20303APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
Building Project Identification
Budd Ong Add rete: ,
PERMIT NO.
0 00Yroee� E QAJ 00 CD1. i
20303,
nor.
E
CITY OF CUPERTINOtBUILDING DIVISION
APPLICATION / PERMIT
BLIILDINGELECTMCAL-PLIIMBINGMECHAMCAL
Contmeme. ams: Lk. No:
V / r
CATEGORY
CONTROL N
Archi ed/Engineer. Lie. No,
ELECTRIC PERMTT FEE
BUILDING PERMIT INFO
-QTr
Add.
ler 1�
PERNUTISSUANCE
LICENSED CONTRACTOR'S DECLARATION
Iherebyaffirm that am licensed under prwWonsofChapter 9 (comment,
Ingwith Se on7000)o(Dlvigm3afthe Burin mdProfe onsCodeandmy
license Is in (u8 forte Land effect
License CLss Lkec
APPLIANCFSRESIDENTIAL
JOB DMC ON
"� A Nr
5:F,
.�1 �.1^ ^
PANELS
Date Contactor
UP TO 2DO AM
�r�\J L(.1.{l
2014000 AMPS
ARCHITECT'S DECLARATION
I understand my plansehsl be used u public records. -
OVERIODOAMPS
SQ. FT. FLOOR AREA
S/SQ. FT.
SIGNS ELECTRICAL
Ltoomed Professional
SPFCIALCIRCUIT/M1SC
OWNER -BUILDER DECLARATION
I herebyaffinnthat I an, exempt from the Contractors License Law for the
f.D.wingaason.(Swi..70315,Budnenand Profenbns Code Mydtyor
muntywhichrequinaapemdtWmmlruc"ten, pmve,demolish,orrepair
�]�(��
/
�(p METER OR POLE MST.
anystmciurc prbrlo lb Wuance,aborequlmthe appBunt(er ouch pemdtto
Ole a signed statement that he Is licensed pursuant to the provisions of the
C-otmen'. License Law (Chapter 9(commencing with Section 7DOO) of Divi-
skn 3 of the Business and ProfessbnsCods) or that he b exempt therefrom and
the basis for the alleged exemption. Any violation of Section 70315 by any
applicant fora permit •ubjectathe applicant to a civil penalty of not mon than
POWFRDEVICFS
/
SW004NENG POOL ELECTRIC
OUTLETSSW ITCHESFIXfURES
VALUATION
Q( /
five C]Lasrowearc thepro
❑ L, as ower the properly, or empbyen with wages there mk
NEW RESIDENTIAL ELECIR SQ}T.
SORTIES
TYPE CONSTRUCTION
ll he r
mm 15m,70ry Busio the ness
sale (Sec 7614, And rKand thestmcie:TheCure is intended orofferedLa r
and Cade: The License Law
V
TOTAL:
to an ow f property or imps me
does noesapplysuch torn owner dpnpertywho buildsorim,provied that such
who dvesmch are ntlmself or tendedhroughed ownemp, however,
provided Wilting or
Improvements arendlninded caroic mplotifor k. If, tower-but&WlWl have
improvement bwldwlthlnomycaro(compldbnthe owner-bullderwlil have
OCC.GROUP
�'�
RES, UNITS
OILIiurden of proving that he did not build or improve for purpose of sale.).
LJ L as owner of the property, am exclusively contaRing with Beensed
contactors 61, to construct the projed(Sm 70Business and Professions Code:
6TY FEE
,., ,PLUMBINGPERMIT
I'QtMRI�TlANCE ,
FLOODTONE
APN
The Contnat&z License Law don not apply to an owner of property who
Wilds or Improves thereon, and who contracts for such p(ojects with a
mpllectar(s)Ilmneed pursuant to the Contractor's Llcenae Law.
151 am exempt under Sec. B & P C for this naron
ALTER -DRAIN & VENT - WATER (EA)
i FEE SUMMARY
BACK FLAW PROTECT. DEVICE
OUTSIDE FEES
/
DRAINS FImRROOT', AREA, COND. rb'I�.i+
NCPARY Y N_
J
RECEIPT .
Owner Date
WORKMAN COMPENSATION DECLARATION
E31 hereby affirm that I have a certificate of consent to se f4resure, or a
curtificate o(Worken'Compensallonlnsuranaera certified copy thereof (Sec.
