23863APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Project Identification
B"°ding Addams:
i i4, ,
_ PERMITNO.
23863
cern aonC: ones
/LI CHAZ ase an
CITY OF CUPERTINO-BUILDINGDIVISION
APPLICATION / PERMIT
BUILDING-ELECTRCCAT PLUMBINGMFCHAMCAL
�J
1' / Z
Contractor's Name: / L✓ 1 LIc. Nei,
5.
CATEGORY
CONTROLN
Architect/Englner. LIc, No:
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Address:
❑ ❑((� ❑
�J
PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION
I hereby th&di.( MOhatlam Bcrn3.fth.under provisions off a..9(commrn
Ing wlth5ection7000) of Dlvfect. ofthe Buainevand ProlesslonsCode, and my
Ii= le In _o a c.0
Limn C6 LIC.N t�uZ 7'
Date Contract. - Il+3
ARCHITECTS DECLARATION O
I understand my plamehafi be used as public records
Licensed Professional
DECLARATIONSPECIALCIRCUIT/M1SC
I herebyafOren that l am exempt from the Contractor's License Law for the
reason.(Section 70315, Business and Professions Code: Any city or
counlywhichrequimaperedtmromtmd,alteplmpmv dem Ush,orrepair
anystructure priorto Ire heuance,abo requims(heappllunt f.rsuch permdto
file a signed statement that he Is licensed pursuant to the provisions of the
Contrador'a License Law (Chapter 9(commencing with Section 7000)of Diel-
slon3 of the Businessand ProfemlonsCode) orthat hein exempt thenefromand
the basis for the alleged exemption. Any violation of Section 70315 by any
applicant fora permit subjects lheappllcant to a civil penalty of not more than
five hundred dollars(5.SM.
❑I, as owner of the property, or my employees with wag" as their sole
compensation, will do the work and the structure isnot Intended or offered for
sale (Sec. 7034, Business and Professions Code: The Contractors License Taw
does not apply to an owner of Property who builds or impneves theme, and
who does such work himself orthrough his.wn employees, provided that such
Improvements are not Intended oroffered fursale. If, however, thebulldleg or
Improvementusoldwlthle bneyearofcompletl.n,lheowner-bu0derwlll have
tl)L,tiurden of proving that he did net Wild or Improve for purpme of sale.),
LJ L ae or of the property, am exclusively contracting with lim acd
mntncims to construct the project(Sec. 7044, Business and Profession Code:
The Contractor's License Law does not apply to an owner of property who
builds or improves thereon, and who contracts for such pt ojieta wRh a
�gB(reasonsdons) licensed pursuant to the Contractor'. License Cow.
LJ I am exempt under Sec. R k P C for this reasons
APPLIANCFSRFSIDENI7AL
JOB DESCRIPTION
,� ��� Alt r /'
C/il/LT( -r/!F
e
PANES �
RPS
701-1000 AMPS
OVER1000AMPS
4SQ.Fr. FLOOR AREA S/SQ.FT.
E(.Bowing
I R
.
7
SIGNS ELECTRICAL
-RINLEDOWNER-BUILDER
TEMP. METER OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
VALUATION
�_
r a
OUTLET&SWITCHFSFIXTURFS
NEW RESIDENTIAL ELECTR _SQ.Fr.
SfORIES
TYPE CONSTRUCTION
TOTAL:
Q y, PLUMBING PERMIT FEE
PERMIT ISSUANCE p'71
r U V
-
ALTER -DRAIN & VENT - WATER (FA)
OCG CROUP
RES UNITS
FLOODZONE
APN
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
DRAINS FLOOR ROOF, AREA, COND.
FDn ARES. PER TRAP
SANITARY Y N—
RECEIPT aPENSATION
Owner Date
WORKMAN COMDECLARATION
of content to "If -Insure, ora
I hereby affiorkem that I have o Insurance
ce IIabcxom of Worken'Compematlonlmunnce oracertifled ropy thereof (Sec.
