24423APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
LA
F y
2
W >
C
CL
D2
U2
LL
OW
IL
Fin
2
U—
r Building Project Identification
BuildingA dress:
PERMIT NO 4 4 2 3
rase ams: one
A
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION 1 PERMIT
BUILDING -ELECTRICAL -PLUMBING MECHANICAL
/
CATEGORY CONTROL#
rchimet/Engineer. Lk. Na
QTY ELECTRICPERMIT FEE
BUILDING PERMIT INFO
Addrces:
❑ ❑
PERMITISSUANCE
1 :LASED CONTRACTOR'S DECLARATION
I r tl Vicenaed underprovlaloneaf Chapter 9(commenc
ingw ctl vlslon3 ofthe guelmgea rof elonsCode and my
lien d effect.
I.Imn _ Llc N
Date—/� L." Our _
(f CHITECf' U 1
APPLIANCFSRESB]ENTIAL
TOB DESCRB'DON
PANF25
70140DOAMPS
OVER 1000 AMPS
SQ. Ff. FLOOR AREA
E/SQ. Fr.
Ion an p am shall be used as public records
SIGNSELECTRICAL
Licensed Professional
SPFCIALCIRCUIT/MISC
OWNER -BUILDER DECLARATION
1 hereby affirmthat I am exempt from the Contractor's License Law forthe
TEMP METER OR POLE INST.
followingma n.(Sedion7a315,Buslness.nd Profeeslons Code:Mydtyor
ocuntywhich requlresa permotocomtruct, alter, Improve, demoWh,ar repair
any.tacture priorto Its isauamq also requlrestheappllcant forsuch permit to
file a signed statement that he is licensed pursuant to the provisions of the
POWER DEVICES '
SWLV4MING ECPRIC
OUTLETSSWI 4 FI
Contractors License Law (Chapter 9 (commencing with Section 7000)of Divi-
therefrom and
tie 3 of basis he for
eed professions Any)viothat lation f Section
the balls for the alleged subjects re, on re any
Any violation of penalty
ape applicant
a.lbon$500). the appVcanttoativll penalty of rad morethan
w VALUATION
/YV�1J
06
W.
RESIDENTIAL TR Yr.
huntfor
flue hundrewnerof thep0).
M 1,NEW
orha nty emnuminwithwages their ache
STORIES
TYPE CONSTRUCTION
e sowneroftheework,a Intended or d for
compensation, wllWa,.n,1Pu
uchrehe
Contractorot
sok (Sm. 7004, BusWa• and liofessloa Code: The Contractors Llcenac law
ohms License IA.
don not apply to an owner of property who builds or Improves thereon.and
who does such work himself or through his own employees, provided that such
OCC.GROUP
RES. UMTS
Improvements are not Intended or offered for sale. If, however, the building or
Improvement is sold within oneyearofcompletbry the owner-bullder will have
the burden of proving that he did not build or 4nprove for purpose of ukJ.
u L as owner of the property, am exchuierly mntnding with Ilanaed
contractors to construct the project(Sec. 7016, Business and Professions Code:
QTY. PLUMBI R I FEE
FLOOD TONE
APN -
PERMIT IS
The Contractor's License Law does no apply to an owner of property who
Wild. or Improves thereory m
and who contls for such p�m jewith a
catlor(s)hcenac'd pursuant to the Contractor's License Law.
n I am exempt under Sec B & P C for this ..on
ALTER -DRAIN VENT- WATER(EA)
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
DRAINS FLOOR ROOF, AREA, ND.
SANITARY Y N
RECEEFT N
OwnerDate
WORKMAN COMPENSATION DECLARATION
❑1 hereby affirm that I have a certificate of consent to self -Insure, or a
artificers o((�ly9q�c�ovc 1� cupythereaf 6ec.