3500. Lab CJ
Policy Y
FIXTURES. PER TRAP-
SCHOOLTAX Y_ N_
REC EIPT N
GAS FA. SYSTEM -1 OUTLETS
Y N —
RECEIPT N '
Com
any -
GAS EA. SYSITM-OVER 4 (PA)
BUILDING DIVISION FEES
coed copy b hereby furnished.
P. Pied copy b filed with the city Inspection diviclon.
GREASE/INDUSTFU. WASTE INTERCEPTOR
PLANCHECK FEE
GREASETRAP
CERTIFICATE OF EXEMPTION MOM WORK ERS'
PAID
COMPENSATION INSURANCE
(TMssection need not be completed lithe permit lafor one hundred dollars
Date Recei t#
SEWER-SANITARYEA 200FT
WATER HEATER W/VENT/ELECTR
ENERGY FEE Y N
(SI00Om
fy th that in the
I certify the performance o(ehewark (orwhlch this permit Issued,,
WATD2 SYSIFM/TREATING
I shall not employ any person In any manner m as to become subject to the
W.Arra Ccmpensatim Laws.( California. Date
PAID
ApplicaN(3TTCnt
NOTICE co APPLICANT: a atter making pea Certificate is Exemption,eLyou
become to the Workers'
NEW RESIDENTIAL PLMB. SQbT.
Date Repel t#
TOTAL:
BUILDING FEE
, p
Code,shoul
forth
Code, rnked. forthwith comply with such provbkns orthb permit shall be
such provisions or
deemed cooked.
SEISMIC FEE
11075
CONSTRUCTION LENDING AGENCY
laamrutmRlon lending agency CIv. .) perform,
Thereby ffirmorkfo which
anu piste work br whish this permit V blued (Sec. 307/, Clv. C.)
1.oe er'. Name
Lemler9Address
I mnlfy Outl have readthiscppliutionend natethatthe above Information
kcorred. I agree to comply with all city and county ordinance and gate lawn
TOTAL:
ELECTRIC FEE
PLUMBING FEE
.-
QTY. � �i MECHANICAL PERMIT.
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID:
relating to building construction, and hereby authomer representatives of this
dtyto enter upon the •bove entloned property for WpeRlon purposes.
(We) agree to ave, Indemnify an d keep harming, the City of Cu penin.
aga Wt llabOltles, pdgments,cons and expenses which may In any way accrue
ALTMORADDTOMFCH.
Date ReCei t#
F
AIR HANDLING UNIT (TO 10,00) CFM)
SUBTOTAL:
s%
agaWt aid ncypWupntt of anon 4lhh pemnit.
/�J
AIR HANDLING UNIT (OVER IO,000CFM)
CONSTRUCTION TAX
�fe%L��%
Signature of Appllunt/Contractor IAm
EXHAUSTHOOD(W/DUCI)
CONSTRUCTION TAX PAID:
HAZARDOUSMATERMINDISCLOSURE
HEATING UNIT (TO IO(LODO BTU)
Date Recel t#
Will the applicant orfuture building ottvpant atom or handle haaardoun
material as defined by the Cupertino Municipal Code, Chapter 9.12 and the
Health and Safety Cade Section 2S32W}
❑ Yes No
HEATING UNIT (OVER 100,0011 BTU)
TOTAL:
a T
VENTILATION PAN (SINGLE RFSID)
ISSUANCE DATE
Will the applicant or lure building occupant use equipment or device
which tent hares dour air contaminants as defined by the Bay Area Air
Quality Management District?
Yea❑ No
Oil
OIil
BOILER -COMP OHP OR 100,000 BTU)
BOILER-COMP(OVER 100,000 BTU)
have read the hmardous materials requirements under Chapter 6.95 of
the California Health&Safety Code, Sed ions 25505, 25533 and 25536.1
understand that lithe buddingdonnm currently have&tenant, that It is my
tl'
NEW RESIDENTIAL MECH. SQ.FT
responsibility to notify the occupant of the requirements which must be met
prior to Issuance d a Certificate of O=pa my.
ys
Cityof r nin..1`.a
ii3ntsl)
ISSUED
Ownerorad
uth.na.agem Date
TOTAL:
BY.,
OFFICE COPY