23673APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Ii Project Idebtiflotims
Building
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23673.,
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CITY OF, CUPERTINO-BUILDING DIVISION.
APPLICATION / PERMIT
BUILDING-ELECTWCALPLUMBING-MECHANICAL
/k -
7
j��,trors Name: J uc.N/°/:
' C t7. "J— /'�
CATEGORY -
CONTAOLN _
ted/Engleeer. Lic. No:
�Q1Y +•,' 4 „ ELEGTI-jRICPERMIT s+�'"'FEE s
' i BUILDING PERMIT INFO
Addreui
PEPMTISSUANCE
LICENSED CONTRACTOR'S DECLARATION
Thereby offlan that l amlicensed under provlsl°nsofChapter9(mmmnc
'ngwlthSenlon9(100)of DiAslon3afthe Buslnessand Pref"wmsCo andm
limnselelnfu jjpprcnan effect
If
Date Contractor (%offUP
ARCHITECT'S DECLARATION f(r
I understand my pansshallbe used as public records
APPLIANCES -RESIDENTIAL
JOB DFSCRB'ITON
IY1V OcT
04r-
&T7P,_
PANELS
TO 2i00AMPS
20]-IppO AMPS
OVER 1000 AMPS
SQ. I. FLOOR AREA
$/SQ. FT.
SIGNS ELECTRICAL -
Licensed Professional
SPECIAL CBtCU1T/MLSC
OWNER -BUILDER DECLARATION
f hereby afRrm that I am exempt from the Contractor's License Law for the
'
TEMP. METER OR POLE!NST.''
following reason. (Section 7031.5, Business and Professions Code: Any city or
countywhlch requlresa permit Wmnstmd, alter, Improve, demolah, orrepaer
'
anystrucrure prior to Its Issuance, also requireathe applicant for such permit to
:file a signed statement that he is licensed pursuant to the provisions of the
Contractors License Law (Chapter9(mmnendng with Section 700)) of Dlvl-
sloe 3 ofthe Rosiness and Professions Code) orthe he a exempttherefromand
POWER DEVICES
''
..
SWDAMNIC POOL ELECTRIC
VALUATION
the basis for the alleged exemption: Any violation of Section 7031.5 by any
applicant for a permit subjects thea pplicant to a civil penalty of not even than
OU7LETSSWITC1iESFIXTl1RES -
'
J
❑On
500)
five hundred dollars ($.
I, as owner of the property, or my employees with wages as their sole
compensation, will do the work and the structure Is not intended or offered for
NEW RESIDENTIAL ELECTRSQ.Fr.
STORIES
TYPE CONSTRUCTION
sale(Sec. 7044, Business and Professions Code: The Contractors License Law
does not apply to an owner of property who builds or Improves thereon, and
whodonsuchworkhlmselforthr gh Msownemployees,providedthatach
OCC.CROUP
-
RIS. UNITS
impro ,amens are not Intended oroffered for sok. If, howevep thebuilding or
improvement bsold within oneyearotcompletion,the owner-builderwill have
this L,orden of proving that he did not build or anprove for purpose ofsale.).
L I, Ise owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7M44, Business and Professions Code:
TOTAL:
QTY.' '` ' PLUMBING+PERMITI FEE"
'
PERMIT ISSUANCE �,. C
✓ VV �Y)i
FLOODIDNE
APN
TM Contractors Urease Law don not apply to an owner of property who
Wilds[EA)
Wilds or Improve thereon, and who contracts for such projects with a
P°
mpJ[actor(el licensed pursuant to Contractor)License law. -
iJ I am exempt under See, B k P C for this reason
ALTER -DRAIN VENT
BACK FLOW PROTECT. DEVICE
,
, •'''+.ii,t..., FEE SUMMARY
"'
DRAINS FLOOR ROOF, AREA, COND.
FIXTURES PER TRAP
SANITARY Y IN
'T'A
RECFJPTN
Owner Data +
WORKMAN COMP I:NSATION DECLARATION
I hereby a01rm that 1 have o Insurance
nsura c of consent to opytneure, or a
certificate ofWorkero Campensationlnsuranreora rertlfled copythereo((Sec.'
