23773APPLICANT TO FILL IN INFORMATION WITHIN RED LINES'- USE BALL POINT PEN ONLY
Building Prow, Identification
Building Address: 7532
124 S
- PERMIT NO.
23773_
wn enc:
C6-UOcY.2/U.0 GUay
CITY OF CUPERTTN0.BUILDING DIVISION
APPLICATION / PERMIT
BUILDINGELECTRICAL PLUMBIN&MECHANICAL
A
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(6 -q7L-
Lie. No.
CATEGORY
CONTROL a
Ambltect/Englomr. Lie. No:
QTY ELECTRICPERMIT FEE
BUILDING PERMIT INFO
Address: 2z G /NGa p S
UL hl,�l PLUMB AILL'I
71 1:1 1:1LICENSED
PERMITISSUANCE
CONTRACTOR'S DECLARATION
I hereby affirm that l are licensed under providers of Chapter9 (mmmen
Inure is ectlon to=anDlvfect. (the Buslnneand Pro(euloneCode, and my
Ilcenss is ti s force end effect.
License tau Lic_
Date ContConn ractor O—
ARCHITECTS DECLARATION
I understand my plans shall be used as public records.
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contrectorb License Law for the
(ogowing reason.(5eelon 7Bf1.5, Buslneu and Pm(eulone Code: Any tlty °r
muntywhichmquiresapen ttomrutrun,eller,Improve,demnlish,orrepair
anystm=mpdortult.kssname,alsorequireatheappBantfwsuchper tto
file a signed statement that he la licensed pursuant to the provisions of the
Contractors License Law (Chapter 9 (commencing with Stolon 7000) of Diel-
sion3 ofthe Budoesse rad Liddeubro Code) orthat he leexempt lherefromand
the basis for the alleged exemption. Any Violation of Section 70312 by any
applicant for a permit subjects the applicant to a civil penalty dna more than
five hundred dollars (SM.
❑ I, as owner of the property, or my empl-wre with wages as their sole
compensation, willdothe wor"rulthestructure h, not Intended or offered for
.In (Sec. 7044, Bueinns and Professions Code: The Contractors License Law
does not apply to an owner of property who Wilds or impmvn thermn, and
whodoessuchwork hlmselforthreugh blsownemployees, provided thatsuch
Improvements arc not Intended oroffered for sale. If, however,thebuilding or
improvement Issoldwlthln mayearofcompletios, theowner-W IWerwill have
t"relen of proving that he did not build or improve for purpose of sale.).
L.J L as, owner of the property, am exclusively contracting with Beamed
contractors to mna lruct the project (Sec 7044, Business and ProfessimCode.
The Contractor'. License Law don not apply to an owner of property who
build. or Improves thereon, and who mntmets for such Tuapds with a
onact°Ka) licensed pursuant to the Contractor's License Law.
L� I am exempt under Sec. B k P C for this reasonOUTil
APPLIANCESRRSIDENHAL
JOB DESCRIPTION
� - ,��
�,
PANELS
LIP TO 200AMN
IDI -1000 AMPS'
OVER 1000 AMPS
SQ. FI. FLOOR AREA
S/SQ. FT.
SIGNS ELECTRICAL
SPECIALCIRCUIT/MLSC
TEMP. MEEROR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
OUILETSSWITCHESFIXIVRES
VALUATION '
NEWRESIDENTIALELECTR SQ.Fi.
STORIES
TYPE CONSTRUCTION
TOTAL:
QTY. PLUMBING PERMIT FEE
OCC. GROUP
RES. UNITS
PERMIT ISSUANCE
ALTER -OKAPI & VENT- WATER (EA)
FLOOD TONE
APN
FEE SUMMARY
BACK FLOWPROTECT. DEVICE
EELS
DRAINS FLOOR ROOF, AREA, GOND.
FI(•fURES PER TRAP
SANITARY Y N•
RECEIPIM
Owner Date
hereWORKMAN COMPENSATION DECLARATION
ofby aftlrm that I have . certificate of consent to self -Imam, ora
cal(lateof Workers'Comperuatlonlmunnmoraudifledmpylher f(S.e.
