20495APPLICANT TO FILL IN INFORMATION WITHIN�RED LINES —USE BALL POINT PQ4 ONLY
Ituilding Project Identmation7^\• •� •Q
Building Add mss: ^&
z 115sL/ L000D bU Z Oke; � Lgs'o�
PERMIT NO.
20495
97
OQ �lR"WlrY1 p-(�
CITY OF CUPERTINO- BU ILDING DIVISION
APPLICATION / PERMIT
BUILDINGELDCTRICAI.PLUMBING-MECHANICAL
(� I l eq
Contractor's Name: Lk. No:
CATEGORY
CONTROL 1Y'
'O O
Architect/Engineer: Lk. Na:
QTY ELECTRICPERMIT FEE
BUILDING PERMIT INFO
Add.
❑ ❑ ❑ ElLICF.NS
PERMIT ISSUANCE
ED CONTRACTOR'S DECLARATION
I hereby affirm m700that lam Licensed under provisions Pm Cbapts CDde men
tagwtthoce.hin fen force ofDlWect. aftheBudnesand ProfesdanaCodeand my
Littre Is in full force and affect.
License Ckss LIEN
Date GHITE I
ARCHITECT'S DECLARATION
I understand rrry plans shall be used s public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I son exempt from the Contachn . License Lew for the
following reason.(Setilon70315, Business end Professions Code: Any city or
county which requiresa permit to construem
, alter, Improve, demolish, or repalr
anydmtiumpdortolb Wuance,ahorequl otheapplimntforsuchpermlttoIb
file a signed statement that he is licensed pursuant to the provblons of the
Co.3ofths.goshdPoeseler9(cods) mthmhe ih xemptthr,frorDlvl-
don3ofthe BueIness end Poo(eslonsCode)orlhat hekemmpt tM1am(romand
the basis for the alleged exemption, Any violation of Seaton VMS by any
applicant fees permit subjectstheapplicant tea civil penalty of nor main than
J (fEe Fundmd dollen (f500).
I, as owner of the property, army employees with wages as their sok
asaeon, will do the work and the structure k net Intended or offered for
le(Sec.7094, Business end Professions Code: The Contractor's License Law
does not apply to an owner of property who Wlkh or improves thereon, and
who does such work htrvelforthrough his own employees, provided that such
impmn:.cU are not Intended oroffered for sale. If, however thebullding or
Improvement b wld within oneycarofcompletion, the owner -build erwill have
the burden of proving that he did not build or improve for purposeofsak),
F1 L as owner of the properly, am exclusively contracting with licensed
commences to construct the project (Sec 7044, Business and Profeslom Code:
The Corrector's License Law dos not apply to an owner of property who
Wilds or Improves thereon, and who contracts for such ptojeem with a
LJ I amt pt under R & P C for this meson
roro4aaor(s) licensed pursuant to 1 te Contrition's License Law.04
Owner c— ale
A 6N ATIO DEC TION
❑I here affirm that I hive i certl(ic a of c nt to self-Inwm, or a
certiticate o(Worken'Compensatlon (rout n ora cedlfled copythercof (Sea
3800, Lab C.)
Policy p
API'LIANCESRESIDEM7AL
JOB DESCRIPTION
4A(7'—/VA//4
TO 1A2 F,
PANELS 1
AMPS �
OVE000
OVER 1000 AMPS
SQ. FT. FLOOR AREA
f/SQ. FT.
SIGNSELECTRICA
SPECIAL CIl2C1117/MSC
{
s�
TF3dF METLR ORPOTE SNSf.
�EVICFS a V V I `
r .y
' 1
SWIM'w GIVOLFd.ECIRIC �{_ f\\\;�;
OUTLETS.ry.N7hE&FI%.L[,1RE4� ( \
-• — - s �''.. L' \
VALUATION �D
• f.
'40o
OTT
NEW RESIC AL ELECTR -r tI \� sQpr, is
f5
TYPE CONS 'fItI/CTION'
'y
LOCC.CROUP
TOTAL:
QTY. PLUMBING PERMIT ,FEE
RES. UNITS
FLOOD TONE
APN
PERMIT ISSUANCE
ALTER -DRAIN &VENT- WATER (EA)
FEE SUMMARY
BACK FLOW PROTECT. - DEVICE
r
DRNNS FLOOR ROOF, AREA, COND.
