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AnDi lnAKiT Tn 9:1I I IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
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BuildingPro'ect Identiflcatien
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tlu0ding Address: x{� ���
EItMI 21455 1 4 5 5
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ams: one:
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CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BUILDINCELECTRICAIPLUMBINCMECHAMCAL CATEGORY
I� br LL
Cont cera Name: Lic. No:
al/
mL/ '17 84
CONTROLN
Architect/Eaglmen Lie. Nm
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Add.:
PEMTISSUANCE
LICF.NSEDCONTR DECLARATION
Thereby affbmthatlam Bcmunder etd under provisions of Chapter9 (commene
Ingwith Sedion7D00)of DIvIYon3afthe Buaintsand Prolssion.Code,and my
license le in full force end effect.
Ltcense Clas G LION /72NESC
AI'PLIANCESRESIDENfIAl
OB DESCRB'DON
r
PANES
TO 20D AMPS
e ir Contract
ARCHITECTS DECLARATION
I understand my plane @hall be used as public records.
SQ. FT. FLOOR AREA S/SQ. FT.
201-10DO AMPS
OVERIWOAMPS
LicensePmfesloral
d
SIGNS ELECTRICAL
SPECIALCIRCUIT/MISC
OWNER4UILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Taw for the
following reaaxa.(Section7071.5, Business and Professions Code: Any city or
county which regWrce a permit romnYrvct, alter, Improve, demolish, or repair
anyetrudure prlortaltslemance,abo requires the applicant for permit to
ilk a signed Yaterrcnt that he is licensed pursuant to the provisions of the
Contractor'. License Law (Chapter 9(mmmencing with Section 7000)of Divi-
sto03 of the Busine nand Profeslmo Code) orthat he is exempt therefeemand
the basis for the alleged exemption. Any violation of Section 7031.5 by any
applicant for a permit subjects the applicant to a civil penalty Of no reure than
five hundred dollars($SM.
�I, es owner of the property, ar my employees with wages as their wk
mmpcnsatlon,willdothework andtheswcture lenat Intended or offered for
sic (Sec 7014, Bustnes and Profesbns Code: The Contractote Llcens Law
does no[applyroan awnerdproperty who Wilds arimpmveathereon,and
TEMP, MEIRORPOLEINSF.
POWER DOCS
SWIMMING POOL ELECTRIC
_
OUTLETISWITCHES-FIX,ES Sa,O
NEWRESIDENTIALELEC —SQ -FT-
VALUATION
STORIES
TYPE CONSIRIICTION
OCC.GROLW
RES. 11NIT5
who does euchworkhimeaBorihrough hleownemployees, provided thatsuch
improverrcnb are not Intended oroffercd forst@. If, hawevegthewiIdingor
Improvement bwld withinoneycaroftompldioo,theowner-bu0derwIII have
t7leQarefers ofproving that he did not build or improve (or purpose ofale.).
L� L as owner of the Property, am exdu+ively contracting with licensed
contractors to cons/rvct the project (Sm.7616, Buelnas and Prdeslons Code:
The Contnctori License Law does not apply to an owner d property who
wilts or Improves thereon, endww contracts !or such pRojecta with a
cgRtTactar exempt pursuant to the ContractoYe Lkes PLaw.
LJ I am exempt under Sec B & P C far this reason
TOTAL:
QTY. BI ERMIT FEE
FIAODZDNE
APN
FF CE
'7L & -W
FEE SUMMARY
BACK O T.DEVICE
D F A ND_
SANITARY Y N
RECERT N
Owner Date
WORKMAN COMPENSATION DECLARATION
❑1 hereby affithat 1 have a certificate of consnt to self -Insure, .r a
rm
certificate ofWorkers' Coroperwdarelcoommo ata certified copy thereuf6ec.
3800, Lab Q
S, PER TRAP
SCI100LTAX Y— N _
RECEIPT M
G EA. SY6TEd'1I 60 ETS
—
PARK FEE Y— N-
RECERT N
AS. EA. BY -0 (EA)
EASEAN LWASIEINTERCEPTOR
BUILDING DI VISION FEES
PoliryN
in
cum any
copy is hereby furnished.
❑Cert Wed copy Is filed with the city inspection division.
CERTIFICATE OF UVv[PTION FROM WORKERS'
COMPENSATION INSURANCE
(TAlssectlon need not he completed lfthe permit is forces hundred dollars
($100) or les.)
I certify that In the performance of the work for which this permit is blued,
I @ha11 not employ say person In any manner so u to become subject to the
PLANCHECK FEE
PAID
Date Rcc i t#
GREASE
SEWERSA ARY-STORK{ EA. 200FT.
ENERGYFEE Y N—
—
PAID
WATER HEATER W /VENT/E.ECTR
WATEIRSYSTEM/TREATING
WorkersCompensation L,w.of California. Date—
ateApplicant
Applicant--NEW
NOTICE TO APPLICANT: If, after making this Certificate of Raemption, you
should become subject to the Workers' Compensation provisions of the Labor
Code, you moat forthwith comply with such provbiom or this permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there ts a constrvctlon lendingagenry (or the perform•
Date Recei t#
NEW RESIDENTIAL FLMS.__SQ1.7.
TOTAL:
BI JILDING FEE
SEISMIC FEE
TOTAL:
ELECTRIC FEE
PLUMBING FEE
ance of the work for which this permit ts Weed (Sec. 3097, Civ. C.)
QTY, MECHANICAL PERMIT FEE
MECHANICAL FEE
Lender'@Namre
Lender. Add...
Icertlfythatl have readthts applleatlonand a tatethatlheabmwelnformrtloo
is correct. I agree to comply with all city and county ordinances and Yate laws
relating tobuilding construction, and hereby authorize representatives ofthts
city to enter upon the abevcmentloned property for WpecHon purposs.
(We) agree to save, indemnl(y an d keep harmless the City of Cupertino
against llabllltkre, pdgmm:enb, cosnendy see which may lnanywayacaue
a ainses Cmr come roue of amingdmb permit.
PERMIT ISSUANCE
FEES PAID:
ALTER OR ADD TO MECH.
Date Recei t#
ATR HANDLING UNIT (TO 10,000CFM)
SUBTOTAL:
CONSTRUCTION TAX
AIR HANDLING UNIT (OVER 10,000 CFM)
SI mrvre pp ca t/Contractor r Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle harardous
material as defined by the Cupertino Municipal Code, Chapter 9.12, and the
255324)7
Health and Safety Code � noun,
❑Yea IJ No
Will the applicant or come building occupant use xtuipment or devices
which emit h.rardousalrcontaminants.. defined by the Bay Area Air
f Quality Management District'
4stns NO
have read the h. ous materials requirements under G95 a(
the Califomia Health & Safety Code, Sections 25505,25533 and 25534. 1
understand that it the building does not com,atly have a tenant, that it I. my
responsibility to notify the occupant of the requirements which It be met
prior to issuance of a Certificate of Occupanry.
EXHAUST HOOD (W/DUCT)
CONSTRUCTION TAX PAID:
HEATING UNIT l00,OD08TI!)
Date Recei t#
IiFATWC UNIT (OVER 100,000 BTU)
TOTAL:
s�
VENTILATION FAN RESID)
ISS{J,Q� I*ATE
��pn1e
(� u 1990
( y
/eswr��
J'�)
ISSUEDBY: ae,
BOILER -CAMP QHPOR 1m,000 BTU)
BOILER COMP 100,000 BTU)
NEW RESIDENTIAL MECH SQ FT
,TOTAL:
Owner orauthorired agent Date
OFFICE COPY