20312APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification
Build Ing Address:
42/00 7aze.E &JE 01JI //a Doi.I
PERMIT NO.
Z 0312
en ante: one:
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CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION /PERMIT
D
L
Cmtrector'e Name: Lie. No:
BUILDING ELECTRICAL-PLUMBINC MECHANICAL
CATEGORY
CONTROL N
Architect/Engineer. Lie. Na:
`QTY ELECTRICPERMIT FEE
"BUILDING PERMIT INFO
Address:
f -/Y I�
[_1l FJ
PERMITISSUANCE `
LICENSED CONTRACTOR'S DECLARATION
Ihthb ifirmlhafDlvicmwd under mvWonsol Chaptec9( anrn
Ingweh I.fon(a.anDividon3of[heguelnauandProfnelOnsCode,and my
Bronx is in full torr_ and effect.
APPLIANCES -RESIDENTIAL
S r_j08 N
PANES
Cls® LIO N
Date
Date Cantndor
UP TO 2DOAMPS
2014WOAMPS
ARCHITECTS DECLARATION
I undentaM my,plans eha8 be usMupubllc temrds
OVER IOOO AMPS
SQ. FT. FLOOR AREA
E/SQ.FT.
SIGNS ELECTRICAL
Licensed Professional
SPFGIALCIRCUIT/MLSC
OWNER -BUILDER DECLARATION
I hereby of rmthat l am exempt from the Contracture License Law for the
county greased(imsperg reason. (Sucton m31.5, Business itmomutmctandProfessions prove,Code:Anytltyor
county which requiresa pemnitromnswgalten improve, demnlhh,orrepair
�.L
v
/.�
7t.�•� CAN
i
�P.METERORPOLEINST.
any structure prior to Its Issuance, also requires the applicant for such Fermat to
file a signed statement that he is licensed pursuant to the provisions of the
Contractors License Law (Chapter9(mmmenclng with Section MOO) of Divi-
_km3 ofthe Businmand PmfembruCode) orthat he is exempttherefromand
the balls for the alleged exemption. Any violation of Section 7011.5 by any
appllantfora permitsubjectatheapplIcanttoa civil penaltyfnal morethao
POWER DEVICES
!/
SWIMMING POOL ELECTRIC
OUTLEISSMTCHMFIXTURES
VALUATION
�-• "
, i 7 • 400
NEW RESIDENTIAL ELECTR SQXT.
Bv�c,�undreddoRaza(5500).
u I, as owner of the property, or my employers with wages as their sole
STORIES-
TYPE CONSTRUCTION
compensation, will d a the work. and the structure isnot intended or offered for
sole (Sec 7004, B. uses, and Professions Code: The Contractors Llaue law
_
does not apply to w owner of property who builds or imprxwes thereon,and
who doesauch work himself orthrough his own employees, provided that such
Improvements are not Intended oroffered Ionil_. If, humvepthebuildlegor
improvement hsoldwBhinoneyearofcompldve
ion, theownenlruilderwill ha
TOTAL:
.
OCC, GROI1Ts
A ii —3�
RES. LINES
the burden of proving that he did nm build or Improve for purpose ofule,).
L as owner of the property, am exclusively contracting with licensed
contractors to mnsWct the project (Sec 7014, Business and Professions Code:
QTY. ,;:' . PLUMBING PERMIT ,.FEE
FLOOD ZONE
APN
I'EtMITrem rANCE
The Contractor's License law does not apply to an owner of property who
builds Or Improves thereon, and who contracts for such p(ojects with a
c9atractot(s)Bernard pursuant to the Contractor's License Law.
I -J I am exempt under Sec B & P C for this mown
AL7ELDRAIN &VENT -WATER (EA)
FEE SUMMARY
BACK FLOW PROTECT DEVICE
OUTS[ DE FEES
DRAINS FLOOR ROOF, AREA, COND.
SANITARY Y_ N_
, RECEIFT
Owner Date
WORKMAN COMPENSATION DECLARATION
C31 hereby a((Irm that I have a mdlOcate of consent to self -Insure, ora
certificateO(Worken'Compereationlnsunnm on. certified copy thereof(Sec.
