23559APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification
Oullding Addreas: ��\ VV*a7✓•a7V1
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CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION I PERMIT
p
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cams or'sNamr: Lic'Ne:
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BUILDINCELECTRICAL-PLUMBINGMFCHANICAL
CATEGORY
CONTROL#
Itect/Engineer. Llc, No:
QTY ELECTRICPERMIT FEE
BUILDING PERMIT INFO
matn
Addreas sq HSN F-aaLd a1L
❑
PFRh9TIS5UANCE �'
LICENSED CONTRACTOR'S DECLARATION
I hereby affimn that l am licensed under provisions of Chapter 9 (commene,
Ing with Section 7000).faetsicn 3 ofthe Bueineseand Profeni... Code,wd my
limns is in farce and effect
License Class Llcp i�
APPLIANCES -RESIDENTIAL
]00 DFSCRB'DON
PANELS
-
Data Contractor 4Wy-AacxV>G
UP TO 200AMPS
201-10Y)"PS
ARCHITECTS DECLARATION
I understand my plans shall be used as public records
OVER 1000 AMPS
Fr. FLOOR AREA
S/SQ. Fr.
SIGNS ELECTRICAL
Licensed Professional
a�SQ.
Sl'FGIALCBtCNT/M15C
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors License Lw for the
V�
TEMP. METER OR POLE INST.
following mason.(Section 7031.5, Business and Professions Code: Any city or
county which requires a permit tomruhuM alter, improv, demolish, oreepair
anystmmmprlortolsbwame,aborequimtheappUmntfwsuchpemdtto
file a signed statement that he is licensed pursuant to the proWiow of the
Contractor's License Law (Chapter 9(commencing with Section 70DO of Divi-
con3 of the Businesdrsb
and Prs Code) mIhat he h exempttherefromand
the bash for the alleged exemption. Any violation of Section 7071.5 by any
applicant for a permit subjects the applicant to a civil penalty of not more'ban
POWER DEVICES
SWIMMING FOOL ELECTRIC
UTLETSSWITCHESF1%TURES 1
VALUATION
L .{a ``ga
LL ,gyp
NEW RESIDENTIAL FLECTR SQFr.
five hundred dollars ($500).
M 1, as owner of the property, or my employees with wages as their wk
STORIES
TYPE CONSTRUCTION
compensation, will do the work and the structure is not Intended or offered for
sale (See. 7040 BueUres and Professions, Code: The Contractor's License Law
does not apply to an owner of property who Wilda or imprevn t harem,and
who does such work himself or through his own employees, provided that such
l]CC.GROIID
RCS.UNITS
Improvements are not Intended oroffered forsale. If, however, the buildingor
improvement hsold within oneyearof completion, the owner -builder will have
tlUjurden of proving that he, did not build or Improve for purpose of sale.).
Lj L as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec 7044, Business and Profesbm Code(°`�
The Contractors License Lw does not apply to an owner of property who
Wor improves thereon, and who contracts for such ptojecta with a
cgptfachu(s) Unread pursuant to the Contractor's License Law.
nal am exempt under Sec. B & P C for this reawn
T ��
QTY, PLUMBING PERM[ FEE
PERMIT ISSUANCE
ALTER-DRO N & VEN'FJ WA (EM
Ir
67,0010 ZONE
APN
FEE SUMMARY
BACKFLOW ROTECT. DEVICE
OUTSIDFFEES
DRAINS FLOOR ROOF, AREA, COND.
SANITARY Y N
RECE91T #
Owner Date
WORKMAN COMPENSATION DECLARATION
,Zfl hereby affirm,that I have a certificate of consent to self -insure, ora
cedtflcateafWorkers' Cmepmuatloeleactemmors cartlfiedmpythemof(Sec.
lab CJ
dlry Y
Policy
FTX7VRLS PER TRAP
SCHOOLTAX Y_ N_
gpGp-grp #
GAS EA. SYSTEM -1 INC.60[11LEf5
PARK FEE Y N
RECEET #
amO
Cany
GAS EA. SYSTEM -OVER 4 (EA)
BUILDING DIVISION FEES
Certified mpy is filed city
the cid.
