20796APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Pm eat Identification
Building Address:
PERMIT NO.
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-/ O 7lJEVI1 C
33ej ✓o LLGO pk
G 1!
wnera time: 4og+) ane:
S 296—
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION I PERMIT
r21 t_fit`
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Cantrator's Name: LIB N.
BU[LDINC-ELECTRICALPLUMBINGMECHANICAL
CATEGORY
j CONTROLP�
1O
Arohltect/Engineer. Lk. No:
QTY ELECTRICPERMIT FEE
BUILDING PERMIT INFO
•O0T(A:
Add..
PERMITISSUANCE
El 0 ❑
LICENSED CONTRAROr pr DECLARATION
affim that Chapter 9 o-
licensed under erprovland
APPLIANCESRESIDEN77AL
JOB DESCRBs1TON
PANG -4
7000)olam
Pro de,and
homseh Section force of DIV IMon 3 ofthe BuMnessand Pro(esaloneCode, and my
license lsln full force and effect.
License Clan LIc.N
It.0/�W til
Data Contractor
ARCHITECT'S
used as pARATIOed
I undentaiW my psmlhaR6e used ea public remda
OVER00AMI5
OVERT
SQ. Fi. FLOOR AREA
5/SQ. FT.
SIGNS ELEC
Licensed Professional
SPECIALC T/
OWNER -BUILDER DECLARATION
I hereby afBrentlut I am..empt from the Contractor's License Taw for the
p LE INST.
following reason. (Section 7031.5, Business and Profeselons Code: Any city or
counlywhich requirm a permit tocemmuct, alter, improve, demolish, or repair
anystructure prlortolls Lsuance,asorequbestheepplirant forsuchpermit to
file a signed statement that he is Horned pursuant to the provision of the
DEVICES
OUTLETS-SWITCHES-11ES4
Contractor's License Law (Chapter9(rommencing with Section 7000)of Divi-NrG
Mori of the Bu.sessand Professions Code) brmhat he Isexempt therefromand
the bass for the alleged exemption. Any violation of Section 7MIS by any
applicant fora permit subjects the applicant to a civil penalty of not more than
VALUATION
(�a
\/ I —10
five hundred do1lars($500).
❑ I, as owner of the property, or my employes with wages as their sole
NEW RESIDENTIAL ELEC SQ.FT.
STORIES
TYPE CONSTRUCTION
compensation, will do the work, and the structure is nor Wended or offered for
-
sale (Sec 7094, Business and Profassbna Code: The Committees License Law
does not apply to an owner of property who Wilde or Improv, thereon, and
wh'od..... chwork himself orthriough blsownemployeea, provided thatsuch
OCC.GROUa
RES. UNITS
Improvements arc not Intended eroffered forsas. If, however, thebuilding car
TOTAL:
'
Improvement ssold wlthinancyearofcompldl Ntheowner-Wilderwillhave
tbqrden of proving that he did not WBd or improve for purpose ofsale.).
C -1L as at of the property, am exclusively mrtmecung with Iimved
.i.e rs to construct the project (Sm 7044, Business and Prafeniom Code:
QTY. PLUMBING PERMIT FEE
FLOOD ZONE
APN
PERMIT ISSUANCE
The Contractors License Law don not apply to an owner of Property who
Wilds or improves thereon, and who contracts for such p(ojecs with a
coOS(ator(s)Bcansed pursuant to the Contrator� License Law.
LJ I am exempt under Sec B & P C for this reasonOUTSIDE
ALTER -DRAIN &VENT- WATER (EA)
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
FEES
DRAINS -FLOOR ROOF, AREA, COND.
PER .�I.
FICTURERECEIPT
SANITARY RECEIPT M
Owner Date
WORKMAN COMPENSATION DECLARATIONS
[:]I hereby affirm that I have • certlfices of consent to self -Inure, ora
cetlHcate of Worken'Compersamlonlnaurance ora certified copythe.Hgac.
