20314APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Pro ect Identification
Build
PERMIT NO.
0
idoo 72)"'E- E. AJ-
Z 314 ..
Owner. Name. v one:
AVIL1CAIIKJNSU5M111ALDALiL
Conlrm r'aName: Wc.No:
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT � '
D
CATEGORYCONTROL X
- BUILDINGELECnUCAI PLUMBING hCKHAMCAL
Amhltecl/Englrser. Lie. No:
QTY ELECTRIC PERMIT pgg
BUILDING PERMIT INFO
Add.. '•
Imo'
I'FRh9iIS5UANCE
LICENSED CONTRACTOR'S DECLARATION
Thereby dflrmthat [aiv Bcmse4 under ftheBupemandP (CsionsCodhapterg c amenc
in Pro(nelonaCade,and
1.fell 70res
APPLIANCFSRESIDENTIAL
)i
�_�v�0
ease 1. and dfron3oltheguslnerand
license le in (uB force and dfect.
Llcanse Cler Lk.X
PANELS
Dale Contractor
LE! TO 200AMPS
—
201 -IOW AMPS
ARCHITECTS DECLARATION
1 understand my Flaw shall be used s public records.
OVER 1000 AMPS
SQ. FT. FLOOR AREA
$/SQ. FT.
SIGNS ELECTRICAL
Licensed Professional
OWNER -BUILDER DECLARATION
Contractor's License Law for the
Thereby-.(Natiam exempt A Business
followingreason.(Seatfpe7 two Budnes and Propmve, emlCode hnycilyor
county hichMmrequlmsape tomulmct,alter,Improve,demolish,eretto
SPECIAL CItCI11T/M15C
ry,D ass
,\/J,
��.
q�p METER OR POLE INST.
a
an . signere statement he is licensed to the lmsuions of it a
file a signed c[atement that he is licensed pursuant to the provisions o! the
thatpursuant
Contractor's License Law (Chapter 9(mmmencing with Section 7000) of Divi-
skm3 ofthe Budnenmd ProfemionCode)or Nat heis exempitheref emand
POWER DEVICES
SWDANUNG IDOL ELECTRIC
VALUATION
the basis for the alleged exemption. Any violation of Section 7011.5 by any
applicant fou permit subjects the applicant to a civil penalty of not more than
OUTLETS -SWITCHES -FIXTURES
(�J (,-� Q 0 ,
I
NEW RESIDENTIAL ELECTR SQFT
flue i, ., dollars ($50B.
T, as owner the property, ass my empkryen with wages as there dole
V'S
STORIES
TYPE CONSTRUCTION
compen❑ tion,will
wllldoMeweak estructure not Intended o
iofferedfor
.1. Sec.
uk (Sec appy xina
e and Professions Code: The Contractors Limns, Law
h
to an o mR and
. ea not apply to res owner of propertyghhis
o nem oyees, prves ovided
whodoe eatsuch amrkMmself nded oroffered own�. If,hoes,p ,the br ildlsuor
Improvementaared withindneyearferect(orsk.TLenvoe,builderwillog have
Improvement issold within oneyear,(complMbn,theowner-bu0derwlll have
TOTAL:
,
QTY. "'. PLUMBING PERMIT rEE
OCC. GROUP
R 1z
RES. UNIT'S
the burden of preving that he did not build or improve for purpose of rte.).
0 L as owner of the property, am exclusively contracting with licensed
contromest. mnsmad the project(Se 7044, Busher and Profeulons Code:
PFRMITISSUANCR
FLOOD ZONE
APN
The Contractors License law does not apply to an owner of preperty who
builds or improve therein, and who contracts for such pko)ects with a
actor(.) pursuant to the Contred,rr License Law.
cgR((m
lJ I am exempt under Sec. B A P C for this rean
ALTER -DRAIN & VEM-WATER (FA)
FEE SUMMARY
BAIX FLOW PROTECT. DEVICE
DRAINS FLOOR ROOF, AREA, COND.