Certified mpy ty l
b hereby inspection division.
GREASEANDUSTRL WASTE INTERCEPTOR
PLANCHECKFEE
( V 7
GREASE TRAP
CERTIFICATE OF E( EM "ION FROM WOR KERS'
PAID
SEWER -SANITARY -STORM EA. 20017.
COMPENSATION INSURANCE
(rhissection need not be completed UIFe permit h forom hundred dollan
Date RCCeI t#
WATER HEATER W/VENT/E,ECTR
ENERGYFEE Y N
PAID
(f100)orles)
[certify that int the per(omunceof the work forwhich this permit ishroed,
I shall not employ any person In any manner w s to become subject to the
Wmkcri Compensatbn Laws of Califmnla. Date
WATER SYSTEM/TREATING
Applicant
NODCETO APPLICANT. IL after making thisCertiflale of Exemption, you
should become subject to the Workers' Compensation pe,111 ofthe Labor
Date Recel t#
NEW RESIDENTIAL PLMB. SQFr.
TOTAL:
Code, you swat forthwith comply with such provisions orthis permit shall be
BUILDING FEE
deemed rooked.
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
Ihereby affimnthat there is a construction lending agency for the perform-
ance of the work for which this permit b blued (See. 3097, Civ. C.)
tandem Name
Lender's Address
I certify that) cave mad thhappllatlonand statethaltheabove, Information
Is correct. l agreeto comply with all cityand county ordinance and state laws
TOTAL:
ELECTRIC FEE p�
PLUMBING FEE
QTY. MECHANICAL PERMIT FEE
MECHANICAL FEE
PERMIT ISSUANCE l �^
FEES PAID:
relating tobuilding combocdon, and hereby authortac representatives of this
city to enter upon the above-mentioned property (or hupectlon purposes.
(We) agree to save, Indemnify an d keep harmless the City of Cu Perm.
against liabilities, judgments, cors and expenses which may in any way accrue
agaist said Cl consaryence ✓of`ty ting of this permit
/O�n— �'-/?_9Z
Date Revel t#
F
L ALTERORADDTOMECH.
AIR HANDLING UNIT (TO 10,000 CFM)
SUBTOTAL:
Nftl-IANDLING UNIT (OVER IO,000CFM)
CONSTRUCFION TAX
..f Ap
Sd wturLc of A��nt/Co Date
EXHAUST HOOD (W/DIK'D
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
BEATING UNIT (TO 100,000 BTI)
Will the applicant or future building occupant store or handle bacardous
material as dented by the Cupertino MuNcipal Code, Chapter 9.12, and the
Hr.hh and Safety Code Se ctlon 2S532G)7
❑ Yea
Will the applicant rfuture building occupant use equipment or devices
Date ReceI t#
HEATING UNIT (OVER 100,000 BTM
M)
'F
VENTILATION FAN (SINGLE MID)
ISSUANCE DATE
which emit harardous air meta mmants as defined by the Bay Area Air
Quality Management District?
Yes �'No
Itf p p0
Ifs P9 D
BORER -COMP OIIP OR 100,0010 BTU)
BOILER -COMP (OVER 100,000 BTU)
have read the hazardousmaterials requirements under Chapterii.95 of
the California Health & Sa fety, Code, Sect ions 25505, 25533 and 25534. 1
understand that lobe building does not currently have. tenant, that It h my
1(3E�q
MAY 13
NEWRISIDENTIALMECH. SQ.Fr
responsibility to not ify the occupa of the requirement, which rtwat be met
vv77ss77LL'4�`
prior to ilia co/a Certl Occupancy.
CITY Ur Y`j f
ISSUED BY:
Owner or authorized agent Date
TO
OFFICE COPY