23689APPLICANT TO FILL IN INFORMATION WITHIN REDLINES —USE BALL POINT PEN ONLY
Building Project IdentificationPERMIT
Building Addrase: �,.
U �.S �r
NO.
23689
• am I, one:
52 - /733
CITY OF CUPERTIN6BUILDING DIVISION
APPLICATION It PERMIT
BUILDING MECTRICAL-ML BINGMECkf NICAL
AI'PLICAIIONSUHMIIIXr p .
f
6
c°nn o .Nam: 39Da.N5
CATEGORY
CONTROL x
Archimet/Engineer: Tic. No:
QTY ELECTRICPERMIT FEE
BUILDING PERMIT INFO
Address:
❑ ❑ ❑
PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION
IherebyaffiredNat lam Bceneed underprovisionsofChapter9(commenc
ingwith Sedion 7000) of Division 3 ofthe Budnnsand Pmfese =,Code,andmy
license is In fuli9 ea affect,
Li=i. m Lk.N D— II
Date Contractor SO//%!.j
ARCHITECT'S DECLARATION
Iundemlend my plana slvR be used azpublic reroMa
Licensed Pmfiodr al ,.
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt feed the Contractors License Law for the
following r. (Section Nati, Bush. and Prolenlum Code: Any city of
counlywhlch requidda permit tomeatudm
, alter, improve, demolish, orrepalr
anystructum prlorto Its Issuance,alsorequlreathe appliantlorsuch permit to
file a signed statement that he Is licensed pursuant to the provision of the
Cantradorb License Low (Chapter I(on."cing with Section 7000) of Divi.
da.3 of the Bushmsa nd ProfemionsCode) nether he is exempt therefrom and
the basis for the alleged exemption. Any violation of Section 7031.5 by any
eppllont fora permit mbpdsthe applicant toadvlipmulty ,(nd more than
five hundred dollars ($SOO.
nI, as owner of the property, or my employees with wages as thelreule
compensation, will do the work and the strudua it not Intended or offered for
sale (Sec. 7044 Busbies, and Pmfeasbtu Code: The Contractors License Law
does not apply to an owner of property who builds or improves thereon, and
who dorsa,(], work himself or through hisown employees, provided that such
improvements ate not Intended oraffemd for mle. IL however, thebuilding ar
improvement lasold wilhinoneyearofcompldion,lhe °caner-bullderwlll have
tke.truedcnof provingthat he did nmbulldorlmprove forpurpoaeofsale.).
uu L as owner of the property, am exclusively contracting with licensed
contractors m rorulrud the project (Sec 7016, Business and Prefembv Code:
The Conlredor's License Law does net apply to an owner of property who
bu Oda or Improves theater, and who contracts p
for such xojects with a
cgganor(s) licensed pursuant to the Contractors License Law.
L -II am exempt under Sec. B k P C !or this reason
APPLIANCES -RESIDENTIAL
JOB DESCRII'17(JN -
PANELS
201-1000 AMPS
OVER 1000 AMPS
`(�`(�� FL $/✓Q. FT.
�
AFL V
p U T E
/) i
E l -J Or"�
JI
SIGNS ELECTRICAL
SPECLYLCIRCUIT/MISC
YEMI•MET[R OR PCILE INST.
POWER DEVICES D
SWIMMING POOL ELECTRIC t
OUTLEISSWITCITFSF[XTURES
VALUATION
��p p r 06)
NEW RESIDENTIAL RLECTRS2.HI'.
STORIES
TYPE CONSTRUCTION
TOTAL:
QTY. PLUMBING PERMIT FEE
OCCGROUP
FLOODZONE
NBS UNITS
APN
PERMIT IS51JANCE
ALTER -DRAIN A, VENT - WATER (EA)
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
OUTSIDEFFFS
DRAINS FLOOR ROOF, AREA, CONTI.
FIXTURES PER .TRAP
SANITARY Y N_
RECEIPT x
Owner Date
WORKMAN COMPENSATION DECLARATION
❑I hereaffirm that I have a certificate of consent to self -Inco, or
unifimteofWorkeWC=Nmatimlu mnceoracedifkdmpythemaf(Sec.
