23206APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
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Bu� Addrea BuildingProject Identification
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PERMIT NO. 3 2 06 -
n a ams: one:
A
CITY OF CUPERTINO-6UILDING DIVISION
APPLICATION / PERMIT
�'tl� -T2—
cMtracto Name:2pen?
Lie. No:
OU ^r O
Itvc/Engineer. Lic. N.
BUILDINGELECTRiCAL.PLllMBIN MTCI{AMCAL
CATEGORY IV
OA
�p
ELECTRIC IT FEE
aOTW 6N dijimoopQTY
BUILDING PERMIT INFO
Address
�i ❑
L�]
PERMITISSUAN f i�
LICENSED CONTRACTOR'S DECLARATION
I herehyafflrm that lam Iledaedunder provisions of Chapbr9(mmmme-
ingwbh SectioR7000)of DlA9.3ofthe BuslReaand ProfesdonsCode, and my
Ilmnse le In full fors and effect.
APPLIANCES"DEAAL
]OB DESCREMON
PANELS
License Clam
Date//Contractor�
ARCHITECPS DECLARATION
I understand my plans shall be used as public mounds.
AMPS
I= AMIrS I I I
SQ. FT. FLOOR ARE
S/SQ. FT.
Licensed professional
GNS ELECTRI
! Q �,% s��J}
2C�--
SPECIALCIRCUIT/
OWNER -BUILDER DECLARATION
I hereby affirmthat I am exempt from the Contractor's License Law fou the
TIMP. METER O LE INST.
following reason. (Section 7031.5, Business and Professions Code: Any city or
countywhich requires a permit mmnstruct, alter, Improve, demolish, orrepair
anystmMmprlortoltslen,anse,alsorequimtheappHuntforsuchper tto
file a signed statement that he is licensed pursuant to the provisions of the
POWER D S
SWIMMING POOL ELECTRIC
OfTILETSSWITCHF_SF(%H1RES
Contractor's License Law (Chapter 9(commencing with Section 7000)of Dist.
eloR3 of the Bm
udoessd ProfeabnsCode) orthat he Is exempt therefromand
the Weis for the alleged exemption. Any violation of Section 7031.5 by any
applicant fora permit subjects the applicant to a civil penalty of not mmothan
VALUATION
//�)O -mow
Z O Y
five hundred dollars (%M.
❑I, as owner of the property, or my employees with wages as their sole
NEW RESIDENTIAL ELECTRSQ.FT.
STORIES
TYPE CONSTRUCTION
mmpensatlon, wiildothe work andthedtruesire Is not Intended or offered for
sale (Sec. 7044, Busma t and Pmfea dock Code: The Contractors Lt.. law
,
does not apply to an owner of pmperty who bullae or improves themeRand
who does such work himself orthrough hlsown employees, provided that such
OCC.GROIRs
AFS. UNITS
Improvements are not intended oroffered forule. If, however, lhebuilding or
T
improvement Issoldwithinoneyearo(completmgt W owner-budderwBl have
e(gpurdenof proving that he did not build or Improve for purpomofale.).
Ll L as owner of the property, am exclusively contracting with limned
co
contractors to construct the Protect(Sm. 7014, Business and Professions Code:
QTY. PLUMBING PERMIT FEE
FLOOD ZONE
APN
PERMRISSUANCE
The Contractor's License law does not apply to an owner of property who
Wor Improved thereon, and who contnRa for such pfojects with •
cgB(Tactor(s) licensed pursuant to the Contractors License Law.
LII am exempt under Sec. B & P C for this reason
ALTER -DRAIN & VENT (FA)
FEE SUMMARY
BACK FLAW PROTECT. DEVICE
turrclrtv .17n
DRAINS FLOOR. ROOF, AREA, COND.
SANITARY Y_ N_ _
RECEIPT tl
Owner Date
WORKMAN COMPENSATION DECLARATION
pl hereby affirm that I have a certificate of consent to del( -Insure, w •
esrtHlcateofWorkers'Compewtionl..r ceoracertifiedmpythereof(Sec.
