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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project IdentificationPERMIT
Building Addresaq LI- L-�- �u ���
NO.
22658
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CITY OFCUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BUILDING-ELECTMCAL-FLUMBINGMECHANICAL
APPl1CAr5R3U87MFAUb=
,,a#te� .•� /'� �/
c dor'a Name: r
is G ` � ) 1DZZ �
CATEGORY
CONTROL #
Architect/Englncer. Lie No:
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
-
Address:
PFRMITISSUANCE 1 Sat
�T�
PT ❑
LICENSED CONTRACTOR'S DECLARATION
APPLIANCES
lhth Saefon70thatiamaoa3 d underofhalla P...and Pmf..Jpter9(mmmm<
If --.i Section 7000)of Divfect. ofthe Businasand Pro(nsionCode,and my
license is In fuI fQ$e and effect.
License i #
PANES
JOB DESCRIPTION
� �� � '-r Fs ?
i( Qj�'
CLic.m
Date Contractor
ARCHITECTS DECLARATION
I understand my plans shall W used as public records.
201-1000 AMPS
OVER IWO AMPS
SQ. Fr. FLOOR AREA $/SQ. FF.
SIGNS ELECTRI
Licensd Professional
OWNER -BUILDER DECLARATION
IherebyafBrmthat lam exempt fromthe Contractors License Law for the
following reason. (Section 7ml.5, Business and Professions Code: Any city or
caunlywhlch requlm a pemdt to comtmd, alter,improve, dertnikh,orrepair
anystructure prlorto its hastance,aborequlrestheappilcaut torso&permit to
file a signed statement that he Is licensed pursuant to the provision of the
Contractor's License Law (Chapter 9 (commencing with Section 7000) of Divi-
sion3 of the Busineasind Pnefemiora Code) or that he b exempt therem froand
the basis for the allegd exemption. Any violation of Section 7031.5 by any
if untfora permB$500).tathe applicant too dull penalty of net more than
flue hundred dollen he prO
❑L as owner of the property, or my employees 6 with waged r their dole
compawtlon, do heworkandthes Intended or Offered for
SPECIALCIRC M ""'
/r� VALUATION
L/sx 1 �1
V L
_
P. METER L I � - 1
['OWER DEVICES
SWAihINGII�OL ELECTRIC
OUTLETS$WITCHESFIXTURE5 1
NEW RESIDENTIAL ELECTR e"O�'
STORIES
TYPE CONSTRUCTION
B-imaxl
sale (Sec.7(94, Buelero.and l'rvfeplow Code: TFs ContraRots Llcerue Law
oca: The Contractors
does not apply to an owner of property who Wilda or improves thereon, and
who does such work himself or through hisown employees, provided that such
Improvements are not intended or offered for sale. If, however, the building or
improvement IssoldwithinoneyearofcompleiogtMe er-builderwBlhave
UISjiuMen ofpmvingthat he did not Wild orlmprove for purpowofvle.).
LJ L as owner of the PmPety, am exclusively contracting with licensed
contractors to coktruct the project(Sec. 7094, Business and Protmion Code:
The Contractor's License Law does not apply to an owner of property, who
Wilda or Improves thereon, and who contrarn for such Projects with a
OCC.CROUP
RFS. UNI75
TOTAL: \
QTY, PLUMBING PERMIT FEE
PERMIT ISSUANCE f� l
DRAM k VENT. WATER i W
ALTER- TEN
W -ODD ZONE
APN
Mador(s) licensed Pursuant to the Contractor's License Law.
rl am exempt under Sec B h p C for this re
BACK FLOW PROTECT. DEVIC
FEE SUMMARY
Owner Date
WORKMAN COMPENSATION DECLARATION
❑I hereby affimr that I have a certificate of consent to self-Inwrc, or a
certificate of Workers Compensation Wuranm or a certifkd copy thereof (Sec,
3B00,Lab C.)
