20426APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
Building Project Identification -
Building Addres,:
Ie .
PERMIT NO.
2 0 4 2 6
wners ams. Phoo.
I-
CITY OF CUPERTINOQBUILDINGDIVISION
APPLICATION / PERMIT
BUILDING-ELFCTRICAL.PLUMBING-MECHANICAL
' �y 0
Contractor's Name: Lic. No:
CATEGORY CONTROL If
BUILDING PERMIT INFO
Arc tea/Engine Lic Nm
QTY ELECTRIC PERMIT FEE
YS-
Addrcas:"
❑ ❑ ❑
PERMITISSUANCE ,
LICENSED CONTRACTOR'S DECLARATION
Thereby affirmthatI amlicensed under provisionsof Chapter9(commene-
in licease I Secfon force of d affeon3 a(the Bueimasand Pro(esstona Code, and my
Licerelalntullforceand ieec[.
Data eCWss ontr
Date Contractor
ARCHITECTS DECLARATION
I understand my plans shall be used as public records.,
Licensed Professional - -
OWNER -BUILDER DECLARATION
I hereby affirmthat l am exempt fromlhe Contractor's License Law for the
followingreason.(Section7031.5, Business and Professions Code: Any city or
countywh ich requ Tres a permit to commact, alter, Improve, demolla h, or repair
anystructurepdorm Its Issuance,aLsorequires theappliant forsuch permitto
file a signed statement that he h licensed pursuant to the provisoes of the
Contractor's License Law (Chapter 9 (commencing with Section 70M) of Dlvl-
3ofthe Business and Professions Code) orthat he is exempt therefrom and
the basis for the alleged exemption. Any violation of Section 7MI.5 by any
for a permit subjects the applicant to a civil penalty ofnat rrorethan
five hundred dollars ($500). -
F-1 1, as owner of the property, or my employees with wages as their sok
compensation, will do the work, and the structure is net Intended or offeredfor
Mile (Sec. 7044, Business and Professions Code: The Contractor's License Law
does not apply to an owner of property who Wilda or improves thereon,and
who does such work hlmselforthmegh his own employees, provided that such
Improvements arc not Intended or offered for We. If, however, the building or
Improvement is sold within one yearofcompletlon, the owner-builderwlll have
re anOfpmvingthat he did not Wild or Improve for purpose of ssld.).
I, as mvner of the PmJZ y am exclusively contracting with Ilcenssd
on_ to comwct the pro)ect (Sec.7(M4, Business end Professions Code:
The Contractor'. License Law does net apply ro en owner of property who
Wre
builds or Improves thereon, and who contracts for such p(o�ecta with a
cc actor(a) licensed pursuant to the Contractors License I.
I am exempt under Sec. B k P C for this reason
APPLIANCES -RESIDENTIAL
JOB DESCRIPTION
-
�jf�
4—/`t uke
P ^
•^ 4x0
201 OOO AMT'S' t
" O 1 AMPS - -
SQ. FT. FLO17�OR �
�'J V �•/
'
n �
� (��,� (�IAh��
$/SQ..FFT.
7r'_ CL
SIGNS E�[1F�CaT-R_.I�i�L
Ch
tiuIQUTT/MI
,
gEMPMETER OR POLE INS.
['OWER DEVICES
SWIs1MING [POOL ELECTRICMen
_
OUTLETSSWITCHESFIXTURFS
VALUATION
/_
applicant
Oy /
NEW RESIDENTIAL ELUCTR FT.
SQ'
STORIES
TYPE CONSIRUCTION
TOTAL: a
QTY, PLUMBING PERMIT' FEE
OCC.GROUP
RES. UNITS
FLOOD ZONE
APN
PERMIT ISSUANCE r'1
ALTER -DRAIN kVENT- WATER (EA) s (,'b
el
FEE SUMMARY
BACK FLAW PROTECT. DEVICE
OUTSIDE FEES
DRAINS F[OOR, ROOF, AREA, COND.
