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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Bulldin Pmje I Identification
Building Address: -01 6aidd ?1
PLRMH NO.
22549
F
one:
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
t ctoraNama: Lic.No:
BUILDINGELECTRICALPLUMBINC-MECILIMCAL
CATFOORY
CO OL
Architect/Engineer. Lie No:
Q1Y ELECTRICPERMIT FEE
BUILDING PERMIT INFO
Address:
aPERMHISSUANCE
❑
LICENSED CONTRACTOR'S DECLARATION
Iherebyaffirmthat l am licensed under provisions of Chapter 9 (oomereene,
07th)Buslnesantllho(ealonaCAde,and my
liver.hin fon force and
license la ec fu117000) and affect.
APPLIANCESRESIDEIVHAL
JOB DESCRIPTIONingwit
\ 12-eVA(9
PANELS
Date Cba Lk. p
Date Contractor
I To TQ W AltTS
oL
3 S (IC
ARC HITECPSDECLARATION
I understand my plan shag be cared a public records.
OVER0ODUAM
OVER ]000 AMPS
FT. FLODR AREA
SIGNSELECTRICAL
Licensed Professional
eSQ.
p 'N
A'
SPECIAL CIRCUIT/MLSC
OWNER-BUILDERA_, DECLARATION
fR
I herebyarentlut lam exempt fmmthe Contractor's License law for the_64
P
TEMP METER OR POLE INS(.
following reason.(5ection 70115, Busineaand Profesions Code: Any city or
my which requires a permit w mnstmd, alter, bnp mve, demolb h, or repal r
T E R
any structure prior to Its Issuance, also requires the applicant for such permit to
file a signed statement that he Is licensed pursuant to the provisions, of the
POWER DEVICES
— DATE
Q
SWIMMING POOL ELECTRIC
UTLETSSWHcHESHXTURE l a
Contnetor's License Law (Chapter 9(mmtmencing with Stolon 7000) of DWI-
sion3 ofthe Business and Profenlom Code) orthat hob exempt Nerefromand
the bas
appRis for the alleged exemptmn. Any violation of Section 70)1.5 by any
antforapermitsubjectseheapplkantloadvllperultyofnamor)than
( / VALUA N Q
fidred dollars ($5M.
owner of the property, or my employees with wages as their sole
nation,
K.
NEW RESIDENTIAL ELECTR SQ.FT.
STORIES
TYPECONSRRUCTION'
cope will do the work, and the structure is net Intended or offered for
sale (Sec 7046, Business and Profs Blom Cade: The Contranorh Lt.. Law
does net apply to an owner of property who Wilda or improves thereon, and
who doessuch work himself or through hisown employees, provided that such
OCC. CROUP
RES. UNITS
TOTAL: l
Improvements arena Intended oroffemd formle. If, howevep the W Ildingor
i pmvementlawld Mthinomrarofcompldiogtheowner-WBderwillhave
th*rdenofpmvingthat he did net Wildorimproveferpurposeofuled.
u 7, as owner of the property, am exclusively contracting with licensed
core see s to construct the project (Sm 7044 Business and Profealom Code:
QTY. PLUMBING PERMIT FEE
FLOOD ZONE
APN
PERMIT ISSUANCE
7I
The Contnnor's Limine Law don na apply to an owner of property --
Wilds or Improves thereon, and who contracts fee such pgDjeas with a
taetor(s)Bcenxd punuwmthe Conenctots Llcenae Law.
LJ I am exempt under Sec B & P C for this reason
ALTER -DRAIN& VENT - WATER (EM
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
DRAINS FLOOR ROOF, AREA, COND.
SANITARY Y N_
RECEIPT 11
Owner Data
WORKMAN COMPENSATION DECLARATION
1-11 hereby affirm that I have a certificate of consent to selfdnmm, or a
certificate ofWorkeri Compensation Insurance oracertifled copy thereof(Sec.
