20307APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLYa
Building Project Identification
Building Address:
PERMIT NO.
/'� ^
/0/00 & Uc- ,u o Dl. /
O O
G 3
(Jwe e ams:
one:;:
Contractors Name: Lic
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
D
_
BUILDING-ELECTRICA4PLUMBING-MECliAMCAL
CATEGORYC
NTROLM
Architect/Engineer. Lk. No
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO -
Add. -
1y F%r [!iLJ/ Er
1 �i LJ l_7
PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION
I herebyaffirmthal lam 11cenaedunderpmvWoneof Chapkr9(commen
it... ISection 7000) of Dlvlsiect. NeguslnessandPro(eWonsCade, and my
ligwithS (uara
to.
APPLIANCES -RESIDENTIAL
JO p DISC N
'`,.,
rl6/(\(1J`/I'„Jarl�yjJ(
PANELS
Lienee Class Lk.a -
Date ContractorUP
TO 2DO AMPS
201-1000 AMPS
ARCHITECTS DECLARATION
I understand my plane shall be used as public records,
OVER1000AMPS
SQ. FT. FLOOR AREA
$/SQ.FT.
ISIGNSELECTRICAL
Licensed Profmado.l
SI'ECIALC@CUIT/MISC
OWNER -BUILDER DECLARATION
!herebya(Ormtbatlamexemptfrom
essa Contractor's License Lawforlhe
fouowirs whichequims(Section 7mit to osneu and Professions Cade Anydtyor
countywhlch requlmsa permit to construct, alter, Improve, dennlbh,orrepalr
��
TEMP. METER OR POLE IN57.
anystmctum prbrto Its issuance, alsorequlrestheappaant(orsucb permit to
file a algned statement that he la aroused pursuant to the provisions of the
Contractors License Law (Chapter 9(commencing with Section 7000) of Divi-
Yon3 ofthe Businms.d Professlaa Code)arthat he la exempt thenfmmand
the bask for the alleged exemption. Any violation o! Section 7011.5by any
applicant fora permit sibjeMlheapplkanitoacivllpevltyofns mosthan
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS-SWITCHFSFECAPRFS
VALUATION
�—
NEW RESIDENTIAL ELECTR SQ.FT.
five hundredres (5,500),
owner
I, see owner o! the property, or my employees with wages as their sok
STORIES
TYPE CONSfRLCTION
compensatles, will do the work and the structure b net Intended or offered for
1'� it,
ask(Bet. 7064 Busluss and Professions Code: The Contractoee License Law
v ,u
does not apply to an owner of property who Wn mn,
builds or imprnvl herand
who don such work himselforthrough hlsown employees, provided that such bea
improvements arc not intended proffered (orsale. If, however, the Wilding or
imment
provesald withinomyrufcomplelbNtheavner-builderMit have
TOTAL:
OCC. GROUP
� _�
RES. UNITS'
OW-Ilouden of proving that ha did not build or Improve for purpose ofuk.).
L j L as owner of the property, am exclusively contracting with licensed
contractors to construct the profess (Sec. 70K Business and Professions Code:
QTY'._^': PLUMBING PERMIT FEE
FLOOD ZONE
,
APN
PERMIT ISSUANCE
The Contractors License Law does not apply to an owner of property who
Wilds or Improves thereon, and who contracts fee such pkojeU with a
cgR(pclor(e)acensed pursuant totha Contractors Llnnee La W.
ec
L -f I am exempt under SB k P C (or this reason
ALM -DRAIN &VENT- WATER (EA)
FEE SUMMARY
BACK FLOW PROTECT. DEVICECE
OUTSIDE FEES
DRAINS FLOOR, ROOF, AREA, GOND.
In A asRICE
SANITARY N
Owner Date
WORKMAN COMPENSATION DECLARATION—
❑I hereby affirm that I have • artificem of consent to self -Insure, or a
nrtalaof Warken'Compewtlonlwuranawaartifkd copy thereo((Sec.