1�/�m /�`'�j.Y���P/a�//,/��'
3800, La1KDI� u
Policy# V��
FIXTURES PER TRAP
se
SCLIOOLTAX Y N
RECEIT r N
GAS-IINC.40,
PARK FEE Y N
ep
4 (EA
GAS EA.SYSTMSE/INDUSFRL
DINGRDCDIVISION
BUILDING DI V ISION FEES
1�/ / 1/4d
Co fany #
Cert ed pyis arc �ndivi �G-��'N
�fCenifled copy b (fled with the city inspection divider.
I'�
WR
CREASE/INDUSIRLW NTERGEPTOR
PLANCHECK FEE
GREASE TRAP
CERTIFICATE OF INEMITION FROM WORKERS'
PAID
COMPENSATION INSURANCE
(Ihlesectlon need nor be completed If the permit Is forces hundred dollars
SEWF.IbSANITARY-STORM FA 200FI
Date RCC21 t#
WATER HEATER W/VENT/ELECTR
ENERGY FEE Y N
($1I camlmJ
lartl(ylhat In the performanceal/he work for which this permit is loved,
WATER SYSTEM/TREATING
I shall not employ any person in any manner w as to become subject to the
Workers' Compensation Laws of California. Date
PAID
Applicant
NEW RESIDENTIAL PLMB. SQ.IT.
Date RC i t#
NOTICE TO APPLICANT: If, after madding this Certificate of Exemption, you
should become subject to the Workers' Compensation proviiom of the Labor
TOT
Code, you moat forthwith comply with such provisions or this permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
BU
SEISMIC FEE tit
I herebyafftrm that there is a construction lending agency for the perform
anceof theworkforwhkh his r Wued(Sec.3D97,CIv.C)
Lender's Name ��w
landae. Addrese�
I certltythatl have read[ is applicelionand smielhat theabovelnformalIon
kcorrect. l agreeto comply with all city and county ordinances and nate laws
TOTAL:
ELECTRIC FEE
PLUMBING FEE
QTY. MECHANICAL PERMIT FEE
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID:
relating tobulldo g construction, and hereby aulh.mm representativesof thio
dtyt'enteru t abovcmentWnsdP rtyf rinapectlonpurposm.
(We) a o e, Wdemnify an p ss the Ciy of pe Ino
agaWtlla ,).dg. te, coat. ass k ylnany ey crus
Date Receipt#
ALTERORADDTOMFCH.
AIR HANDLING UNIT IO
SUBTOTAL:
against tyi con.equenon. ting t
AIRHANDUNGIIMT( ER
FM)
CONSTRUCTION TAX
of p 'ant/ r Or F
IXFIAUST HOOD (W/DUCT)
CONSTRUCTION TAX PAID:
NA RDOUS MATERIALS Dig RE
Ill the applkan or lumrebuilding occvpanbl CILD handleh rdous
anterial m defined by the Cupertino Municipal Code, Chapter 9.12, and the
Hea)thand Safety CgQe, 1on25532(a)7
❑ Yes No
Date R,nei
HEATING UMT(TO I Oq B
HEATING UMT(OV 100,000 BTU)
TOT
VENTILATION FA (SINGLE RESID)
ISSUANCE DATE
Will theappllont rcbuilding ..pantu.e equipment mdevims
which emit hazardous air contaminants as defined by the Bay Area Air
Qii.lity Maagnment st t
Yes 10
have read the M1vjFdcas materials requirements under Chapter 6.95 of
B
BOILER -COMP WOR lO Y)OBTU)
BOILER-COMP(OVER 100,000 BiU)
the California Health & Safety Code, Sections 25505, 25533 and 25534. 1
understand that lithe building does not currently have a tenant, that It is my
NUV
N 19n
NEW REMDEMIAL MECH. SQ.FT
responsibility to notify the occupant of the requirements which =at be met
.I
prior to Jesus race of a Certificate of Occupa nry.
C, , „c r,j �.nlnl
ISSUED BY:
r.horired agent Date
cr aw
TOTAL:
DOFFICE COPY