20311APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project
ldandfWelan
Building Address:
PERMIT NO.
1 1
O1 oil E VE• IUIT III I. 1
.
Y 0 3
caner.
A
/ES
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
contracior.wme: Llc. o:
BUILDING-ELECTRICAI PLUMBING -MECHANICAL
CATEGORY
CONTROL X
Arcisitett/Engineer. Liv. Nn
QTY ELECTRIC PERMIT . FEE
BUILDING PERMIT INFO
Address:
E!iY �' .-V
L�
PERhITISSUANCE
LICENSED CONTRSDECnsodChON
I hthsy..7000that lamlicensed si=3ofheBuM...nd PofftM pter9(mmmenc
under
Inense 1. 1. fullto Andlvfect. oltheBusinenand PmfevlonaCode,and my
Ilmnw le ie full form and effect.
Llcenw Clan Lk.p
APPLIANCESRESIDEMIAL
]O t5C N
.tel as n
'
PANELS
Date Contncior
UP TO 2DO ANTS
101.1000AMPS
ARCHITECT'S DECLARATION
I understand my plans shall be used As public records.
OVER IOW AMPS
SQ. FT. FLOOR AREA
$/SQ. FT.
SIGNSELECTRICAL
Licensed Professional
Sl+p-CIALCiRCUfT/MISC
OWNER -BUILDER DECLARATION
I
folloherebyaffirm that lam exempt from the Contractor'. License Law for the
wing rescan. t5ecilon 7mlS, Buanen curd Professions Code: Myciry er
county which requires a permit mrutruct, alter, improve, demolish, ormpalr
`
TEMP. METER OR POLE INST.
anystructure prlorto its beuartce,aborequirmthe appBmntforsuch peredtto
file a signed statement that he is licensed pursuant to the provisions of the
POWERDEVICRS
SWIMMING POOL ELECTRIC-
OUTLRTSSWITCHESFIKTURES
Contractors License Law(Chapter 9(commencing with Section 7000) of Divi-
ivi-
Alcoa
don3af the Buslnesaand Pro(emlonsCode)orlhat hebeumptherefromand
the iasis for the alleged exemption. My violation of Section 70315 by any
Applicant fora permit subjects the applicant to a dull penalty of not morethan
VALUATION A
V
NEW RESIDENTIAL ELECTR SQ.FT.
flt�uns rd owner (epm -
7, as owner of the property, or my employee with wage. as their seta
STORIES
TYPE CONSTRUCTION
compensation, will do the work and the structure is not Wended or offered for
sale (Sec 7014, Business and Professions cens
Code: The Contractors IAe Law
��
N
doe not apply to an owner of property who builds or improves thereon, and
who does such work himselforthrough hisown employees, provided that such
imprornmentsmenot intended oroffered for sale. If, howeveg thebullding or
TOTAL;
OCC. GROUP
''''////���� _
R%t
RES. UNITS
-
improvement iswld wilhinoneyearofcompldiomtheowner-buBderwill have
s �l
tliLtsuden of proving that he dim eat build or Wpmve for purpose ofule.).
LJ licensed
G as owner tr the property, am exclusively Business
construct ject ess contracting Professions Code;
QTY; " PLUMBING PERMIT. FEE
FLOOD ZONE
MN
PERMITISSUANCE
lbaconContractor's Law
The Contractor. License Lw tlm, mho apply to en owner of property who
due( nor apply to owner of pro er
builds or Improves thereon, and who contracts for seL Pro)eRs with a
,➢tfactor(s)Bcensad pursuant loth. Contractor's License Law.
"I am exemp order Sec B A, P C for this rescan
ALTER -DRAIN k VENT- WATER BIN
FEE SUMMARY
BACK FLOW PROTECT. DEVICE'
DRAINS FLOOR ROOF, AREA, CONTI.
