21017APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification
Building Addmas:
PERMIT NO.
/"I o a�
G I
sere ame: C one:
6�S��G�G�7YJ/�JE�
CITY OFCUPERTINO-BUILDING DIVISION
'APPLICATION / PERMIT
AL DA IL
c°ntratlnin Name: LIc.N°:
O[i O
BLILDINGELECTRICALPLUMBINGMFGHANICAL
CATFLORY
CONTROL N
Archltetl/Engineer, Lk. No:
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Addreac � r
�AXy�I
r�
� PFRh11TISSUANCE (�
LICENSED CONTRACTOR'S DECLARATION
•fl
I hereby affirm that l am Bcensed under provisions of Chapter9(mmmenc
Ingwlthsecilon7000M Divislon3ofthe Buainessand Profess)°nsCode,and my
Ilmnsc Is In fullf ddfeR-� ' n_'
License Clam_Lk.N .L6b�. Jnr— c�ji•`
Date Contactor
APPLIANCES -RESIDENTIAL
JOB DFSCRRTTON
/y- n
I.DOANTS{ ,�"%� R .., `f1,d -4e I
�\CC..
-
PANLS
UPT02
701-1000 AM
-'
ARCHITECTS DECLARATION
] understand my plans shallbe used as public records.
\ i `
OVER 1000 AMPS
SQ. FT. FLOOR AREA
$/5Q.FT.
SIGNS ELEC AL
Licensed Professional
SPECIALCIRC /MISC
OWNER -BUILDER DECLARATION
I hereby affirm that? am exempt from the C m.ohrb Lioness law for the
TEMP. 0WOLE Av
following reason. (Section 70315, Business and Pro(essbns Code: Any city or
cmntywhichrequlreaaperm tWcomt d,altegimprove,de=lB h,orrepair
anystmcturc pdorloltebwance, also requlrestheapp0anl for each permit to
fila a signed statemum that he is Bmeaed pursuant to the provisions of the
Contractors License Law (Chapter 9 (mmmencing with Section 7000) of Divi.
.too 3 of the Beef... it Predred.. Code)°r that he is exempt therefrom and
fisc bash for fisc alleged ezempll°n. Any violation a(SecHon 7m15 by any
appBandfor apermit$SM. the appltcant toe tivil penaltydnal morcthan
Rvehundroddolbrshepr).
❑Las owner the property, or my employes wkh wage as their sok
POWER
SWPdMI E
OU1LE TCHLS, ES g. D
NEW . DENTI EC SQ.FT,
VALUATION
oD
p D D a
b -{O TYPE CONSTRUCTION
compensation, ll do workfessimstructure brMkractortended oroffendfor
.In(Se Business
sale (Sec. 7044, Business and Prafmsl°ns Code: The Contractors License Taw
�17 D
QTY, PLUMBING P MIT FEE
does not apply to an owner of property who builds crimprovea thereon and
who dons suchworkhlmself orlhrough Nsownempl°yea, prwWed that such
improvemcntsarenol Intended oroffemd forsak. ILhowevepthebuildl^gorTOTAL:
Improvemenl ba°Id within oneyearofcomplellon,theowner-builderwlll have
tl urdenof Provinglhat hedldentbullaorlmproveforpurpossofsle.).
u I, as owner of the property, am exclusively contracting with Ilmosed
mntrect°re to construct the project (See 7074, Business and Professions Code:
OCC.CROUP RES. UNITS
---FO
PERMIT ISSUANCE
UD APN
The Contractor's License Law does net apply to an owner of property who
builds or Improves themes, and who contracts for such pLojecta with a
galracter(s)Itanxd pursuant to the Centrages Lioness Law.
Lf I am exempt under Sec. 0 k P C for this mason
ALTER -DRAIN h VENT A IEA)
Q
--
FEE SUMMARY
BACK FLOW PROT T.D CE
DRAINS. F, AREA, COND.
