.'ML E
reason. (Section 70315, Business and Professions Code: Any city or
cauntywhkhrequb apermittoWNtmd,alter,Improve,demnlbh,orrepair
anystructure prlortoits bsuancGaiso requlre.the appllcantformch permit to
file a signed statement that he is licensed pursuant to the provisions of the
MWERD
.
SWIM G CIRI _
Contractor's License Law (Chapter9 (commencing with Section 7000) of Divi-'
sion3ofthe Rusinessand Professions Cod0orthat heisexempttherefromand
VALUATION
the bash for the alleged exemption. Any violation of Section 7011.5 by any
applicant fora permit subjectsthe applicant to a civil penalty of not more than
W 12 7 L` L-
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five hundred della. ($500). '
ME, as owner of the property, or my employees with wages as their sole
STORIES -
TYPE CONSTRUC'11ON
cempensallon, urUldo the work and the structure b not intended or offend for
sale(See.7o44, Business and Profasslere Code: The Conlrsctors Lkenx law
does not apply to an owner o(pmperty who Wilds orlmproves thereeNtd
who does such work himself orthrough his own employees, provided thal ouch
Improvements are not intended or offered for sale. If, however, the building or
i provementissoldwithinoneycarofcompl&iogthe owner-bullderwlll have
t rdenmf provingthat he dicince Wild orlmprove for purpose ofsale.).
I, as owner of the property, am exclusively contracting with licensed
contractors to mmtrud the project (Sec. 7044, Business and Professions Code:
TOTAL:
QTY,"� ,� PLUMBING''PERMIT"" r''FEE,'.
OCC.CROIRa
RES. UNITS
FLOOD ZONE
'
APN
pFRMIT ISSUANCE CE Z•
TTe Contractors Llcerse Law does not apply to an owner of property who
Wilds or improves thereon, and who contracts for such p (ofects with a
cgBUadorWhromed pursuant to the Convador's License Law.
IJ I am exempt under Sec. B & P C for thb'reason
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ALTER -DRAW &VENT- WATERMA)
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}" �'}' `q• TEE SUMMARY' ••"'
BACK FIAWPR077LT. DEVICE
OUTSIDE FEES
FOR ROOF, AREA, COND.
DRAINSLO
O FERFURES, PER TRAP
1 - ^' �'
SANITARY Y N
RECEIPT
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Owner Date
WOR KMAN COMPENSATION DECLARATION
❑I hereby affirm that 1 have a «rtifiam of consent to self-insureor a
mrtifialeofWorkers Compereatlmli ranceoraceAlfWmpythem.((Seers
3800. Lab C.) G
Puiry# S — If7
SCHOOL 7A% Y_ N
PT
RECEIPT X
S
.CAEA, SYSTEM -1 WC.40II7LE75
'PARK IT:E Y
RF.CERN
- GAS EA. SYSTEM -OVER a(EA)
CaanvP{ •�(JI�_
''- , BUILDING DIVISION FEES
LJCArtIfi.dT5pybherAby famished.
copy is filed with the city Inspection division:
GREASE/INDUSTRL WASTE IN77RCQ'TOR
PLANCHECK FEE
GREASE TRAP
,Werlifled
CERTIFICATE OF E%IM PHON FROM WORK ERS'
PAID '
COMPENSATION INSURANCE
Cfhb section need net be complded If the pemdt is foronc hundred dollars
SEWER -SANITARY -STORM EA. 200FT.
Date Recei t#
P
WATER HEATER W/VENT/ELI-CTR
ENERGY FEE Y N
_
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($IW)or lay.)
I certify that In the performance oflhe work forwhlch this permit issued,
`` ,�qq
WATER SYSTEM/TREATING erlX OV
I shall not employ any person In any manner n v to become subjeci to the
Werkers'Compensatlon Gwe e(Glitomla. Date
PAID '
NEWRESIDFNIIALPLMB, SQ.FT.
Applicant
NOTICE TO APPLICANT: R, after making this Certiriate of Exemption, you
Date -' Recei t#
TOTAL:
should become subject to the Workers' Compensation provisions of the Labor
Code, you must fort hwith comply with such provbiom or this permit 'shalt be
deemd revoked.
BUILDING FEE.
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
Ihereby affirm that there is a construction lendingagonry for the performTOTAL.
anceoftheworkforwhlchthbpermittshsred(Sen3097,CIv.C.)
Lander'. Name
Leadve.Address
I mnlfylhat i have read thisappBrmionaod A.u,lhat the above infer rAdion
is correct. I agree tocomplywithalldtyandcountyordlnancesandstatelaws
XC
ELECTRIC FEE
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QTY: ). .t-'•ME_CHANICAVPERMIT''' ,•.PEE',, -MECHANICAL
PLUMBING FEE
•d
FEE
PERMITIS51-ANCE
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FEES PAID: ,
relating to building corotmdion, and hereby asvhoriee representatives of this
citytoenterupontheaWve-mentlooed property for inspection purposes.
(We) agree to save, indemnify an d keep harmiess the City of Cupertino
against)labllltles,jadgments,costsand expeaseawhich may inanywaya«rue
ALTTRORADDTOMECH. -
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Date Receipt#
AIR HANDLING UNIT CTO 10,000CFM)
'' SUBTOTAL:
aga Wtsal ity In aronee en«.(the granting ofthis permit, pp
��.�"x
AIRHANDLING UNIT(OVER 10.000CFM)
CONSTRUCTION.TAX.
Signature of Applla^t/ContractorJT—te
EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
I HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (TO 100,000 BTU)
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Date ' RCcei 1#
Will the applicant or future building occupant store or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.12, and the
'Health and Safety Code�Saection 25532(a)?,
Yes I�INo
Wllltneappilcant orfutumbuilding occupant use equipment ordevlcol
HEATING UNIT (OVER 100,000 BTT)
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TOTAL:
D
VENTILATION PAN(SINGLE RFSID)
ISSUANCE DATE
which emit hazardous aircontaMwntsaadefired bythe Bay Arca Air
Quality Management District?
4Yean No
havcread the bazar�iuus materials rcqulremcntsunder Cho pter6.95of
^O�
J�s10
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F 77 QQry�ssX
BOILER -COMP DEEP OR 100,000 BTU)
BOILCR-COMP(OVIR100,000 BTU)
the California Health&Safety Code, Sections 25505,25533 and 25534.(
understand that lithe building does not cemntly have a tenant, that it to my
NEW RBSIDENTIAUMECH. SQIT
rrsponsibllitytonmtlfythe occupant fthe requirement. which at be met
prion. Issuance of a Certificate efOccupancy.
a�
(Sika otsay
W p(�u
ISS UL'DBY: W`
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Owner or aulhorimd agent Date
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7L1TA L:
OFFICE COPY