SANITARY Y_ N_
RFOEBT X
Owner Date
WORKMAN COMPENSATION DECLARATION
❑1 hereby affirm that I have a certificate of consent to self -In um, or a
carllBcale of Workeri Comperuallon Insurance me nrtlfied copylhereof (Sec.-
3800, Lab C.)
Policy
I9XNRF&PER TRAP
SCHOOL TAX Y_ N_
REGm'T X
GA SFA.SYM-11NCAOUTLETS
PARKFEE Y_ N_
RECEIPT
XGAS.
X
Com any
EA. SYSTEM -OVER 4 (EA)
BUILDING DI VISION FEES
Cardlied copy is ed -Me
thty
,Allied copy is flied hereby futh the cityimpaction division.
GREASEANDUSIRL WASTE INTERCEPTOR
PLANCHECK FEE
GREASETRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
PAID
COMPENSATION INSURANCE
(fhlss km need not be completed lithe permit Is fevore hundred dollar
Date Recei t#
SEWER -SANITARY -STORM EA. 200Rf.
WATER HFATERW/VENT/ELECTR
ENERGY FEE Y N
PAID
(5100),rfer.)
Icartlfytha[isthe performance o(Nework forwhkhthls Femur is Issued,
1 shall net employ any person In any manner so as to become subject to the
Workers' Compensation laws of Callfornla. Date
WATER SYSTEM/TREATING.
ApplicaNOTICE
NOTICE m APPLICANT: a after making this Certificate of of
should bemnre sub)ect to the Workers' Compenutbn provisions of the Labor
Labor
NEW RESIDENTIAL PLMB. SQ}T.
Date Recei tN
TOTAL:
Code, you moat forthwith comply with such previslons or this permit shall be
dnrtad revoked.
BUILDING FEE
41in"Ll. D
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that there iso contraction lendingagency forthe perfom,
ance of the work for which this permit is blued (Seo 3097, Civ. Q
lander, Name
Lender's Add..
Imrtlfythatl have read thisappllnthmimd natethdthe above Information
Is cornet.] sgreeto comply with all cllyand county ordinances and Mate laws
TOTAL:
ELECTRIC FELE
PLUMBING FEE
-
CITY. MECHANICAL'PERMIT FEE
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID:,
relating to building c,nstmctlon, and hereby authorize representatives of this
city to enter u pan the above-mentioned property fee inspection purposes.
(We) agree to uve, Indemnify an d keep harmless the City of Cu Fatten
agalrt Babdities, Pcigmenb, mals and expend which may in any wayacome
ALTERORADDTOMECH.
Date Receipt#
AIR HANDLING UNIT (TO 10,000 CFM) -
SUBTOTAL:
agatest cald�t �query� f�s,gr/a, ling of thlapermit.
�Cb•�
AIRHANDLING UNIT (OVER 10,000CFM) -
CONSTRUCTION TAX
Signature Applicant/Contractorate
EXHAUST HOOD (W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MAT ALS UIS LOSURE
HEATING UNIT (TO 100,000 BTI)
Will the applicant orfulure building occupant atom or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.1 2, and the
IIn❑It Yand ea Safety Code SeNian 25532(.)]
Will the applicant m❑❑fumm building occupant use equipment m devices
Date Recef [il
HEATING UNIT (OVER 100,000 BT()
TOTAL:
VENTILATION PAN(SINGLE RESID)
ISSUKVs�aqYNTE
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management District?
Myer �No
have readth, Fav oua materials requirements under Chapter6.95 of
( r IU41J
I I•ii e' J
BOILER -COMP OHP OR 100,0110 BTI)
BOILER-COMP(OVER100,000 BTU)
the California Health k Safety Code, Sections 25505,25S33 and 25534. 1
understand that if the building don not currently have a tenant, that 11 is my
responsibility to notify the occupant of the requirements which most be met
City of C11n(+.t1ion
NEW RESIDENTIAL MECH. SQ.FT.
prior to ussua om of a Certificate of Oompa nty.
ISSUEDB 1 _ •'V '
Owner or authameed agent - Date
TOTAL:
V
OFFICE COPY V