Lab Cd
Policy M
FIX•DIRES PER TRAP
OOL TAX Y_ N_
RECEIPT M
GAS EA. SYSTEM -
1 INCA jn ( r3800,
PA FIE Y N
+..uU RECER'IM
Cam any
GAS. EA. SYSTEM -OVER 4 (EA)
BUILDING DIVISION FEES
Uledcopylaherebyfumlehed.
ertified copy b filed with the city Inspection division.
CREASE/INDUSTRL WASTE INTERCE' '1 J of rlln.
RKCHEGK FEE
r1
GREASE TRAP
CERTIFICATE OF UEMPTION FROM WOR KERS'
PAID
COMPENSATION INSURANCE
(Thlseectlon need fiat bacomple[ed Uthe permit lalorone hundred dollars
SEWER -SANITARY -STORM EA 20aF7
Date Recef t#
WATER HEATER W/VENT/ELFLTR
ENERGYFEE Y N
PAID
(9100)ortess.)
ce
1 rtifythat In the pma
erfornceof tha work (orwhkh this permit Is Issued,
1 shall net employ any person In any manner an as to become subject to the
Worksm Compensation Laws of California. Date
WATER SYSTEM/TREATING-
Applicant
NOTICE TO APPLICANT: U, after making this Certiliate of Exemption, you
should become subject to the Workers' Compensation provisions of the Labor
Date Reeel t#
NEWRESIDENTIALPLMB. SQFr
TOTAL:
BUILDING FEE
Code, you must forthwith comply with such provisions or this permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
SEISMIC FEE
Iherebyafflrm that then lea construction lending agency for the perform
once of the work for which this permit b Issued exec. 3097, Civ. C.)
Lender'. Name
Lenders Address
I nrtilythal I havereadthle appllationand katethattheabove Information
Iscorred. I agree to comply with all cityand county ordinances and Yate laws
TOTAL,
ELECTRIC FEE
PLUMBING FEE
-
QTY. -, MECHANICAL,PERMIT , FEE' -
MECHANICAL FEE
PERMITISSUANCE a
FEE _PA ID:
relating to building construction, and hereby authorize representativn of this
city to enter upon the above-mentioned property for lupectlon purpose.
(We)agree to uve,Indemnify ent,cost.andknpharcrUesswhich the in any
Cu portionmy.cma
age lmtllabRltln,judgments, expenses whish may in anywayacvue
ALTER OR ADDTO MECH.
Date Receipt#
AIR HANDLING UNIT 10,000 CFM)
SUBTOTAL:
a7
ceof
against said C, Inco ern (t an ng of this penmlt.
AIR HANDLING uFrlT rovEt 10,000 CM
CONSTRUCTION TAX
Sigmture of Appaonl/Contractor mt.
EXHAUST I IDOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAZAR DOUS MATEC6DI SCLOSURE
HEATING UNIT (TO 100,000 BTU)
Date Recel t#
Will the applicant or future building occupant atom or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.1 2, and the
Health ami Safety Code Smilon 25532(a)I
YeaNo
HEATING UNIT (OVER 100,000 BTI))
TOTAL:
VENTILATION PAN (SINGLE REBID)
ISSUANCE DATE
�Vltl the epplianto uwmbuildingoccupantuseequipmentordevicxs
which emit harardous air contamhnnb as defined by the Bay Area Air
Quality Managen ort District?
Yee No
BOILERLOMP OHPOR Iffy= BM
BOILER -COMP (OVER 100,000 BTI)
have read the h.9 us materials requirements under Chapter 6.95 of
the California Health k Safety Code, Seettore 25505,25533 and 25534. 1
understand that if the building does not currently have a tenant, that it is my
J [gypp``,,
1 .,, 1 J tss7V
NEW RESIDENTIAL MECH. SQF.
responsibility to notify the occupant of the requirements which cont be met
prior to issuance of a Certificate of Occupancy.
/�
CIty ofrBnertlnn
ISSUED BY: �'j• `1
Ownnrarauthorlaedagent Date
TOTAL:
OFFICE COPY .