20116APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification
Build ing Addreae:
Gd0 — 'a
PERMIT NO.
1"1 O 1
G I
dante r one:
Af a, "r 1AAA,"/
-
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BUILDINC-MECTRICALPLUMBING-MECHANICAL
l
Contractor's Name: Lic. No:
/
CATEGORY
CONTROL,
Architect/Engineer. Lt, Na:
QTY ELECTRICPERMIT FEE
BUILDING PERMIT INFO
Address:
PERMITISSUANCE
® ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby afErmthat l ane licensed under provisions of Chapter 9(commen
70M)of Dlvisim3ofthe Businessand PmtessionsCodgand my
license la in (uLL form ntl d(ed.
License Cis Contra �"�
Date GHITECIry,�
ARCHITECTS Das phi
]understand my pore ehaB be used as phi recordw
Licensed Professional
OWNER -BUILDER DECLARATION
I herebyaffirm that I am exempt fromthe Contractor's License Law for the
following mum. (Section 7031S, Business and Professions Code: Any city or
countywhich requires a permit to mrutma, alter, improve, demolish, orrepair
anystmcture prior to its issuance,aborequiresthe applicant forsuch permit to
file a signed statement that he Is licensed pursuant to the provisions of the
Contractor's License Law (Chapter 9(mmrometng with Section 7000) of Divi-
stop 3 of the Business and Profradma Code) mthat he is exempttherefromand
the basis for the alleged exemption. Any violation of Section 70315 by any'C
applicant into permit subjects theappgcant toe dell penalty ofnot more than
five hundred dollars ($500.
L as owner of the property, or my employees with wages as their sole
mmpensatfon, wO[ do the work and the structure Isnot Intended or offered for
sale (Sec. 7034, Business and Profeavlom Code: The Contractor's License Law
dace not apply to an owner of property who builds or improves thereon,and
who doeseuch work MmeeBarthrough hie own employees, provided that such
Improvements are not Intended oroffered forsale. If, howeveq thebuilding or
improvement 6suld withinoneyearafmmple im the owner-bufiderwlLL have
tilLkuMen of proving that he did not bund or Improve for purpose of sale.).
Lj I, as owner of the property, am exclusively contracting with Bernardi
contractors to mraW ct the project (Sec. 7034, Businessand Profmake. Code:
The Contractors License law does out apply to an owner of property who
builds or Improve, thereon, and who contracts for such p(ojecia with a
cgIl![ador(9) hcensed pursuant to the Contractor'sLicense Law,BACK
LJ I am exempt under See. B k P C for this reason
APPLIANCES -RESIDENTIAL
JOB DESCRIPTION
W I IA.c1 Q W c
_
PANUS
UP TO 2DO ANTS
AMPS
OVER00
OVER 1000 AMPS
SQ. 1T. 77AOR AREA
'
§/SQ. FT,
SIGNS ELECTRICAL
SPECIALCIRCUIT/MISC
TEMP. METTR OR POLE INSP.
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETSSW[TFiFSF1X'NRES
VALUATION
r ,It d v
NEW RESIDENTIAL ELECTR SQ,FT.
STORIES
TYPE CONSTRUCTION
TOTAL:
QTy, PLUMBING PERMIT FEEFLOO
OCC.GROUP
RES. UNITS
pp(MIT ISSUANCE
ALTER -DRAIN &VENT- WATER (EA)
DONNE
APN,
FLAW PROTECT. DEVICE
FEE SUMMARY
DRAINS FLOOR, ROOF, AREA, COND.
FU(TIIRFS PER TRAP
SANITARY Y N•
BBC= N
Owner Date
WORKMAN COMPENSATION DECLARATION
I hereby am that I have a certlfiate of consent to self -insure, ora
[]Iffir
artlflateofWorken'C=peruatlonlr mnmaramnifWmpylhereof(Sec.
3800, Lab C.)