3800,I# CJ
EER TRAP
L /r
SCHOOLTAX Y N
RECEIPT. 8
GAS FA. SYSTEM -1 WC60UD.ETS
PARK FEE Y_ N
RECEIPTN
GAS EA. SYS EM-OVER6(EA)
CoCom any
BUILDING DIVISION F[f:5
BCertiRed copy is hereby furnished.
❑Certified copy b filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
GREASE/INDUSDRL WASTE INTERCEPTOR
PLANCHECK FEE
PAI \(
GREASE TRAP
SLIVER -SANITARY -STORM EA 200FT
COMPENSATION INSURANCE
(I'hlssectimi need net be completed if the permit b for.. hundred dollars
at R 1 t#
WATER HEATER W/VENT/ELLCTR
ENWG FGE Y—
(f100)orlesa.)
I certifythat N the performance of the work for which this permit Is histeed,
WATER SYSTEM/TREA Ill
I shall not employ any person in any manner so as to become subject to the
Worlu, Compensation Laws of California. Date
PAID
NEWRESIDENTIAL RAB. SQFT.
Applicant
Date R wi t#
madding TO APPLICANT: If, after mang this Certificate of Exemption, you
ahmld become subj)ct to the Workers' Compers,aHon provisions of the Labor
TO AL:
BUILDING FEE
7.s. 0
Code, you must fort hwith comply with such provisions or this permit shall be
deemed revoked.
CONSTRUCTION LENDING AG ' '
SEISMIC FBG
a
I herebyaffrrmthat there bamnstruction lectileg4ency forthe perform-
once oftheworkforwhkhthbperMtbissued(S .3097, W.C.)
I<nder'sName
Lenders Addrea
I cedl/ythatl havercadthb application dexte the heaboveleformatlon
bmrned. Iagmetocomplywithall city d rounty9rdinanmsan statelaws
TOTAL -
ELECTRIC FEE
sZ
PLUMBING FEE
ae90
QTY. MECHANICAL PERMIT FEE
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID:
relating by aut rep. Ives of thin
relating tobuilding co
city to enter upon the abovnmen0on prop) formspecil 'purposes.
(We) agree to ave, indemnity a &cep armies th Ity of Cupertino
agalrethe lltim,),id et,c0 A. d �c..which Inanyw yaccrue
t d City 1 s 5 n 0f. the permit.
ALTER OR ADDTO MECH.
Date RM IPI#
MR HANDLING I1MT (TO 10,000 CFM)
-
SUBT IAL:
0 - q
AIR HANDLING UNIT (OVER 10,000CFM)
CONSTRUCTIONTA
L
Signatu it / ontrador Datc
EXHAUST HOOD(W/DUCT)
CONSTRUCTION
PAID:
HAZARDOUS MAT ALS E
Ith ppllant or tuturc Wildin pan or and le arardous
a defined by the Cupertino Municipal ode, Ch aptcr9.1$andthe
randSafetyCodeSection25533(a)?
❑Yesr(��.l No
Will the applicant or-fuhm Wilding occupant use cefulpment or devices
HEATING UNIT (T0100,B00 BTU)
-
Dale R Ci I#
HEATING UNIT(OVER I00,000 BTU)
—
TO L:
VENIATION PAN(SINGLE RESID)
I$$UAI�i6PA1J
which emit haaaMous air contaminants as defined by the Bay Area Air
Quality Management District?
4Yes o
havcrcadtheba muterialsrequirementsunderChapter6.95of
a'�s�
C
BOILER -COMP OHPOR 100,0710 BTU)
BOILER -COMP (OVER IW,000B7U)
the California Health & Safety Code, Sections 25505, 25533 and 75534. I
understand that if the building does net currently have a tenant, that it is my
responsibility to notify the occupant of the requirements which =sibs met
Pdty
�1�
NEWRPSIDFNIIN.MECH. SQ.ET
to issuance of 'ateof Occup ry.
IS.SUEDRY: \I (J4l%�J/
or authorlud agen Dto
OTAL:
OFFICE COPY