23987APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification
Buildqing•\A\ddreac
PERMITNO.
^n(117
23987
Z-Wrre aces: \ 'i,\ ,- one:
M�.�Mrs �ocfna��e `ti6ci.,3-7L
CITY OF CUPERTINO-BUILDINGDIVISION
APPLICATION I PERMIT
BUILDING-E.FCTRICALPLUMBINGMECHAMCAL
A
�s
ontrector'sN
`T 7
CATEGORY
CONTROLS
Architect/Engineer. Lie No:
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
aA� _
Addres.v: 2TSy D 6P \ O o\C 4f S. ,3
PLUMB M�H
}� ❑ ❑
LTJ
PEthETISSUANCE
LICF.NSEDCONTRACTOR'SD LARATION
I hereby affirm that l am licensed under provLslona of Chapter9(commenc
ingwith Secttan7000)of Dlvlgon3 olthe Buene,sand ProfeulonsCode,and my
liceneelelnfullf and effect.
Lt.Date , Clam Lk. p
Date -I I.. Contactor %
APPLIANCESRESIDENIMAL
_ )Oat DESCRIPTION
PANELS
UP TO 2DO ANTS
2014000AMPS
ARCHITECPS DECLARATION
I understand my pts¢ shall be used u public records.
Licensed Professional
OVER 10DOAMPS
SQ. FT. FLOOR AREA
/^:, p
E D '
f/SQ. FT.
I
SIGNSELECTRICAL
OWNER-BNLDER DECLARATION
I herebyaEren lam exempt fromthe Contractors License Law fm the
following reason. (Section 7871.5, Business and Professions Code: Any city or
counlywhich requires a permit tocorumuct, alter, improve, demolish,oreepalr
anystmdure prlorto Its Issuance, alsorequlreathe applicant for such permit to
file a signed statement that he Is licensed pursuant to the provisions of the
Contractors License Law (Chapter 9(commencing with Section 7000) of Divi.
of the Business and Peofembmu Code) or the he is exempt thercfromand
the IoW forth. alleged exemption. Any Wolatlon of Section 7mlS by any
applicant for a permit subjects theapplicant too civil penalty of not more than
five11'as owner ed
thepr,
owner of the property, or my employes with wage as there door
t
SPECIAL CBtCUIT/MISC
/r '\ r0 '
�� u�
f
hof `
-
JI
TPMP METEAOR POLE INST.III.
POWER DEVICES
SWIMMING POOL ELECTRICslon3
OMLEMSSWIM'CHESEJ(TVRES
VALUATIO11a1
4 oI\A S�-�
NEW RESIDENTIAL ELECTR SQ.Ff.
STORIES
TYPECONSIRUCHON
compen❑Las
will doth. wink and the of
mcturc is not Intended or for
.1. $c .7044, ted.. cefend
saor (Sec. 764y Buskures est Prolessiomu Code: The Contractota License Law
docs not apply to an owner of property who Wilde or Improve, thereon,and
whodoea suchworkhimselforthrough hisuwnemployee., previdedthatsuch
OCC.GROUp
RFS. UNITS
m
Improveent, are not Intended orolfered for sale. IL however thebullding m
Improvement 6sold wlthinoneyearofcmnpl&WNtheowner-buBderwlll have
T
t rden of proving that he did not build or Improve for purpose clash.).
LJ L as owner of the property, am exclusively contracting with —v—
contractors to construct the project (Sec 7044, Business and Prefessio¢ Code:
QTY, PLUMBING PERMIT FEE
pppp LSSUphICE
bIADD ZONE
APN
The Contactors License law does net apply to an owner of property who
Wlld, or Improves thereon, and who contracts for such p\ojects with s
ctor(s) 1lmosed pursuant to the Contneta'd License Law.
ec
LJ I am exempt under SB k P C for this reason
ALTER -DRAW &VENT -WATER (FA)
FEE SUMMARY
BACK PLOW PROTECT. DEVICE
DRAINS FLOOR, ROOF, AREA, COND.
