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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification I
Building Add res:n
/a ✓5� 2
PERMIT NO.
3 5 1 n
G G
here ams: one:
litaf P,4,es
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
/y BUILDING-ELECTRICAI PLUMBING- MECFUMCAL
A A
Let�/O�G'/^L
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contracue.Nan'e: Lic.N.
-,z:6� 5t`XA ' Cho 57F'49006
CATEGORY CONTROL#
BUILDING PERMIT INFO
Archltect/Engineer. Lk. N.
QTY ELECTRICPERMIT FEE
Address:
❑ O (\j ❑ -
L.F
PERMITISSUANCE
LICENSED hat I a CONTRACTOR'S DECLARATION
I hereby atn7ODufDiviscen3ofthe uMnmalonsof Chapter9(e,and y
Ingwlt ISI fulif000)of doffeen3olthe Budnnsand ProfesdonsCede, and my
Iiwnee Is Infulleo and t.4
License classuaa /„erY
x,ia//4.I
Dale jr CHITEtor DECLARATION
• ARCHITECPSDBCLARATION
1 understand my plata shall be unto as public records.
Licensed Professional
OWNERDECLARATION
DECLARATION
1 hereby affirm e m that I am exempt frothe ora License w for the
following
following reason. (Section 7031.5, Business and Pretensions Code: Any city or
cmntywhichmqulresapermittommlmd,alteplmprov deanollsh,errepair
Wuance,aborequlmtheappbmntforsuchpemdtto
file it signed statement that he in licensed pursuant to the provisions of the
Contrectorb License Law (Chapter 9(cormur•ncing with Stolon 7000) of Divi-
don 3 efthe Budermand Pref nalonsCode) orthat he etexempt themfromand
the balls for the alleged exemption. Any violation of Section 70315 by any
applicant fora permit subjects the applicant to a civil penalty of not more than
flue Nuns delbrs($ W�.
❑ 1, as owner of the property, or my employees with wages as their sale
compensation, willdothe work and the structure In not intended or offered for
elle (Sec. 7044, Buslmss and Prefesslons Code: The Contractors License Law
does not apply to an owner of property who Wilde or Improves thereon, and
who does such work himself or through hisown employees, provided that such
Improvements are not intended or offend for Me. If, however, the building or
Improvement Is cold within one yearo(emnpletion, the owner -builder will have
tmen of paving that he did not Wild or Improve for purpose of sale.).
: ,u I, as owner of the property, am exclusively contracting with licensed
centrectore to constsuctthe project (Sec. 7054, Business and Professions Code:
The Contractor's Licence Law does not apply to an owner of property who
builds or Improves thereon, and who contracts for such pwjects with a
"bacgR((adorW licensed pursuant to the Contractors License Law.
t am exempt under Sec. B h P C for this reason
APPLIANCESRESIDENTIAL
BDESCRIPTIO
1r -r Vra J
L-itW
l TI
PANELS
201-IOVER1O AMPS
OVER IBRO AMPS
� E D I N
P U E R
/jJ
�'�i
§/�- FT.
SIGNS ELECTRICAL
SPECIALCIRCUIT/MLSC
TEMP. MEMORPOLEINST.'
UAIE
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETSSWITCHESFIXTUREq
VALUATION
NEWRESIDENTIALELECTR SQ.FT.
STORMS
TYPE CONSTRUCTION
TOTAL:
QTY, PLUMBING PERMIT FEE
OCC.CROUIa
RES. UNITS
PERMIT ISSUANCE�-
ALM -DRAIN k VENT - WATER (EA)
FLOOD ZONE
APN
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
FEES
DRAINS FLOOR ROOF, AREA, COND.
SAMTARY Y_ N_
RECEIPT #
Owner Date
-
WORKMAN COMPENSATION DECLARATION
❑I hereby affirm that I have a certificate of consent to self -Insure, ex •
certificate m Workers'Competwten lruuranmora cenlfled copy thereof(Sec.
3800, lab C.)
