20215APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Prom Identlflcaasn -
Building Address:
s s -f
PERMIT NO.
2021.5
Name;
'Uv,rter.r.,
l U • W3s,
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION/PERMIT
BUfLDING—LFJCTRICALPLUMBING-MECHAMCAL
C
S '—
Contmdor's Name: Lic. No:/
CATEGORY
CONTROL p -
Arcd/ gineer. Lic. Nen
q�, PEItMTT'I .. �'i
BUILDING PERMIT INFO
•. ..� -'
Address aO IC
54
•Qrr,�,' [ELECTRIC ,,iE
IPFRMITISSUANGE
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provbiona of Chapter9(comment,
Incense I In full force and dielon3o(lhe BuelneasandProtnaloneCode;and my
license le In full form and died.
APPLIANCES -RESIDENTIAL
JOB DESCRIPTION
PANELS
Llma.Class LIc.0jP
&
Date Contractor
UP TO 2DOAH!S
201-10MAMN "
ARCHITECT'S DECLARATION
[understand my planashzl be used as public records.
OVER IOOO AMPS
SQ. FT. FTOOR &RFA
/SQ:Ff.
SIGNS ELECTRICAL
Licensed Professional
SPECALCI6CUIT/MISC
OWNER -BUILDER DECLARATION
Ihercby a(Orn that l amexempt fmm the Contractors, License Law for the
following reason. (Section 70115, Business and protestors Code: Any city or
countywhich rcqulms a pemdt to mmtrud, alter, Impmve, demolish, or repair
'
^
f
TEMP.METTRORPOLEINr.
-
anystrudure priertobeasuance,alsorequlresthe applicant for such permit to
Its a signed statement that he is licensed pursuant to the pmNalov of the
Contractor's License Law (Chapter 9(commencing with Section 70f1f1) of Divl-
aion3of the Businss eand Professlona Code)orthal hebexempt therem
froand
POWER DEVICES
^
-SWIMMING [POOL C
VALUATION
the basis for the alleged exemption. Any violation of Section 7031.5 by any
applicant for a permit subjects the applicant too civil penalty of not morothan
OU LRTSSWI
.
'
NRWRESIqWLELEC4 SQ.Ff.
five hundred dollars($SM.
nL as owner of the property, or my employees with wages as their sole
STORIES
TYPE CONSTRUCTION
mmpensaboar,wlll dothe work andthe strudurc isnot Intended or offered for
_
..
-In (Se. 7064, Business and Professions Code: The Contractors License Law
_
does net apply loan owner of propedywho bulldsorlmproves thereon,and
who does such work himself orthrough his own employees, provided that such
OCC GROUP
-
RFS. UNITS
improvements are not intended oroffered forests. it, however, the building or
Improvementlesoldwithinoneyeaiofecmpldlogtheowner-bullderwillhave
tt,,�urden of proving that hedidnwt ildorlmpmveforpurposeofele.).
LJ L as owner of the property, am exclusively mntmcting with Iireneed
dent adam to comtmd the project (Be. 7064, Business and Profess.. Code:
TOTAL:
,
Qty. I;,1�• PLUMBING''PERMIT','
.'FEE+,
PERMIT ISSUANCE
,
FLOOD ZONE
APN
The Contrai License Law does me apply to an owner of property who
Wilds or Improves thereon, and who contracts for such pLojects with a
�gR�{ad.r(a) licensed pursuant to the Contractor's Law.
LI I am exempt under Sec. B k.P C for this mama
ALTER -DRAIN k VENT -WATER [EA)
it
,'�. 'FEE"SUMMARY'
BACK FLOW PROTECT. DEVICE
DRAINS -FLOOR ROOF, AREA, CONTI.
FIXTURES PER TRAP
SANITARY Y N -
RECEIPT#
Owner Date '-
WORKMAN COMPENSATION DECLARATION
Ofhereby affirm that I have clrtof m
SCHOOL TAX Y_ N
ao difi pythaure, ore
o
certificate ofWorkers'Compenaatlonlnaurance ora certified copy thereof (Sec.
cane
abs
..
