21393APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Proed Identification
Building 1'7333 v�u.�.o-� �
PLMT NO.
21393
Owns ante: one:
GWI7� ��S
CITY OF CUPERTINO-BUILDINGDIVISION
APPLICATION I PERMIT
BUILDING-aM RICAI.PLUMBING-MECHANICAL
p
l 1-5—q O
c °r•"•np� urs."°�
e
CATEGORY
CONTROI•7Y�•yn)
A � r: Llc. N°:
QTY ELECTRIC PERMIT FEE
—PERMITISSUANCE
BUILDING PERMIT INFO
Address U-3 — t I/5�-• 561
�j ❑ ❑ El
L f
CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under pr°vislonsofChapter 9(mmmenc
ingwith Sedion700D)of DlWNon3ofthe BuslnemandPmfeasionsCode,and my
license Is In fu and effect.
APPLIANChBRFADENTIAL
JOB DESCRE'HON
�x
PANELS
LicenseClea I LIc.0
Dale //-l/-Il I7 ContractorUP
TO 200 ANTS
201-1000 AMPS
�• �— ARCHITECTS DECLARATION
I understand my plans shall be used as public records.
OVERIODOAMPS
SQ. FT. FLOOR AREA
$/SQ. FT.
AGNS ELECTRICAL
Licensed Professional
2 Q �� j'I
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt fromthe Contractor's Llceme Law forthe
following reason.(Section 7031.5, Buslneoand Pmfexhma Code: Anycityor
countywhichrequlrnapermittocom ruct, alter, Improve,dernolbh,orrepair
SPECIALCE6CUIT/ML)C
(� LlY
'
TEMP.METER ORPOLE INSf.
anystfuctum prlortotts Issuance, also requimstheappllcant forsuch perotto
file a signed statement that he b Boomed pursuant to the pmvlsloes of the
Contractors License law(Chapter 9(mrmunclng with Section 7000) of Divi-
sion3oftheBuslnnsand Profembsu Code)°,thath.ie.empttherefromand
POWER DEVICES
SWIMMING IDOL ELE C
VALUATION
the boob for the alleged exemption. Any violation of nanbn act m by any
apermB the applicant toacivil penalty of act nnrethan
OU uTSSWITC
����rI
ate• `7 coo,�e3,�
�J & L 00
NIiW DENTI L SQFT.
liveapplicantdred
five hundred dollars he pr .
500).
❑ I, as owner of the property, or my employees with wages as their sole
STORIES
TYPE CONSTRUCTION
compensation, will do the work and the structure Is not Intended or offered for
sale (Sec 7061, Business and Professions Code: The Contractors License Law
does not apply to an owner of property who Wilda or improve thereon, and
who does such work hlmselorthrough his own employees, provided that such
OCG GRO(lI'
RES. UNITS
Improvements are not intended oroffered for sale, IL however, thebulldingor
Improvement Becht withlnomyearofcompletioo.theowner-bulWerw111 have
TOTAL:
to rdenofproAng that he did we build crlmprove for purposeofule.)
LJ L as owner of the property, am exclusively contracting with license
centnctora to construct the project(Sm. 70th, Butler end Profenbns Cad e.
Q7Y, III PERMIT FEE
FLOOD ZONE
APN
MXVSSUAN
The Contractors License Law don not apply to an owner of property who
bunds or Improves thereon, and who mnmmu, for such pto)ects with a
cgIlt�+ctor(s) licensed pursuant to the Contractors License Law.
TTI am exempt under Sec, B & P C for this reason
A D A (EA)
W T.DEVICE
FEE SUMMARY
N^r RR F,A
SANITARY Y N
RIC= N
Owner Date
WORKMAN COMPENSATION DECLARATION
❑I M1ereby affirm that I have a certificate of consent to self -Insure, or.
3800,1 teo(Workers'Compennllonlnsunnce ora certified mpythereo((Sn.
380E Lab C.)
Policy M
UREsreR
SCIil70L TA% Y N_
REC®'T I
EA SY -1 C.1 I1IL
I
PARKFEE Y N
RECEIPT M
EA. SY 1 )
Com any -
BUILDING DIVISION FEES
j��pC Nified mpybhereby fumished.
�7 Certified mpy Is filed with the city inspection division.
SE/IND W INTERCEPTOR
PLANCHECK FEE
ASE TRAP
r CERTIFICATE OF IXEM[TSON FROM WORKERS'
' COMPENSATION INSURANCE..
Qhlssection need nd be completed if the pemdt V for one hundred dollars
T—
PAID(k—"C' �Q(7
Dale Recel t# `•(7
Ep pN; 1•
WA.I.�.I.�W,/vENT/¢ECTR
ENERGY FEE Y N
(••S�yd [QC/ [.J
PAID I
Date Recei t# ZOa�
(8100)°ries•.)
I certify that In the perforesnm of thewmm
k forwhich this pedt is lssurd,
I shall not employ any person In any manner so as to become subject to the
Workere'Compenutbn Lawsof California. Date
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you
should become subject to the Workers'Compensation provisions of the Labor
WATER SYSTEM/TREATING
NEW RESIDENTIAL PLMB. SOFT.
TOTAL:
Code, you moat forthwith comply -with such provisions or this Parrott shall be
deemed revoked,
CONSTRUCTION LENDING AGENCY
BUILDING
SEISMIC FEE I
I hereby dorm that there is a construction lending agency for the perform-
ance of the work for which this permit is Issued (See 3(797, Cls. C.)
Lender's Name
I.ender.Address -
I certify that I have read this application and skate that the above le fornmien
vionmect.Ixgree to mmplywllh allcityand muntyordinancef and Nate laws
TOTAL.
ELECTRIC FEE
PLUMBING FEE
QTY. MECHANICAL PERMIT FEE
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID.
relatleg mbullding construction, and hereby authorize reprtxntatives of thio
city to enterupon theabove-mentioned property for Wpection purposes.
(We 7 grFF[L save, Indemnify and keep harmless the City of Cupertino
agal Izb(lltin,judgments, consand expenses which may In anywayacxxue
ALTERORADDTOMECH.
Datil Recei f#
AIR HANDLING UNIT (10 10,000 CFM)
SUBTOTAL:
xg rut said City in =sequence of the granting of this permit.
AIR HANDLING UNIT (OVER 10,000 CFM)
CONSTRUCTION TAX
o A pBcent/Contractor Date
EXHAUSTHOOD M/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT CFO 100,000 BTU)
Will the applicant or future building occupant store or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.12 and the
Health and Safety Cod 1..25532(.)2
Date Recei t#
HEATING UNIT (OVER 100,000 BM
TOTAL:
❑ Yes No
Will thezppllcanl Nture building occupantux equipment or devices
VFNIILATION FAN (SINGLE RESID)
ISSUANCE DATE
which emit havrdou air contaminants as defined bythe Bay Area Air
Ilty Marugement Nct?
D1y�j
u�L�
�j)'p
AW
BOILER -COMP DIIP OR 100,000 BTU)
Yea No
BOILER.COMP(OVEi 100,000 BTU)
I have read the haafedoua mderials requirements u nd aptr,6.9
�a..
the Glifor Safety Code, 25505, 75 d 75536
undo rad that if the building dose rently ha a nank th fanny
r®po to notify the ocmpan ernry4e which st be rral
prlort ssu ce cats Certiflcateo panty
(� z " 199Q
Ity of Crmpyinn
NEW RESIDEN77AL MECH. SQ.FT.
ISSUGD BY:
Owner °r authorizedaRe Date
TOTAL:
I OFFICE COPY