FIXTURES. PER TRAP
SANITARY Y N
RECEIPT B
Owner Date
WORKMAN COMPENSATION DECLARATION
01 hereby affirm that I have a cerlIDate of consent to self -Insure, or a
certi3800,LabofC.Workeri t
Comperuation Insurance or a certified copy thereof(Sec.
Policy I
SCHOOL TAX Y_ N
J RECEIPT M
GAS EA, SYSTEM -1 INCA OUTLETS
I �(�
PARKFEE Y N '
RECEIPT M
GAS EA.SYSCEM-OV(E
ER3A)
Com any -
BUILDING DIVISION FEES
❑pccrtl0ed copy is hereby fumished.
❑Certlfled copy Nfiled with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thm I.xaion need not be completed tithe permit V (Dross hundred dollars
($I Ic)orlessJ -
[certify that or they personiperformance n [he wwksfor is Issued,
as to b this apermit
I shat not employ any person in any manner so m to become subject to the
subject
a'Compensatlon Lawa o(Callfomia. Date
Applicant
Applicant
NOTICE w APPLICANT: a alter making this Cerllfkra of Exemption, you
shde,you atforthwit the Work era' Comprovisinprovbiomrmit s Lab be
cermed you =at forthwith comply with each provisions orthks permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirmthat there is a construction lend Ing agency for the perform-
ance of the work for which this permit is issued (See. 3097, Civ. C.)
Lender'.Name
["ender'.Address
Icertify that l have read this application and slate that the above Information
Is correct.I agree to comply with all city and county ordinances and state laws
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 it keep harmless the City of Cupertino
against Niles, pdgments, eastsand expenses which may in anywayaccme
agar tsar n e
Chytery matt t oflNspermit.
-
GREASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE �
PAID L"1 Q6 gSTL7
Date RCeel Iii
-yfa
ill
GREASETRAP
gE}VER-STORM-STORM EA 200F1•
WATER HEATER W/VENT/ELECTR Q
ENERGYFEE Y N
.PAI ,l�V � $y1
Date Recei tilt
p
WATER SYSTEM/TREATING
NEW RESIDENTIAL PLMB.SQ.FT.
TOTAL:
ING
6
SEISMIC FEE
TOTAL: .
-
ELECTRIC FEE
p
1
PLUMBING FEE60
x-
QTY. MECHANICAL PERMIT FEE
PERMIT ISSUANCE I C•�
MECHANICAL FEE
FEESPAID:
syr
ALTER OR ADD TO MUCH.
Date Receipt#
AIR HANDLING UNIT (TO 10,000 CFM)
SUBTOTAL'
AIR HANDLING UNIT (DYER 10,000cIM)
CONSTRUCTION TAX
5 nalureof Appli nt/ antraaor Date
HAZARDOUS MATERIALS DISCLOSURE
Will the app0ont or future building occupant store or ha relic hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.1 2, and the
Health and Safety CoQe,finectlon 25532(a)7
E3 Yea , o
Will the applicant future building occupant use equipment or devices
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management st 7
4Yes o
requirements 2555,2553 and Z7A34.I of
haif rnia Health
the GBandt Health b ildingCode, es Searone7550.5,ve a tand25534.I
understand that if building dons not currently have atcnanq that It is my
repo lito notify the occupant of the requirements which must be met
Pub Dislys .',o fa itlfic t mOcn
EXHAUST HOOD(W/DLrT)
CONSTRUCTION TAX PAID:
HEATING UNIT (TO 100,000 BTU)
�-
Date Recei of
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
177-0,7
Z
VENTILATION PAN(SINGLE RESID)
]rjs'j•J.���
4:.da�ai^DA
Qrq
0
AUC
/'1r'
f5epr t�?r�^s?rtrla�
U1ly F' " -
�'T'�v s
U�
BOILS&COMP QHpOR 100,000 BTU)
BOILER-COMP(OVF7i ]00,000 BTU)
NEW RESIDFN7IAL METH. SQ.IT.
ner or authorized agent Date
-TOTAL:ISSLIEDBY:N
OFFICE COPY