3500, Lab C.)
Policy M
541700E TAX Y N
RECEIPT Y
GAS EA. SYSTEM -1 INCA OUTLETS ��
PARK FEE Y N
RECEIPT N
CAS EA. SYS773.1-0VER 4 (EA)
'Com ray
BUILDING DIVISION FEES
OCertlfied copy b, hereby filed the city
�Certlled copy V filed with the city Irapectlon division.
CERTIFICATE OF EXEMPT ION FROM WORKERS'
COMPENSATION INSURANCE
(This section need sol be completed If the permit is(eros. hundred dollars
($100)orless.)
I certifythet In the performance of thework forwhlch this penult is iseued,
I shall not employ any person in any manner so as to become abject to the
Workers' Compensation Law. of Ca Ufomla. Date
AppNOTICE
GREASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECKFEE
PAID
- Date RCmI [#
CREASE TRAP
SEWER -SANITARY -STORM EA IWFT
WATER HEATER w/VENT/ELFLTR
ENERGY FEE Y N
PAID
Date Remi t#
WATER SYSTEM/IREATTNG
NEW RESIDENTIAL PLMB. SQ.FI.
NOTICE co APPLICANT: a after making thisCertificate
pro of Exemption, you
Code, becomesubjectto the Workers' CompevatlonpmWiowofthe Labor
deemed you =at with comply with such provisions or this permit Asti be
deemed revoked.
CONSTRUCTION LENDING AGENCY
I hembyaffirmthat there is a construction lending agency forthe perform
ante of the work for which this permit is Issued (Sec. 3097, Clv. CJ
lendar'a Name
Leader: Addree.
1 certi/y that I have mad this appllatbn ami state that the above Information
iscorrect l agree to comply with all city and county ordinances and slate laws
relating to building construction, and hereby authorise representatives of this
city to enter upon the aWve-mentioned property for inspection purposes.
(We) agree to save, Indemnify an d keep harmless the City of Cupertino
against liabilities, NdgrmrdBmst.rx[expensnwhlchmgin anywayaceroe
agairut said City i° consequenceof the granting of this permit.
6
TOTAL:
BUI •E
SEISMIC FEE
TOT ��
ELECTRIC FEE
QTY. MECHANICAL PERMIT FEE
PERMIT ISSUANCE
PLUMBING FEE
MECHANICAL FEE
FEES PAID .
ALTS( OR ADDTO MUCH.
Date Recelpt#
AIR HANDLING UNIT(TO 10,0DO CFM)
SUBTOTAL'
AIR HANDLING UNIT (OVER IO,000CFM)
CONSTRUCTION TAX
Signature of Applicant/Contractor Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfutum building occupant storeor handle hazardous,
material as defined by the Cupertino Municipal Code, Chapter 9.12 and the
Health and Safety Cade Section 2S532(a)?
❑ Yea r] No
Will the applicant orfuture building occupant use equipment or devices
which emit luvrdous air contaminants as, defined by the Bay Area Air
Quality Management District?
4ID
Yes No
have read the hazar nus material. requirementsunderChapler6.95of
the Callfernla health k Safety Code, Sections 25505,25533 and 75534. 1
understand that if the building does not currently have a tenant, that it is my
responsibility to na lfy the occupant of the requirements which must be mat
prior to Issuance of a Certiflate of Ocr.V panty.
EXHAUST HOOD fY✓/DUCD
CONSTRUCTION TAX PAID:
HEATING UNIT (TO 100,0D0 BTU)
Date RCCeipl#
HFATING UNIT (OVER 100,(100 BTU)
TOTA .
VENTILATION FAN (SINGLE RFSID)
ISSUANCE DATE
ma p
P i k
� Iasas�t
—4199
•Jum, 1{y.�VS"�,'
V IQ
n I I O—C)
CII ' __rte r�
ISSUUD BY:
BOILER -COMP OHPOR 100,0(D BTU)
BOILER -COMP 100,OOD BTU)
NEW RESIDENTIAL MECFI. SQn
Owner or authorized agent Date
TOTAL:
OFFICE COPY