21642APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Prmect Identification -
Oullding Address:
LL co qRk ,,)
11333 ,
PERMIT NO.
qaI /"9 A ^
G {v642
I
cones one:
M
TANdem COV I T' QIQS
CITY OF CUPERTINO-BUILDING
APPLICATION / PERMIT
BUrLDING-ELECTRICA4MUMBING-MECH LAICAL
A
Contractor's Name: –( C Lic. Nm
O e� 1 EL TRIC 06S55
CATEGORY
CONTROL#
Architect/Engineer. Lk. Nm
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Address:
PERMITISSUANCE `��
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION '
]hereby affirmthat l son llceneed under provisions of Chapter9(commen
Ingwith Section7000)of Divisim3oithe BustneseandProfeasionsCode,and my
licensLtoon lslua to lb efre<t. 506555'
License Clam
Data --contractor
APPLIANCESRESIDENTIAL
P""°S
UP TO 200 AMPq
JOB DESCRE'770N
'ARCHITECTS DECLARATION
I understand any plans shall W used as public records.
201-10W AMPS
wa
OVER I ODD AMPS
SQ. FT. FLOOR AREA
$/SQ. FT.
SIGNS ELECTRICAL - l CZ
Licensed Professional
OWNER -BUILDER DECLARATION
I herebyafflrmthat l am exempt from the Contractor's License Law for Poe
SPECIALCIICUIT/MISC L
following mum. (Section 7031.5, Business and Profesums Code: Any city or
countywhich requims a permlt w mmtmct, alteq improvy demolhh, or repair
anystructure priorto its issuance, also requirestheapplicant forsuch permltta
file a signed statement that he ishmnsed pursuant to the provisions of the
Contractor's License Law (Chapter 9(camormoing with Section 7000)of Divi-
ston3 ofthe Busineuand Profeaiam Code) or that he ba exempt therefromend
the basis for the alleged exemption. Any violation of Section 70315 by any
applicant fora permit subjects the applicant to a civil penally of of nroom than
five hundred dollars ($500).
1, as owner of the property, or my employees with wages as their sole
TEMPMETER ORPOLE ]NST.
POWER DEVICES
SWIMMING POOL ELECCItIC
VALUATION
[ O OUTLETSSW[TCHFSH%TURES
NEW RESIDENTIAL ELECTR SQFF, -
STORIES
TYPE CONSTRUCTION
compensation, will do the work and the structure is nor ntended or offered for
'
sale (Sec. 7094, Business and Professions Code: The Contractor's Liceme Law
does not apply to an owner a property who builds or improves thereon, and
who doeseuch work hmne
ilforthrough his own employees, provided that such
Improvements are not Intended oroffereifor sale. If, hownmrthebuildingor
improvement bsold wlthinoneycarofeampletloMtheowner-bullderwlllhave
the�,,,Jiarden of proving that he did not build or Improve for purpose ofsale3.
a
LLj I, s owner of the property; am exclusively contracting with licensed
contractors to construct the project (Sec 7094, Business and Professions Code:
The Contractor's License Law does not apply to an owner of property who
Wilds or imprwea thereon, and who ommutf for such propcte with a
Cq�EFsctor(a) Bonnard pursuant to the Contractor's License Law.
LJ I am exempt under sec. B & P C for this reason
TOTAL; t
QTY. PLUMBING PERMIT FEE
OCC.GROUIP
RES UNITS
ppgMCC ISSUANCE
ALTER -DRAIN &VENT- WATER (EN
FLOOD WNE
APN
BACKFLOW PROTECT. DEVICE
FEE SUMMARY
_
DRAINS FLOOR ROOF, AREA, COND.
FIXTURES PER TRAP
SANITARY Y_ N—:
RECEIPT #
Owner Date
WORIONAN COMPENSATION DECLARATION
[]I hereby affirm that I have a sate of consent to uB-0nsure, ora
SCHOOL FAX Y_ N
loss
3800, ab of Worken'Compensationlwuranre ora certlfkd copythereof(Sec.
C.)
3Slicy
RECEIPT #
GAS PA. SYSTEM -1 INCA OUTLETS
PARK FEE Y N
#
Policy p
p
RECEDING
Comm any
GAS F.A. SYSIT2d-OVER4(FA)
Df
BUILDING DIVISION FEES
LRCerified copy is heed with tiehed.
ropy ts /fled with the city inspection division. �
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed B the permit is for one hundred dollars
($100)arless.)
I mmlythat m the perfomunceaf the work forwhich this permit is Issued,
I shall not employ any person In any manner w as to become subject to the
Workers'Compenaation Lawaaf California. Date
- GREASEINU _ R
3 ..m `r,'
PLANCHECK FEE
PAID
Date - Recei tic
BEwgg-sANI'f
,
WATERHEA / TRENERGY
FEE Y N —
PAID
TING
NOTICppliE
NOTId APPLICANT: after Exemption,you
Date Remi til
— NEW RESIDEMIAL PLMB. EQ Fr.
bomme tothe rs'Comakinpersation pro is s Labor
should you =at forthwith co Workers'Comperuaii n provisions permit
domed re eked. rthwlth comply with such provisions arthh permit shall be
deemed revoked.
.
TOTAL:
'
BUILDING '
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
Ihercbyafflrmthat them laamnsemctlon lending agency forth perform
ance of the work for which this permit ts issued (Sec. 3097, Clv. C.)
TOTAL:
ELECTRICFEE
Lander'. Name
Lender's Address
I certifythatl have read thisappllaHonand d.tethattheaboveinfomvtion
'Iscorrect.I agmam complywith all city and countyordinamosand statelaws
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
MECHANICAL FEE'
PERMIT ISSUANCE
FEES PAID:
relating to building construction, 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 harmless the City of Cupertino
against liabilities,judgments, coaband expenses which may In anywayamue
against said City In rouse uence of the granting of this permit.
3 ra& r O. 1-7-71
ALTERORADDTOMECH.
AIR HANDLING UNIT (TO 10,000 CPM)
Date Recei tM
P
SUBTOTAL:
AIR HANDLING UNIT (OVER 1 q(nO CFM)
CONSTRUCTION TAX
Signature of Applicant/Contractor "' Data
EXHAUSTHOOD(W/DUCT)
CONSTRUCTION TAX PAID:
- HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or (mum building occupant store or handle hazardous
materials. defined by the Cupertino Municipal Code, Chapter 9.IZ and the
HEATING UNIT (TO 100,000 BTU)
Date Recei ti{
HEATING UMT (OVER vooma BTU)
TOTAL:
Health and Safety Code Section 25532(a)2
❑ Yes Ir�.� No , ,
VENTILATION FAN (SINGLE READ)
ISSUANCE DATE
[$ ao
Will theapplicant or futu.1nuldingoavp.muse equipment ce devices
which emit hazardous aU contamimne as defined by the Bay Area Air
Qj�a,ltty Management District?
Yes ❑ Nodo
BOILER -CAMP DH P OR 100,000 BTU)
BOILER-COMP(OVER 100,000 BTU)
have raid the hazardous materials requirements under Cha Ater 6.95 of
the California Health&Safety Code, Sections 25505,25533 and 25534. I
understand that lithe building does not currently have a tenant, that It is my
��� 6
NEW RESIDENTIAL MECH, SQ.FT.
mponsibility to notify the occupant of the requirements which must be met
.prior to Lwuance of a Certificate of Occupancy.
0
ISSUED BY:
Owner or authorized agent Data
TOTAL:
OFFICE COPY