3800, lab C.)
pp(TUAgg.I'ER
GAS EA.SYSTFM- ET
SCI100L TA% Y_ N
RECEIPTN#
PARK F'kF Y N
RECEE'r #
C. tl
Com any
GAS EA. SYSTEM -OVER d(EA)
BUILDING DIVISION FEES
lWlfenlfled mpybflled with the city inspection division.
Pdifled copy b heed with the city
CERTIFICATE OF EXEMPTION FROM WORKERS'
CRFASE/MDUML WASTE INTERCEPTOR
PLANC14ECKFEE
PAID
GREASCTRAP
SETVER-STORM-gIURM EA p0F7
COMPENSATION INSURANCE
(TMssection need not be completed lithe permit Is forom hundred dollars
Dale RCCCi [#
WATER HrATERW/VENT/ELECTR
ENERGY FEE Y N
(5100)m
Icertl(y that hal tache performance ofthe work forwhich this permit Is blued,
WATER SYSTEM/TREATING
I shall not employ any person In any manner sou to become subject to the
Workeri Compensation Laws of GHfomla. Date
PAID
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you
should become subject to the Workers' Compensation provisions of the Labor
NEW RESIDENTIAL FILMS. SQFr
Date Recei t#
TOT L'
Code, you must forthwith comply with such provisions orthb permit shall be
deemed revoked.
6 N �e
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
Iherebyaflthatthnmb mnstructlon lending agency for the perform-
ares of the work forwhlch this pemdt b Loured (Sec. 3097, CIv.CJ
Lcrdera Name
Lender's Address
I mAilythat I have read this applicationand statethattheabovelnformatlon
Is correct. I agreeto comply with all city and county ordinances and elate laws
TOTAL:
ELECTRIC
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
MECHANICAL FEE
PERMIT ISSUANCE '�
FEES PAID:
relating to building mmtroction, and hereby authorize representatives of this
city to enter upon the above-mentioned property for Inspection purposes.
(We) agree to save, Indemnify an d keep harr dens the City of Cu pertino
against liabilities, judgments, mks and expenses which may In any way amue
Date Receipt#
ALTERORADDTOMECH.
AIR HANDLING UNIT fro CFM)
SUBTOTAL'
of the granting of this peit.
against said City in consequence permit.
AIR HANDLI NG UNIT(OVERI Q000 CIM)
CONSTRUCTION TAX
Signature of Applicant/Contractor Date
EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DI SCL.OSU RE
PLEATING UNIT (TO 100,000 BTU)
Will the a pplhart or future building occupant store or handle hazardous
material as dented by the Cupertino Municipal Code, Chapter 9.1Z and the
Health and Safety Code Section75532(a)7
—I Y. �] No
Raj
_
Date Recel t#
HEATING UNIT (OVER 100,000 BTU)
TOTA .am
VENTILATION FAN (SINGLL•REBID)
ISSUANCE DATE
Blthemt applieset core building devices
ompant use equlay
nants Arear
which eMahazardousairrict? cats as defined bythe Bay Area Air
Thy Management District?
ah Yen ❑No
Itf p S
P A
BOILER -COMP QIB'DA 100,IXtO BTN
BOILER -COMP (OVER IW,OW BTU)
ave read the hazardous materials requlrementa under Chapter 6.95 of
the California Health & Safety Code, Sections 25505,25513 and 25534. I
understand that if the building does not ncurrently have a tenant, that it b my
JAN 31
NEW RESIDENTIAL MECH. SQFT.
r®poruiI'd ty to ify the ocmpard a requlmmentawhlch most be W
s
prior to tee an ofaCertificate panty. _
./s
My Ur CUPtnluvv
lzunrcr
authorluda DaleAL'
ISSUED BY
OFFICE COPY 4