Policy N
SCHOOL TAX Y N
RECEIPT N
GAS EA,SYSIEM-i INGNOUILETS
PARK FL? Y N
RECEIPT N
GAS EA. SYSITT4-0VER 4 [EA)
Com any
BUILDING DIVISION FEES
Certified ropy Is hereby ed-Mthtle city
❑ Certified ropy b filed -with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
QMaeection need not be completed If the pemJt Is forone hundred dollars
($100)or less.)
I mrtBy that In the performance of the work for which this permit le issued,
I shall not employ any person In any manner nut become sub' to the
Workers Compensation' of rola. Date
Applicant-. (�,`—jL a
CREASE/INDUSI'AL WASTE INTERCEPTOR
PLANCHECK FEE
PAID
Date Recei tM
GREASE TRAP
SEWFR-SANITARY-STORM EA mom.
WATER HEATER W/VENT/FLECTR
ENERGYFEE Y N
PAID
Date Rerel tit
WATER SYSTEM/TREATING
NEW READ[NTIAL PLMB._SQ.FT.
NOTICE TO MPLICA :R, of maWngt eCertificatelof Frrrtptlon, you
should become subject to the °`kens Compematlon provisions ofthe Labor
Code, you moat forthwith comply with such provisions orthis permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the perform
anm of the work for which this permit Is issued (Sec 3097, Civ. C.)
Lender's Name
Lender's Addreas
I certify thatl have read this applicetionand sbtethal theabovelnformatlon
n WMd. idgmcto comply with all city and moty ordinances and Gate laws
misting to building construction, and hereby authorim representatives alibis
city to enter upon the abovo-menBooed property for Inspection purposes.
Me) agree to save, indemnify an d keep harmless the City of Cu Fort [no
against liabilities, j4, dgments,"a and expenses which may In any way accrue
agairatsaid Ci In cons ueryyy{{{of the granting of fhb permit
TOTAL:
BUILDING FEE
/ QD
TOTAL:
SEISMIC FEE
/ t
ELECTRIC FEE
QTY, MECHANICAL PERMIT FEE
PERMIT ISSUANCE
PLUMBING FEE
MECHANICALFEE
FEE$PAID:
Date Receipt#
ALTER OR ADD TO MECH.
AIR HANDLING UNIT (rO I O,ODO CEM)
SUBTOTAL:
I hl, 0
AIR HANDLING UNIT (OVER IQ000CIM)
CONSTRUCTION TAX
'
lgoatureof Appba Cnnt�� Date
, DOUS MATERIALS DI SCLOSUR F.
Will the ap rant or future building occupant store or hand le Itmedous
matcrIsl sad nod bytM Cupertino Munictpal Code, Chapter 9.1 Z and the
Health and Safety Code Sedion 25537(a)7
❑ Yea MN.
Will theappliant or future building omupantussequlpment ordevima
which emit harardous air centandeants as defined by the Bay Arca At,
Quality Management m❑tect7
4 Yes rd No
have read the hares materiab requirements under Chapter 6.95 of
the California Health k SafetyCode, Sections 75505, 75533 and 25534. 1
understandthatifthebulldingdonnotcurrentlyhaveatenant,thatitismy
responsibility to notify the occupant of the nxrylremenb which must be mN
prior to Issuance of a Certificate ofOccupancy.
EXHAUST HOCID(W/DUCT)
CONSTRUCTION TAX PAID:
HEATING UNIT (TO 100,000 BTU)
Date Rete) tM
HEATING UNIT (OV Elt 100,000BT(n
TOTAL:
VD11TIATION FAN (SINGLE RESID)
1$$UANfCE 3yATE
E�'•R/'1R■jQA
1990
F( s7
�� /1,.��y�
ff l ofartlt+oke
BY.
BOILER -COMP 0HPOR 100,000 BTU)
BOILER -COMP (OVER 100,000 BTU)
NEW RESIDENTIAL MECH. SQkT.
0xv.dcraulhorizedagent Date
TOTAL IISSUED
OFFICE COPY