RECL'I'r M
GAS F.A.SYSTEM-1 INC.60UTLETS -
PARK FIB: y N '
Policy3800,
olkyN
RECEIPT
Comny
GAS EA. SYSTEM -OVER
BUILDING DIVISION
SION FEES�Clfed
copy is hereby te
Cb filed with
ertified copy W pedlars division..
the city city
CREASE/INDUSTRL WASTE INTERCEPTOR
PLANC14ECK FEE
GREASE TRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
Cot bec.ATIONINSURA isfor
(fhb sectionneed not be compldI NI permitbCorona hundred dollars
PAID
Date Rece{ t#
SEWER -SANITARY -STORM EA 200Ff.
(81(D)or less.) '"
I certlfythat In the performance of the work for which this permit is bored,
I shall not employ any person In any manner so as to become subject to the
Workers'Compensatlon laws of Callfomia. Date
WATER HEATER W/VENT/ELECTR
O
ENERGY PEE Y N
'
PAID
WATER SYSTEM/TRGTING
Applicant
NONCE co MPLICAM: a after making this
kro is Exemption,ns oftab u
co Worken'Compensationies rthiopermht Labor
should you mustme subjectforthwith
deems r moat forthwith comply with each provlslona orthLs permitahallbe
deemed revoked.
Date - -Reset t#
NEIN RESIDENTIAL PLMB. Ff.
—�
_
TOTAL:
BU LIJING
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
IhercbyafBrmthat there Is a corutrudion lending agency for the perforrm
anm of the w.rk for which thio permit b bored (Sce. 3097, CIV. C.)
TOTAL:
- • • '
ELECTRIC PEE.
QTY. ,,„ ',,-MECHANICAL. PERMIT•'' , •''•FEE+,•,
PERMITISSUANCE
PLUMBING FEE
Leader's Name
Larder's Add mee •. •
I ceditythat I have read thbappliaHonand statethattheabove Infomatlon
.bmrred.Introit, complywith all city and county ordinances and statelaws
MECHANICAL FEE.
FEES PAID: ..
relating to building construction, and hemby authorteencomeentatives of thio
city to enter upon the above-mentloned property for Inspection purposes.
(Na) agree to save, indemnity an d keep harmless the City of Cupertino
against liabilities,judgments, mks and expenses which may In anywayacnue
agubm said City in coneayuenceof the granting of thio permit.
.
• ALTER OR ADD TO MECH.
Date Receipt#
-
AIRHANDLNGUMT(TO10,030CFM)
"
SUBTOTAL;
AIR HANDLING UNIT (OVER l0,000CIMD
CONSTRUCTION TAX
SignaieradApplicant/Contractor Data
EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
-
HFATINGUMT(TO100,0DOBTU)
-
Willtheappllcantorfulure building occupant store or handle hazard..,.
material as defined by the Cupertino Municipal Code, Chapter 9.12, and the
Plealthand Safety Code Section 25532(a)7
Yee ,tr. No
Date Recel t#
HEATING UNIT (OVER 100,000 BTU)
- TOTAL:
11f/
.`lU
VEN77LA770N PAN (gINCLE RLSID)
,
ISSUANCE DATE
PAI r
f
-'FAl
Wiil the applicant or luturebuilding occvpantux equipment ardevicn
which emit hararluus air contaminants as defined by the Bay Area Air
Quality Marsgement DbVid7
IP, Yee � N.
ave readlthe .Itha uammeriabrcquiremems5533aChapter6.95 of
Health Code, 1
BOILER-COMPOHIPOR 100,000 BTU)
- BOR.ER-COMP(OVIR IHI,OfJO RTU)
- -
NEW READENTIAL MHCH.-SQ.Ff.
understand that notifthe thatI534.
understand t building otcurrntlyh have
currently a tenant, thatIt is my
f•,fCM1d U
the occupant of the
responsibility to notify the ocmpantofth.acyr. menti which mustbemet
which
to reofaC< toofOcmpancy. —
.-city,Of13unetlBtl,w
ISSUED BY1�0
VV
_
Owner or au orlud agent„ Date
' TOTAL
OFFICE COPY