3800, Lab Q
SCHOOL TAX Y_ N_
K
GAS EA.SYSTEM-1 INCA OUTLETS
PARKFEE Y N
RECEIPT E
Cy .11q Y
Com sa
GAS E.A. SYSIE2d-OVER 4 (EA)
BUILDING DI VISION FEES
Certified mpy s hereby furnished. -
entified mpy s filed with the city Impaction division.
GREASE/INDUSML WASTE INTERCEPTOR
PLANCHECKFEE
GREASE TRAP
CERTIFICATE OF EKEMPT10N FROM WORKERS'
COMPENSATION INSURANCE
CThissetion need not be completed if the permit sfor one hundred dollars
(S1W)orlack.) ••
I mrtdythat in the performanceof the work for which this permdt Is Issued,
PAID
Date Rami t#
r��-s .sp
8 (s `O
SEWER -SANITARY -STORM EA WIFE
WATER HEATER W/VENT/EI.ECTR
ENERGY FEE Y_ N_
WATER BY
I shall not employ any person In any manner w , to bemire subject to the
Workem'Compensstion Lam of California. Date
Applicant
PAID
Date Renal tj
�(O
NEW RESIDENTIAL PCMB. SQ.FT.
NOTICETO APPLICANT: If, after making the Certlfkame of Exemption, you
should Wmme subject m the Worker' Compematlon provsiom of the Labor
TOTAL:
FEE
Code, you must forthwith comply with such provsiom orths permit shall beIL
deemed cooked.
CONSTRUCTION LENDING AGENCY
SEISMIC FEE
a=Y%
TOTAL
IPLUMBING
ELECTRIC FEE
I herebyaffirmlhat there is a mmtmtion lendingagenty forthe perform
ance of the work far which this permit Is issued (Sec. 3097, Civ. C.)
Iendeee Name
Lcrdcr'.AddmeQTY.
FEE
MECHANICAL PERMIT FEE
MECHANICAL FEE
I.Aitymhatl have readthsapplkallonand Matelh0the above Information
lammed. I agree to complywlth all cityand county ordinances and state laws
PERMITI.SSUANCE
FEES PAID:
relating to building mmwtion, and hereby authorlu representatives of this
city to enter upon the above-mentioned property for inspection purposes.
(We) agree to save, indemnify an d keep harmless the City of Cupetlno
agaimt liabilities, ydgmens, mss and expenses which may In anyway accrue
ALTERORADDTOMECH.
Date Receipt#
aft HANDLING UNIT (TO 10,000 CPM)
SUBTOTAL:
AIR HANDLING UNIT (OVER 10 WOCFM)
CONSTRUCTION TAX
boo said City In mass senor the granting&thls perms'
'��j��/�� 4G
Slgwtum of t/Contractor Date
EXHAUSTHOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfuture building Ocmpanm store or handle hazardous
HEATING UNIT (TO 100,000 BTU
-
Date Reeei t#
material as defined by the Cupertino Municipal Code, Chapter 9.12, and the
Ilealthand SafetyCcdeuo2M32(a)7
C3 Y. No
Wllltheapplianlor(u re building occupant use equi pound or devices
HEATING UNIT (OVER 100,000 BTU -
TOTAL:
VENII LATION FAN (SINGLE REBID)
ISSUANCE DATE
which coot hazardous air mntamlnans as defined by the Bay Area Air
ality Management DSMt7
n{ ^
BOILER -CAMP OHPOR 100,000 BTU
1 Yes �No
have read the haze ous materials rcqulretrcns underCM1apter 6.95 of
the California Health & Safety Code, Sections 25505,25533 and 25534. I
understand that if the Wilding does not co mently have a tenant, that it Is my
i rte"
BOILC2COMP(OVER 100,000 BTU)
NEW RESIDENTIAL MECH. SQ.FT.
retpomibllity to notify the occupant of the requirements which must be int
or to satin sofa Ific. fo p icy. /^' I�O
P W n'� (p'////'1
f� s
1.11y (1f rn'lnfti prl[,[� '
ISSUED BY:
Owner or authorized agent I Data
TOTAL:
OFFICE COPY