FIXTURES, PER TRAP
SANITARY Y N
RECEIPT M
Owner Date
WORKMAN COMPENSATION DECLARATION
❑I hereby affirm that I have ¢rtifieah of consent b
SCSTOOL TAX Y— N_
o pytheure, m ,
3800 fab of Worken'Compevatlan lnsunn¢oracerUfied copy lhereo!(Sec.
pwj lab C.)
Polirya \\ " b21 I
REGEFTN
CAS EA. SYSTEM -1 WC.4O(TTLETS
PARK FEE Y N
RFNGDIR
GAS EA. SYSTRM-OVER
Gmanv 1=.x
BUILUINGDIVISION FEES
�CerllBed copy 6 heed with the city
®C.rtified copy 6 filed with the city Inspection division.
CREASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE
GREASE TRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
R)., I..an need net be completed If the perndt 6 for one hundred dollars
ul1 emilee.)
Icertay that in the p.gornunre of ehework (.rwhkhlh6 permit is Gored,
Ishall not employ any person in any rwnner n Y to become abject to the
Wmkcn' Compensation laws of Gllfom6. Date
ApplicaNOTICE
NOTICE co APPLICANT: R, after making fhbnationCertificate
prm ja Exemption, you
Code,shoulbecomesubjectto the Workers' Comperovisins orthiu¢enthe Lel be
d.c.d you=at forthwith comply with each pmWlov orthb permit shall be
deemed revoked.
PAID
Date Recd tN
SEWER -SANITARY -STORM F.A.200FT
WATER HEATER W/VENT/ELEGTR
ENERGY FEE Y N —
PAID
Date Recei ell
WATERSYSTDN/TREATING
NEW RFMDFNTIAL FLMS._SQ.FT.
TOTAL'
BUILDING
.+
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that them 6 a construction lending agency for the perform -TOTAL
ance of the work for which this permit 6 Gamed (Sec. 3097, Cie. C.)
ELECTRIC FEE
Lcnder's Name
Landers Addrn,
I certifythatl have read th6appBrationand statethaum
heaboveinfoutlon
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
MECHANICAL FEE
FEES PAID:
6correct. l agree to comply withal) dtyand county ordinances and gate laws
PERMIT ISSUANCE
relating to building construction, and hereby authorize representatives of th6
city to enter upon the abovo-meotioned property for Inspection purposes.
(We) agree to save, Indemnlly an d keep harmless the City of Cu portion
against liabilities, judgeumts,.9... d cape.. which may In any way aceme
.bald City In cone_ n¢ of the granting of this pmmlt.
_ ,
'Date
Date Reeei t#
ALTERORADDTOMECH.
AIR HANDLING UNIT (TO 10,000 CFM)
SUBTOTAL:
AIRHANDLING UNIT (OVER 10,ODOCFM)
CONSTRUCTION TAX
Sigrumre of Applicant/Contractor
EXI LAUST HOOD (W/DUCT)
CONSTRUCTION TAX PAID:
HAZA R DOUS MAtrIIUSDISCLOSURE
HEATING UNIT CID 10O,ODO BM
Will the applicant or Future building nempant store or hand In harardous
material as defined by the Cupertino Municipal Code, Chapter 9.1 Z and the
Date Recei t
HEATING UNIT (OVER 100,00) BTU)
TOT
ITealth and Safety CodeSection25532(a)?
Yea l+a No
VFN'DLATION FAN (SINGLE RESID)
_
ISSUANCE DATE
qlllthe applica or or fiBure building occupant use equipment or devices.
which emit harardous air contaminants as defined by the Bay Area Air
Quality Marugement Dls��trr GctI•
if.!
BOILER -COMP OI{P OR 100,009 BTU)
4 Yes
have read the hazarcTi . onecria6 requirements underCha pter 6.95 of
the California Health k Safety Code, Sections 25005, 2593 and 25534. I
^
P A
BOILFR-COMP 100,000 BT V)
NEWRESIDENTIALMECH. SQ.FT
undersea od that if the building does not mrrently have a tenant, that it 6 my
reaponslbilitytonee lfy the occupant of the requirement. which must be met
prior to Lss) o Grtllkateo(O ipancy.
Owner or authorissd agent ` 4-42.
�•-j
Af
6 iso ���
mal F. IF .
ISSUEDBY: CI1111VU
TOTAL:
OFFICE COPY