24426I
APPLICANT TO FILL IN INFORMATION WITHIN REDLINES —USE BALL POINT PEN ONLY
Project IdenBuilding tification _ -
PER.MITNQ,
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4426
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CITY OF'CUPERTINO-BUILDING DIVISION
APPLICATION '/PERMIT
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C to, a Lk.go `
CATEGORY
CONTROL #
BUILDINGELECTFUC l4PLUMBINGMECHAMCAL
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.'A�, y„)ELECTRIC PERMITr i"!FEE.I.
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PERMITISSUA.
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LICENSEDCONTRACTOR'S DECLARATION
Y
1
[hereby etfirm that lam licensed under provisions of Chapter. (comment-
Ing schije f.u 7000)o(DlvGlon 3ofthe Businemandl'r.leasl.a Code, antl my
IfcenaiamJrc�yydcffect. ..
LlaneeCla49 / V p
APPLIANCES -RESIDENTIAL,
JOB DFSCRB'"f10N
- -
.
PANELS :�
Dater//%// Contractor
MPS `�
201-1000 AM1”'
Cle
H
ARCHITECT E RATION
OVERIOOOAMPS
SQ. FT. FLOOR AREA
$/SQ. Fr.
I understand my plaashali be used a public records.
SIGNS ELECTRICAL",
Licensed Professional -
,
SPECIAL CR2CUIT/MLSC ��
'OWNER -BUILDER DECLARATION
I hereby affirm that l am exempt from the Contractor's License law (orthe
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TEIAP. MEEK OR POLE INST.
followingreason.(Section 70415, Bminsaand Protection. Code: Any city or
countywhichrequlreaapert ttommtmd,alteyimpmve,demolbh,ormpalr
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anystructurcpoleatoIts lssuares, also requlreetheapplicent for such permit to
file a signed statement that he La licensed pursuant to the provisloa of the
Contracture License Law (Chapter 9 (commencing with Section 7000) of Dlvl-SWIMMING
sfon3 of the Business and Profcaloru Code).rthat he is exempt therefrom and
POWER DEVICES
POOL ELECTRIC
VALUATION
the basis for the alleged exemption. Any violation of Section 70315 by anyUTLETSSWI7'CF3ESHXTJRES
applicant fora permit subjects the applicant to a civil penalty of not more than
rive hundred as
rowner of thepr.
�p , as owner the property, .r my employees with wages ore their sole
.
+
NEW RESIDENTIAL ELECTR SQ.Fr.
STORIES -
TYPECON5TRUCTION
cumpeneaWkBusiness w.rkrandtheswdnrche
ll orcense
Business andf Code: The
lasulw
Contractor License Law
does not to property uilds or impoctots
apply and
voce not apply torn urealner ofproperty who nemporimproovidedtmguch
who doeaeuchw.rkhimselforthraugh Meownemployees, provldedthat wch
.00CGROUP
RES. UNITS
Improvements are not intended oroflered forsals. It: however, the building or
,
Improvement bsold within oneyearofcompletion, theowner-bunderwill have
the*rdenot proving that he did not build or improve for purpose ofsals.).
Li L as owner of the property, am exclusively con—.", with [lama
rontouton to construct the project (Sec. 7044, Budecas and Prerfeafons Code:
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Q7y;,•�{S'+I.. PLUMBING•PERMIT';',?`• '•;'FEE}.i
pFILyIT ISSUANCE .
,FTppD 7ANE
APN
The Contractor's License Law does not apply to an owner of property who
builds or Imm•
pees thereon, and who contracts for such pkejects with a
no ttjactor(s) Ilmnsed tract
pursuant to the Con./a License Law.
LJ 1 am exempt under Sec. B k P C for this reason
ALTER -DRAIN &VENT- WATER (EA)
''1 '.j''FEE SUMMARY
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BACK FLOW PROTECT. DEVICE
DRAINS FT.00K ROOF, AREA, COND.
FD(TlIRPA I'ER TRAP -
SANITARY .Y N_
RFCF= N
Owner Date
WORKMAN COMPENSATION DECLARATION
r_11 hereby affl. that 1 lu ve.a certlBcaen
te of const to d4f.i.dm, sera
copy theof(Sec.