3800, lab C.)
FIXNRFS PER TRAP
SCItOOL TAX Y
_ N_RECEIPT N
GAS EA.SYSTEM-1 INC.4 OUTLETS
PARK FEE Y N
RECEIPT Y
Policy N
Comm sank
GAS EA. SYSTEM -OVER 4 (EA)
BUILDING DIVISION FEES
O Ned copy h herebyfurnished.the city
ertl(led ropy h Ned with the city Inspection division.
GREASE/INDUSIRL WASTE INTERCEPTOR
PLANCHECKFEE
GREASE TRAP
CERTIFICATE OF FXEMPEION FROM WORKERS'
PAID
COMPENSATION INSURANCE
(Thlsavedoa need net be completed lithe permit b forom hundred dollars
SEWER -SANITARY -STORM EA. a]OFf.
Date RC i til
WATER BEATER W/VENT/ELECTR
NERGY FEE Y N
(S100)Orless)'E•
I mrtitythat In the performance of thewerk ferwhich this permit is issued,
WATER SYSTEM/TREATING
I shall not employ any person In any manner w as to become subject to the
Workers' Co npenaatlon laws of Collfomia. Data
PAID
AppilcaNOTICE
NOTICE co APPLICANT: a after making thin Certnlpro of Exemption, you
some, become subject to the Workers' provisions of the Lobar
NEWRFSIDENTIALPLMB. SOFT.
Date Re i ti!
TOTAL:
UI G
r
Cods you must forthwith comply with each provisions orthla Fermat shall be
such p
deemed revoked.
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a mwtructlon lending agency for the perform
ance of the work for which this permit is Issued (Sec. 3097, Civ. C.)
Lender's NamePLUMBING
Lender's Address
I certifylbatl have read thbappliatlonand statethat theabove Information
is canard. Iegmeto comply with all cityand muntyordinanme and state laws
TOTAL:
ELECTRIC FEE
FEE
t
QTY. '" , MECHANICAL PERMIT;"". !' "IEE•
MECHANICAL FEE
PERMITISSUANCE
FEES PAID:
relating to building construction, and hereby authorize representatives of this
city to enter upon the above-mentioned property fee Inspection purposes.
(We) agree to save, Indemnify an d keep h rrol. the City Of Cupertino
against llabilltics, pdgmenn, costs and expenses which may in anyway accrue
"
ALTER OR ADD TO MECH.
Date Receipt#
AIR HANDLING UNIT (TO 10,000 CFM)
SUBTOTAL•
agalrat xl o hegr nting of this perm t
�Szri/�
-
AIR HANDWNG UNIT (OVER 10.000CFM)
CONSTRUCTION TAX
Signature of Applicant/Contractor r ate
EXHAUSTHOOD(W/DUCT) -
CONSTRUCTION TAX PAID:
HAZARDOUS MA ALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous
material as defined by the Cupertino Munidpal Cade, Chapter 9.12, and the
Heallb and Safety Code Section 25932(a)I
i—I Yes L] No
Bl the applicant or future building occupant use equipment or devices
HEATING UNIT (TO 100,ODO BTU)
Date Recei tN
BEATING UNIT (OVER 100,000 BTU)
TOTAL:
VENTILATION FAN (SINGLE RESID)
ISSUAI"�
�.A ATE
which _mal hazardous air contaminants as defined by the Bay Area Air
Quality Management Dhtddl
YeaveNo
4harcadthehaza2usmaterialsrequirementsunderChapter6.95of
t't'(•�' d IQe�/4J
0
BOILER -COMP DHPOR 100,000 BTU)
BOI rR-COMP(OVER 100,000BTU)
the CalifomW Health&Safety Code, Sections 25505,25533 and 25534. 1
understand that If the building does not currently have a tenant, that It is my
(f�
NEW RESIDENTIAL MECH. SQFL
rcsponsiblllty tO net lfy the occupant of the requirements which =sibs met
prior to bruance of a Certificate of Occupancy.
iS4UED BY: D 'Vc J
Owner or authorized agent Data
.,
TOTAL:
OFFICE COPY