FIX
SANITARY Y N
RECEIPT 4
Owner Date
WORKMAN COMPENSATION DECLARATION
01 hereby affirm that I have a arUReale, of consent to self -Insure, ora
3800,I,eofWorken'Compensallonlnsurana oraanl(led copy themnf (Sec.
ab CJ
SCHOOL TAX Y� N_
RECEB T N
GAS TEM -1 INCA OUTLETS � 1
I
PARK FEE Y N
Policy
Policyp
GAS -PA. STEM-OVER4(EA)
Com env 6
DING DIN
BUILDING DIVISION FEES
amby ebed. '
WCenified copyb filed
CcrtlBcd copy b flkd with the cityIrupnti°n divitlon.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Ihasectlon need net becompleted m
Bthe pedt b fororm hundred dollars
GREASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE
PAID
Date RCOBI [M
GREASETRAP
SEWERSANHARYSIOEM FA 700FI
($]00)orfyth)ed,%
l gout that In the perforon in say coat mk fo as to h mmehis esubjrrot b cto the
I shall na employ any person In any manner a° as to become subject to the
W Compensatbn laws al Gllfom0. Date
WATER HEATER W/VENT/ELECR 0�n
V
ENERGYFEE Y N —
PAID
WATIRSYSTEM/TREATING
plicae
fit
NOTICE
NOTICE co MPLICANT: a after making this Cannata l Exemption,Labor
Labor
Code,shoulbecome mbjh to the ply wit Compensation pro this permit shall
Code, you must forthwith comply with each provisions or this permit shall be
deemed revoked.
Date Recei tit
NEW RESIDENTIAL PLMB. SQFT.
TOTAL:
BUILDING FEE e O
SEISMIC FEE j70
CONSTRUCTION LENDING AGENCY
I herebyaBirmthxl there is a construction lending agency for the performTOTAL
ance of the work for which this permit is lowed (Sec. 3097, Civ. C.)
�Q�
ELECTRIC FEE Z. O
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE _ oD
Laodera Name
L.odere Addmas
Icerilfythall have read this appllallonand alatethatthe above Information
Is comet. l agree to comply with all city and county ordinances and pate laws
relating to building construction, and hereby aulhorlu representatives of this
city to enter upon the above,menlloned property for inspection purposes.
(We) agree to save, Indemnify an d keep ham -dew the City of Cupertino
against BabiliBes,' dgmenI rte and ex pan saawhichmayinanywayaceme
Id CI roe na oft gran ting of this pe L
MECHANICAL FEE i!
PERMIT ISSUANCE
FEES`[aAID:
Z
Date R—`a eC-EBI (#
P
ALTERORADDTOMECH,
AIR HANDLING UNIT (TO 10,00(i
SUBTOTAL'
AIR HANDLING UNIT (OVER ]O,ODOCFM)
CONSTRUCTION TAX
Igvmrcof 11 / atranor to
EXHAUST IIOOD(W/DUCT)
CONSTRUCTION TAX PAID:
N RDOUS MATERIALSDISCLOS RE
Wlllthe ppllant or future building occupant atom or handle havardous
materials defined by the Cupertino Municipal Code, Chapter 9.17, and the
I IMth and Safety Code Section 75537007
❑ Yes Ir��I No
WBltheappllcareefunme building occupant usesqulpment ordevices
which emit hamrdoua air contaminants as defined by the Bay Area Air
Quality Management District?
Yes ❑ N°
have read the haur�owmatcrlab requirements under Chapter 6.95 of
-Date Reeef t#
HEATING UNIT (TO 100,00) BTU)
Ls
HEATING UNIT (OVER 100,000 BTU)
TOTAL: .Z
-
VENTILATION FAN (SINGLE RFSID)
ISSUANCE DATE
AI
PAID
�, �g90
BOfLFR-COMP OHPOR 100,000 BTU)
BorLER.COMP(OVER 100,000 BIM
the California Health k Safety Code, Sodium 75505, 75533 and 25534. I
SEP
NEWRPSIDENTIALMECH. SQ.FT
understand that if the building aces not currently have a tenant, that it is my
raponslbll By 1° notify the occupant of the requireroents which must be met
Prior to Issuance of a Certificate of Omupunry.
city of ruAP,rfptO
ISSUEDBY: tea. \ 'A
Owner or authorimd agent - Dale
,O'`
TOTAL: (/
OFFICE COPY