380), Lab CJ
Pollry a l Z �J� � l� -�2 -
SCHOOL TAX Y N
- RE03PT a
CAS EA.SYSTEM-1 INCA OUTLETS
iPARKFEE Y N
RECEIPT N
Com any �j �r'r—� YazaVJ
CAS G.SYBTEM-0VER
BUILDING DIVISION FRES
WCe tBedcopyi herebyfurnlshed.
ertBled copy Is filed with the city Inspection division.
/ L,wA' 1MfltCgs-IY�RR
PLANCHECK FEE
RFi3SETRAPV 33 p
. CERTIFIGTE OFEXEMPFION FROM WORKERS'
PAID
"-SAMTAIi •'
COMPENSATION INSURANCE
(TMssedi°n need not W completed If the permit Is forone hundred dollars
Date RCCeI
I#
ENERGY FEE Y N
PAID '
($1000arleas) '
I certify that in the performance of the work forwhlch this permit is issued,
I shall not employ any person In any manner eo u to become subject to the
Workcre'CoATER
peneation Laws of California.Calllo . Date
WA r[EnrFx
x
SYSTEM / ,TREATING
Applicant—
,NOTICE
NOTICE co APPLICANT: If,a titer king this Certificate is Exemption,you
Code, mbthwithect to Workers' Compensation provisions oftpermit
Date Recei
t#
NEW REBIDEN'UAL PLMB. SQ.FC.
TOTAL:
you =a co
Coda you =at forthwith comply with such provisions °rthG permit shall be
shall be
deemed revoked. - �
BUILDING • •E
-
-
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that there Is aconstmctlon lendingagency for the perform
anceof the work for which this permit is Issued (Sec. 3097, Civ. G
Tendxea Name
Address
I certify that[ have read thaapplicatlon and gatethattheabove les(°rmatlm
iscormR. I agree to comply with all city and county ordinances and stale laws
` TOTAL:
ELECTRIC FEE -
QTY. MECHANICAL. PERMIT' FEE i.
PLUMBING FEE
6Vlenders
MECHANICAL FEE
-
PERMIT ISSUANCE
FEES PAID:
relating to building construction, and hereby authorize representatives of this
city to enter upon the above-mentioned property for Inspection purposes.
(We) agree to save, IndemNfy a d keep harmless the City of Cu part Ino
aga last liabilities, Ndgments, costs and expenses which may In any way acerae
again a Cl Inconsequence of tb graNing of tole perm it.
nr�v/94,
ALTER OR ADD TO MECH.
Date Receipt#
AIR HA NDLING UNIT (TO 10,000 CFM)
SUBTOTAL:
,
AIR HANDLING UNIT (OVER 10,000CFM)
CONSTRUCTION TAX
a roof Applicant/ ntmctor ' Date
EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAZAADOUS MATERIALS DISCLOSURE
HEATING UNIT (TO 100,ODO Bile
-
Will the appilrant or future building occupant store or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.12, and the'
Fimithand Safety Code Section 25532(a)i
qYes No
'Date, RCCeIp[#
-
HEATING UNIT (OVER 10,000 BTU)
TOTAL:
a5
VENTILATION FAN(SINGLE RF:SID)
-
ISSUANCE DATE
ill the a ppllce nt orfutu re building occupant use equipment or devices
which smithaesrdoueaircontaminsntsasdelined bylhe Bay Area Air
QualityManagement District?
Yea - No
hlvcread the haaaQ us materials requlrcntents underChapter6.95 of
- -
p
BOILER -COMP PFR'OR IOWDM BTU)
BOILER-COMP(OVERIfIDp000IU)
the California Health k Safety Code, Sections 25505, lEiS33 and 25534. 1
-
A D
NEW RESIDENTIAL: MECH. SQ.FT
u nderstand that it the building does not currently have a tenant, that it is my
responsibility
eheoc tem ocftherequircments which must be metprior
responsibauarce of aCertificate
issuance or a y the c occupant
mrpa mcI
UG q�
AUG 1
_
'
r
ISSUEDO,
Owner or authorized agent Data
-
TOTAL:
OFFICE COPY .