Policy#
FIXTURES -PER TRM
SCIiOOL TAN Y_ N_
RECEIPT
GAS EA. SYSITM-]WC.40ITILEfS �^
PARK FEE Y N
RECEIPT#
GAS-
Com ray
BUILDING DIVISION FEES
❑Cenllled copy In hedwithreby the
❑CedBled copy V filed with /he city Inspection division.
city
CERTIFICATE OF EXEM PTION FROM WORK ERS'
COMPENSATION INSURANCE
(fhdlon need not becompleted If tM pemdt V m forahundred dollen
(5100)morlelossJ
Icertlfy that In the dormnceof thework for dch this permit Is issued,
I ah.0 not employ a non t0aey manger e I and subject to the
Workers'Compe nLaw ((Califor 7 -�
ApplicaNOTICE
NOTICE 70 I : If, after making l Itkate a(Exemptlon, you
should becomes oche WmkrrsC atlon provisions of the Labor
CodayoumuatfodhwlthcemplywBh chprovlelonserthlaperretahallbe
deemed revoked.
CONSTRUCTION LENDING AGENCY
Iherebyafflrm that there la a a itmctlon lending agency for the perform
once of the week for which this permit b issued (Sec. 3097, Civ. C.)
Lenders nae .
I maifythat I have read thisapp11cationanl nate that theabove Information
Ia correct. I agree to comply with all etyand countyoMlnances and date laws
relating to building cemtructine, and hereby authorize representatives of thin
city to enter upon the abovo-mentloned property for inspection purposes.
(We) agree to ve, indemnify as d keep ha ess the City of Cupertino
agalmtllablllt dgmente,codsandexpense Ichmayleanywayacctue
against said C' neon nm oNis gcantin this rmlt.
CREASE/INDUSTRL WASTE INTERClTTOR
PLANCHECIC'FEE
PAID
Date Recei tN
GREASE TRAP
SEWER.gpMTARY-SroxM FA pBFl•
WATLRHEATERW/VENT/I.ECTR
ENERGY FEE Y N —
PAID
Date Remi t#
WATER SYSIFA7/TRGTING
NEW RESIDENTIAL ETMS._SQ.FL
TOTAL:
LDING FEE
SEISMIC FEE
T
ELECTRIC FEE
QTY. MECHANICAL PERMIT FEE
PERMITISSUANCE
PLUE
MBING FE
MECH ANICAL FEE
FEES PAID:
ALTER OR AUDIO MECH.
Date Recei t#
P
AIR }iANDLING UMT(TO 10,(#10 CPM)
SUBTOTAL:
AIR HANDLING DMT (OVER 10,000 CFMI
CONSTRUCTION TAX
Signature rat/Contractor Data —
A25ZARDOUS MATERMCSDISCLOSURE
Will the applicant orfuture building occupant store or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.1 Z and the
Health and Safely Cade Sectlon 25537(a)?
❑ Yes MN.
Will the ipplimet orfuturebullding occupant useequlpetsm ordevices
which emit haeardoue air centamhune as defined by the Bay Area Air
Quality Management District?
4Yes the ❑❑ No
haverea Health&Safet mode, a mclutrations2ments 05,25533and25534.95o(
bSafelyCodsSiNonhaveat and ,that. I
the Calif d t at If the nocurrently equfiments tenant, that Itis my
reepntandltul lit Ifthe occupant of
rmponsibalty to naUfythe occupant of the mqulrerrcnta which must be met
prior to Issuance of a Certificate of O=pa ncy.
EXHAUST HOOD M/DUCT)
CONSTRUCTION TAX PAID:
HEATING UNIT (TO 100,000 BTU)
-
pyre Recei t#
HEATING UNIT (OVER 100,000 BTU)
TOTAL
VENDLATION FAN (SINGLE RESID)
ISSUANCE DATE
k�k
r A p1,
6t'
APR 1 0 1(1Qa)
aix7(a Q
Cli i ser LUr -
��s �n nlrU
ISSUED BY:0:%T��
BOILER-COMPOHPOR 100,000 BTU)
BO LC&COMP(OVFRID3,000BN)
NEW RESIDENTIAL MECH. SQ.f•T.
Owner or authorized agent Data
TOTAL:
OFFICE COPY