380D, Lb C.I "
Polirya /ctr-73 h�v'L
Com any �T ._ -
SQlOOL TAX Y— N
RECEIPT N
GAS EA. SYSTEM-11NCAOUILET$
PARK FEE Y— N
RGCER'T«
CAS EA. SYSTEM -OVER 4(FA)
BUILDING DIVISION FEES
Allied copy is herebytd.
orlRied copy Is filed withh the the city inspection division.
CERTIFICATFOF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
( m lection need not be completed lithe permit V foron hundred dollars
(51 I0)0)or1n.J
lcertl(y tmo-Yhat in an person I -any marhe ork for tobhich Niseesubjcrmit is to red,
I shake not employ any person In any manner n u to become subject to the
ApplicWorkers' Compensation law. of California, Date
Applicant
NOTICE
co APPLICbecome subject tote, after making perhis Ction, rovis Exemption,you
Cenle,shoulou=aaurthwit the ply wit'Comperuason pmvbiomrmit the s Lab be
naked.at forthwith comply with such provlelom.rth0 permit shall be
deemed
deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby afOrenthat then le it construction lending agency for the perfomr
ante of the work for which this permit is Issued (Sec. 3097, Civ. CJ
Lender'. Name
Lenders Address
I cenilythatl have read thisapplirnbn and statethat theaboveinformat er
iscorred.I agree to complywith all city and county ordinaressand statelaws
'relating to building construction, and hereby authonae representativesof thio
city to enter upon the above-mentioned property for inspection purposes.
(We) agree to save, Indemnify an d keep hared.. the City of Cu pen Ines
against liabilities, pdgments, costs and expenses which may In anyway amu.
.against C In ronxxryen ?tre acing of this pemNL
GRPASE/NDUSIRL WASTE INTERCEPTOR
PLANCHECKFEE
PAID
Date Recei IN
GREASETRAP
SEWER -SANITARY -STORM EA 700Fr.
WATER HEATER W/VENT/ELEC'IR /�
ENERGY FEE Y N —
PAID
Date Ip
WATER SYSTEM/TREATING
NEW RESIDENTIAL PLMB. _SQFI.
TA
TOTAL:
BUILDING
TOTAL: C
A: a
SEISMIC FEE
ELECTRIC FEE
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
MECHANICAL FEE
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT CFO lo," CFM)
FEES PAID:
Dale Recei tk
SUBTOTAL:
VISO
AIRHANDLING UNTT(OVEe I0,000CpM)
CONSTRUCTION TAX
g tu
5rcof Appll t/ brocim a64e"
A7ARDOUS MATERIALS DISCLOSURE
Will theappllunt orfuture building occupant store or handle haeardous
material as defined by the Cupertino Municipal Code, Chapter 9.17, and the
Health and Safety Code Section 75537(a)7 -
❑ Yes r� No
Will lheappllcant or fumm building occupant use equipment or devices
which emit haeardouaaircontaednnlsas defined by the Bay Arca Nr
Quality Management D❑lstrid7
qYes M No
have read the haza esus materiab requirements under Chapter 6.95 of
the Coliform. Health k Safety Code, Sections 2S50S, 25533 and 75534. 1
understand that lithe building does not arrently have a mr.ct,thatitlsmy
responsibility to notify the occupant of the requirements which must he met
prior to issuance of a Certificate of Ocm pa ney.
IXFIAUSTHOODMVDUCT)
CONSTRUCTION TAX PAID:
HEATING UNIT (TO 100,000 BT1p
_
Date ReceI t#
HEATING UNIT(OVER 100,000 BTU)
TAL:
t
VENTILATION PAN (SINGLE READ)
S$UANCE DATE
,r��ld
ui �Ur r m i llVV
y-y�/
ISSUED By \-
BOILER -COMP (7EIP OR I00,0(U BTU)
BOILER -COMP (OVER 100,000 OTU)
NEWRFSIDEIMALMECH. SQ.2
Owner or authorised agent Date
TOTAL:
OFFICE COPY