Lab C.)
polic39M,y
Polley M_- �/X
RH_fML TAX Y_ N
RECEIPT x
GAS F.A. SYSTEM-]INC.6OIITLEIS
PARK FEE Y N
RECEIPT x
GAS EA. SYSTEM-OOVER CEA)
Cam any
BUILDING DIVISION FEES
[PCedl a py urnls a
F7lCedifled copy b filedi.d with the dtyWpedion division.
CERTIFICATE OF EKEMPTION FROM WORKERS'
COMPENSATIONINSURANCE
NSURANCE
(TM1lesedion need net be Nlithe permit Is for one hundred dollars
(St00)rtifyt .)
I ceout emplohat in y l o d subjExrddtect
any perhe son
I shall out employ any person in any manner dx as to become aubjetl to the
in any mangerhe work so as to c to the
Worken'Compeneatlon laws of GlBornla. Date
Applicant
NODCETO APPLICANT: R, after making this, Certificate o(Exemption, you
should become subject to the Workers' Compemat Ion pmvblaru of the Labor
Code, you moat forthwith comply with such provisions orthis permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
I herebyafOrmthal there N a constructed kndlegagenry, forthe perform
ance of the work for which this permit is Issued (Sec. 3097, Civ, C.)
L.ender's Name
Lendee.Addreea
I ad fly that l have read this application vW
tionstate that the above Information
lacomect. I agree to comply with all etyand county ordinances and state laws
relating to building construction, and hereby authorize representatives of this
city to enter upon the above-mentlonW property for impeedion purposes.
(We) agree to save, Indemrdly an d keep harmiem the City of Cupertino
agaWtllabllitles,pdgmenm,c sandexpenwswhich mayinanywayamue
eget tsald Cl Inc • uence of h granting of thl emit.
71
GREASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE
PAID
Date R emiFt#
CRFASEIAAP
SEWER -SANITARY -STORM EA 200FT
WATER HEATER W/VENT/ELE-CTR
ENERGY FEE 'Y N
PAID
Date Rem1 t#
WATER SYSTEM/TRFATIN'C
NEW RESIDENTIAL PLMB.SQ.FT.
TOTAL:
BUILDING FEE
SEISMIC FEE
TOTAL
ELECTRIC FEE
QTY. MECHANICAL PERMIT FEE
PERMIT ISSUANCE
PLUMBING FEE
MECHANICAL FEE
FEES PAID:
ALTER OR ADD TO MECH.
Dale Recei t#
AIRHANDLINGUNIT(TO10,030CFM)
SUBTOTAL:
AIR HANDLING UNIT (OVER 10,00(1 CFM)
CONSTRUCTION TAX
_
Sigwtum of Ap Reant/Comedo . W
HAZARDOUS ATERIALSD CLOSURE
Wllllheappliant or future building occupant store or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.12, and the
d Safety Code ecton 25532(x)7
I' t ❑Yesi
Will the applies nt or—Wee building«(,pant use equipment a devices
which emit hazardous air contaminants as defined by the Bay Area Air
Qua lity Management Distriet7
M Yes n No
have mad the haze'r�',usmaledals requirements under Chapter 6.95 of
the California Health A SafetyCode, Sections 25505, 25533 and 25534. 1
understand that if the building does not currently have a tenant, that it is my
ropomibility to ndlly the ompant o(the requimmente which must be met
prior to issue ofa rtlfkatc o(O anry.
&HAUSTHOOD(W/DUN
CONSTRUCTION TAX PAID:
HEATINGUNIT(TO100,0001HU)
Date Recei t#
HEATING UNIT (OVER 100,000 RI 4
TOTAL:
VENTILATION FAN (SINGLE RESID)
ISSUANCE DATE
b" B
PAID
,JUL 13 ���„
/�}{�Y/�jL,
ISSUED BY: bI I IIVV
BOILER -COMP OTB' OR 100,000 BTU)
BOILER-COMP(OVE i1B 000 BTU)
NEWRFSIDENTTALMECH. SQ.FT
ner or authodbadagent Data I
TOTAL;
OFFICE COPY