SANITARYY N
RECEIPT
Owner Data
WORKMANCOMPENSATIONDECLARATIONFICilJRES
❑I hereby affirm that I have • certificate of consent to self -Insure or
certificate of Workers' Compensation Insurance ora certified copy thereof (Sec.
MOO, TabCJ
PER TRAP
SCHOOL TAK Y_ N_
RECEIPT p
GAS EA. SYSTEM -I INCA OUTLETS
PARK FEE Y_ N_
RECEIPT p
Cop X
Commany -
GAS EA. SYSTFNLOVER4 (FA)
BUILDING DIV] SION Fr. CS
Ified copy is hereby furnished.
crllBed copy b filed with the city Inspection dlWalon.
CREASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE
GREASETRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
PAID
SEWER -SANITARY -STORM EA 200FT
COMPENSATION INSURANCE
(This section need not be completed lithe permit toluenes hundred dolian
Date Revel t#
-
WATER HEATER W/VENT/FI TR
ENERGY FEE Y N —
PAID
3100)mless.)
I mrtifythat lntheperfomm
anmefthewerk forwhichthls pedtlslnued,
1 shall nm employ any person In any manner w u to become abject to the
Workers' Compensation Lawaof California. Data
WATER SYSTEM/TREATING
Applicant
NOTICETO APPLICANT:1f,after making this Certificate of Exemption, you
should become wbj"ct to the Worken'Compenatlon provisions of the Labor
NEW RESIDENTIAL PLMB.SQFT.
Date Rece1 t#
TOTAL:
BUILDING FE
Code, you =at forthwith comply with such provisions orthb parent shall be
deemed revoked.
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirmthat there In amnswctlon lending agenry for the perform-
anm of the work for which thio permit b issued (Sec 3097, Civ. C.)
Lcrder. Name
Lenders AddmAT
I cenifythatf have reaathbapplicationand Yatelhattheabove information
Is correct. l agree to complywith all city and county ordinances and state law..
TOTAL:
ELECTRIC FEE
PLUMBING FEE
-
QTY. ' ' ;,.MECHANICAL PERMIT, 'FEE
PERMITISSUANCE
MECHANICAL FEE
FEES PAID:
relating to building construction, and hereby authotlu representatives of fhb
citytoenterupontheabov nncmtlooed property for bapecilon purpmes.
(We) agree to save, Indemnify an d keep harmless the City of Coped Ino
against lbbWties,Odgmenb, costs and expenses which may In anywayacorue
-
JALTERORADDTOMECH.
Date Receipt#
AIR HANDLING UNIT (TO 10,000 CFM)
SUBTOTAL'
16
agailn anm glthe anti of this permit
/- —j/ /
AIR HANDWNG UNIT (OVER 10,000 CFM)
CONSTRUCTION TAX
Signature of Applicant/Contractor `7 Date
IXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERInSDISCLOSURE
HEATING UNIT (TO 10D,000 BTU)
Will the applicant or future building occupant store or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 91$ and the ,
Heallhand Safety Code Section25532(a)i
❑ Yea No
Man
Date Recei t#
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
43 D
VENTILATION FAN( SINGLE RESID)
ISSUANCE DATE
Will the applicant building occupant use equipment or devices
which emit hazardous air contaminant.., defired by the Bay Area Air
Quality Management District?
❑❑ No
BOILER -COMP OHP OR 1 W,0(D BTU)
BOILER -COMP (OVER IW,000 BTU)
4Yea
havcneed the haadousmaterials requirements underChaper6.95of
the California Health k Safety Code, Sections 2SSGS, 25533 and 25534.1Ll
understand that if the building does not currently have a tenant, that it b my
maponsibllity to notify the occupant of the requirements wh lch must be mrd
prior to issuance ofa Certificate of Occupancy.
_
•�
fs y,
CIl� Ofr.tl)P,rtlBl)
NEW RESIDENTIAL MECH. SQ.FT.
ISSUED B 611
Owner or authorized agent Data
TOTAL:
OFFICE COPY