Pol1q, #
L DRAINS FLOOR ROOF, AREA, CON 6. ��
a MTURES'PER TRAP
GAS EA. SYSTEM -1 INCA OUTLETS
SANITARY Y_ N_
RECEIPT #
SCHOOL TAX Y N
RECEIPT #
PARK FEE Y N
RECEIPT M
CON"
GAS EA. SYSTEM-0VER4(EA)
BUILDINGDIVISIONP[ES
❑OCcUchtfid copy b herebyturnecityished.
Certified ropy b filed with the city Inpectlon division.
GREASE/INDUSrRL WASTE INTERCEPTOR
PLANCHECK FEE
CERTIFICATE OF EXEMPFION FROM WORKERS"
COMPENSATION INSURANCE '
(Thlssedlonned not becomplRed lftha Permit bforone hundred dollars
(5100)orly,th)WATER
GREASE TRAP
PAID
Date Recei t#
SEWER -SANITARY -STORM EA. 200FT.
HEATER W/VENT/ELEc7'R
ENERGYFEE Y N
PAID
]his Penult Is bsud,
I certify that N the performance of the work an as to
1 shall not employ any person In any manner m u to become subject to the
Appltn'Compenvtlon laws of California. Date
Applicant
WATER SYSTEM/TREATING
NEW RESIDENTIAL PLMB. SQFr.
a [you
NOTICE TOAPPLICt to
after Workers'
should become dub} Y to the Workers' Comperuatlon provision of the Labor
pe Certificate ofons of
Code, you must forthwith Comply with such provisions or this shall be
Dale Recei t#
TOTAL:
permit
deemed revoked,BUILDING
CONSTRUCTION LENDING AGENCY
I herebyaffirmnthat there b a construction lending agency for the perform
ante ofthe work forwhichthb permit b Lawd(Sec. 9097, Civ.CJ
Landers Name
Lender; Address
I certify that l have read thus applicadonand statethat the Mxweinformation
b cored.I agme to comply with all city and county ordinances and state laws
relating to building construction, and hereby authorize repmentatives of this
city to enter upon the above-mentioned property for inspection pu rposes.
(We) agree to save, Indemdfy an d keep harmless the City of Cupertino
against liabilities,judgments, costsand expenses which may In anywayaccrue
agar t Id City In consequence of the granting of this permit.
TOTAL: s(�
E
IC FEE
TRIC FEE
QTY. MECHANICAL PERMIT FEE
PERMITISSUANCE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT CTO 10,00 CFM)
BING FEE"
;FEE5
ANICAL FEE
AID:
'
Date Receipt#
SUBTOTAL:
AIRHANDLINGUNrr(OVFBl0.mCFM)
CONSTRUCTION TAX
'Ign reof Applicant/Contract Dat
HAZARDOUS TERIALS DI SC" URE
ItheappBcant or future building oeevpant store or handle hanrdG
as defined by the Cupertino Municipa l Code, Chapter 9.1 2, and
1lcalth and Safely Code Section 25532(4)?
❑ Yes I] No
Will the applicant or(umrebvilding occupant use equipment ordeviTION
which coat hazardous air contamim otd as defind by the Bay Area AirQuality Management District?
,nNahavereadtheth& 'IYCt1,S riou25enbunderChapte4,I
ealifmthHealththe bSafety does Section25505,ve a tand25539.1understand that notify the ing Occupant of t erentlyhatu.which slut It m1DEN71AL
iss a ce politythe catooftoftherequircmenta which must be mprior to Lssuance ofd CertificateofOccupancy.!
EXHAUST HOORe
(W/DICT)
CONSTRUCTION TAX PAID:
Date Receipt#
UNIT 100,000 BTI"
J)
G UNIT (OVER 100,OOD BTT[)
a -'T
TOTAL: YJ 6 1
FAN (SINGLE RESID)1$SUANCE
DATE
1q�aOwner \
BY: s a
COMP OHP OR 100,000 BTIP,4
COMP(OVEt 100,000 BTU)the
MECH. SQ.FF.morto
or athorlud agent Date/d�
OTAL ISSUED
OFFICE COPY