SANITARY Y_ N_
RECEIVE N
FIXTURES. PER TRAP
SCHOOLTAX Y N
RECF71'T p
GAS EA. SYSTEM -1 INC.4OUTLETS
PARK FID? V_ N
X
R'NO
GAS EA. SYSCI2.I.OVER 4 (EA)
Com any
DI
BUILDING DIVISION FIi65
�Cerlitlet copy k hereby furnished.
Codified copy is filed with lM city Inspection division.
CERTIFICATE OF O(EM PTION FROM WO R K ERS'
COMPENSATION INSURANCE
(This section need not he completed If the permit V for one hundred dollars
(f100)erlass3
tall notettfy that In anyhe Penson In anynce m nnerwork forty to beco Pamir ct to
I shall not employ any person in any manner m s to become subject Io the
e
Worked Compenstlon I�we of Callfamla. Date
Applicant
NOTICE TO APPLICANT. If, after making
pc at lot profs Exemption, you
should become subject to the Workers' Compesmlon provisions of the GW
Code, you forthwith comply with such provisions orthk permit shall be
deemed revoked.voked.
CONSTRUCTION LENDING AGENCY
IherebyafOrm thattherebaconstruction lending agency for the perform
once of the work for which this per V LLwed (Sec.3097, Civ.C.)
Lender's Name
Lendersnddress
I mitilythat I have read thisappliatbnand datethatthe above information
is correct. l agreeto complywith all city and county ordinances; and date laws
relating to building construction, and thereby authorlac representatives of this
city to enter upon the above-rrxmloned property for Inspection purposes.
(We) agree to save, Indemnify an d keep haired. the City of Cu ped loo
against Babillticajmdgracou,cod and expanses whlcherayleanywayamue
a awte tyln con en friss gr Ing of this Permit.
51 wtv AIpB t/ Date
HAZARD US MATERIA URE
Will the appilantor fulurebullding or p ntatoroorhand Dht.rdou.
material as defined by the Cupertino Muni I Code, Chapter 9,12, and the
Health and Safety Cade Seaton 25532(a)?
❑ Ys No
Will theappliaoccupantment
m or tum building occupant use equipor devices
which colt baaardous air contaminants art defined by the Bay Area Air
Quality Management District?
4j❑''Yes
have read the haxarLDmaterlak requiremaets under Chapter 6,95 of
the Califomlx Health & Safety Code, Sections 25505, 25533 and 25534. I
understand that lfthe building does not currently have a tenant, that It is my
rsponsibillty to notify the occupant .(the requirement. which most be met
prior to issuance of a Certificate of Occupancy.
CREASEANDUSERL WASTE INTERCEPTOR
N 1ECIC FEE
PAID
Date Remi t#
\
�f •G
GREASE TRAP
SEWER -SANITARY -STORM EA. 200Fr.
WATER HEATER W/VENT/ELFjCTR
ENERGY FEE Y N
FAIR
Date RCCeI t#
WATER SYSTEM/TREATING
NEW RESIDENTIAL PLMB.SQ.FT.
TOTAL:
BUILDING
SEISMIC FEE
TOTA
ELECTRIC FEE
QTY. MECHANI AL PERMIT FEE
PERMIT ISSUANCE
PLUMBING FEE
MECHANICALFEE
FEES PAID:
ALTERORADDTOMECH.
Date ReCCI t#
P
AIR HANDLING UNIT (TO 10,000 CFM)
SUBTOTAL:
MR HANDLING UNIT (OVER 10,000 CFM)
CONSTRUCTIONTAX
EXHAUST IIOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HEATING UNIT 100,000 BTU)
Date RCeeI t#
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
VENTILATION PAN (SINGLE REBID)
]SrjU/
AWE
�iSelp
JIJ�' a�
IJ JG
.•
p
^i'7 PT``F CBpelvoq
IU p�
ISSUED
BOILER -COMP DID' OR 100,007 BTU)
BOILER-COMP(OVER 100,000 BN)
NEW RESIDENTIAL MECH. SQ.Fr
L
Owner or aulhoriacd agent Data
TOTAL:
OFFICE COPY