3800(fLabC)Workers'Compevau.nlaurana orattrtifled rore
Policy 0
SCHOOL TAX V= N_
RECEIPT M
GAS EA. 5YSTEM-1 INCA OUTLETS
PARKFFE Y _ N j.
RFC= #
GAS EA. SYSTFM-OVER 4 (EA)
Com any
-' BUILDING DIVISION FEES
0Certlfled copy b heed with thehed. ,.
fCedified ropy Is herewithlhecityiapectlan dlvlelon. -
GREASEANDUSTRL WASTE INTERCEPTOR s
PLANCHECK FEE
'
CREASE TRAP
- x CERTIFICATE OF E(EMPTION FROM WOR KER S' -
COMPENSATIONCE
INSURANCE
(1'hiasection need not bo completed N NSURAN (Drone hundred dollars
PAID
Date RC i t#
SEWER-SANITARYSTORM EA 200FT
WATERHEATER W/VENT/ELECTR
ENERGY FEE Y N —
PAID
(ST 00)or lca3
I certify that In the perf.rmantt of the work for which this percut le issued,
I shall not employ any person In any manner m ai to become subject to the
Workerc'Compenaation Laws, of California. Date
WATER SYSTEM/TREAUNG '
ApplIcaNOnCnt -
NOTICE TOAPPLjectot a aftermakingthis Certilicale of Exemption, you
u newt. the Workers' n
should Ifeyou
Date 'Revel t#
NEW RESIDENTIAL PLMB. SQFf.
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TOTAL:
most such provisions
s or this permit shall
dammed remust!.rthwdh comply with such provlslon9 orthb permit ehallbe
deemed revoked.
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BUILDING FEE
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SEISMIC FEE
CONSTRUCTION LENDING AGENCYt.
I hereby affirenthzl them is a construction lending agency for the perform
ane of the work for which this permit u Issued (Sec 3097, Clv. C.I
Lender's Name
Leadees Aaarca' -
I centlylhatl have read Ihisappllcaon and hate thattheabove Information
Is correct. I agreeto comply with all city and county ordinances and state laws
TOTAL:
ELECTRICFEE. '
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Qrr. MECHANICAL', PERMIT," '-FEE `
PLUMBING FEE
MECHANICAL FEE
PERMRISSUANCE
FEES PAID:
relating to building mwtrualon, and hereby authotlu representatives of this
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'city toenter uPon the abwv rrdnlloned property for inspection pu rposes.
(We) agree to ave, Indemnify an d keep harmless the City of Cupertino
ALTER OR ADD TO MECH.
Date ReCcipl#
SUBTOTAL:
.gala,lfabill0re, Judgmenta,astaand expenses which may lnanywayaccrue
against said City 1n consequence of the granting of this permit.
'
AIR HANDLING UNIT (TO 10,000 CFM)
AIR HANDLING l71VIT (OVER ]0,000CFM)
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CONSTRUCTION TAX
Slgruture of Applicant/Contractor - Data
EXHAUST HOOD(W/DUCD
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (TO 100,000 BTU)
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Will the applicant or future building occupant store or handle hazard...
material a defined by the Cupertino Municipal Code, Chapter 9.17, and the
Health and Safety Code Section 25532(a)7-
❑ YeaNo
Date Revel t#
HEATING UNIT (OVER 100,000 BTU) '
—
TOT
VENTILATION FAN (SINGLE R1iSID)
-ISSUANCE DATE '
Will the applieant or .turn building occupant use equipment or devices
which emit hazaod... air contaminants ore defined by the Bay Arca Air
QualityManagementDihdnt
Yea No
ave mord the �'requircme oder Chapter 6.95 o!
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PAI /
BOILER -COMP OHP OR 100,000 BTU)
BOILER -COMP 100,000 BTU)
the IIlornla Healct 533 and 75534.E
W 1 D
NEW RESIDENTIAL MECH. SQ.IT.
Ands ti(te I ave atenanq that It is my
V�bu
respo ility ton t rcmentswhkh mus(be mat'epI1spa
..
"O V 4 #�
ISSUEU BY:
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71-
neror authMzed agent t
TOTAL:
OFFICE COPY