22659 (2)APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Pm en Identification
PERMIT NO.
Building Address: Q80/ l� ` {£
f-J,C.�PCC
22659
e s ante: one:
C11A,/OLGZ � rD£A/G
CITY OF CUPERTINO-BUILDINGDIVISION
APPLICATION / PERMIT
p p A
I
tranohName: Lie. No:
/V"/VSLA MO -Mir. �rt1'1li\ L/G 4tL T?
BUILDING-ELFJCTRICAI.PLUMBING-MECHAMCAL
CATEGORY
CONTROL If
Architect/Engineer. Lie. Na
QTY ELECTRIC PERMIT
FEa�E
BUILDING PERMIT INFO
Addrcsa
PERh9TIS5UANCE
`�LIY
Cil ❑ �j
�• �`j
LICENSED CONTRACTOR'S DECLARATION
Thereby affirmthat lam licensed under provisions of Chapter9 (comment
IngwithSenlon 7000)of Dials on3ofthe Businessand Pmf..donsCode,and my
limn. Is In fuB force and effect
APPLIANCESREADEMIAL
//N--- JOB DESCRIPTION
1
`
PANELS
Limn. Claw
Date Contrr actor
Co
ARCHITECTS DECLARATION
(understand myp6nsslulhe used azpublic recoNa
Licensed Professional
OVER 1000 AMPS
OVEOJ0 0AM
✓Q. FTD fti� f/SQ.
L E
FT.
SIGNS ELECTRICAL
SPFOIALCI4CUIT/MLSC
n NA
OWNERDECLARATION BUILDER DECLARATON
I hereby a(llrm that Iamexemptfrom the ARA O License Law for the
TEMP. METER OR POLE INST.
POWER DEVICES
x
IG
following mason. (Section 7031.5, Business and Professions Code: Any city or
county which requires a permit to construct, alter, improve, demolish, or repair
any structure prior to its Issuance, a iso requires the applicant for such permit to
file a signed statement that he 6licensed pursuant to the provisions of the
n
/ Q
7
SWIMMING POOL ELECTRIC
UTL�SWITCHESFTXTURES
1
l t
Contractors License Law (Chapter 9 (commencing with Section 7000) of Divi-
slon3 of the BusNessend Professions Code) orthat he 6 exempt thercfromand
the basis for the alleged exemption. Any Wolatlon of Section 70315 by any
appu.nt fora permit subjects the applicant to a civil penalty of not more than
VALUATION
/ O (� ,1—�-.
NEW RESIDENTIAL ELECTR SQF.
five hundred dollars ($M.
n1, as owner of the property, or my employees with wages as their sole
STORIES
TYPECONSTRUCTION
ompereation, will do the work, and the structure 6 not intended or offered for
sale (Sec. 7044, Business and Professions Code: The Contractors License Law
does not a pply to an owner of property who builds or Improv. I hermh and
who doussuch work himselforthrwgh his own employees, provided that such
OCC. GROUT'
RES. UNITS
TOTAL:
Q
Improvements am not Intended muttered for sale. ILhowevegthebuildingor
improvements sold within oneyearofcompletion, theowner-builderwill have
that+ rden of proving that he did nor wild or improve for purpose of sale.).
LJ L as owner of the property, am exclusively contracting with licensedPERMIT
contract.. to construct the project(Sec. 70K Business and Professions Code:
QTr, PLUMBING PERMIT
FEE
MOOD TONE
MIN
ISSUANCE
arXx
l.V/
The Contractors License Law does not apply to an owner of property who
Wild. or Improv. thereon, and who contracts for such projects with a
c$0.t{actors)licensed pumeant to the Contractor's License law.
LJ I am exempt under Sec. B & P C for this masonOUTSIDE
ALTER -DRAIN &VENT -WATER (FA)
FEE SUMMARY
BACK FLOW PROTECT. DEVICE.
��
DRAINSFLOOKROOp AREA,COND.
SANITARY RFOEITN
Owner Date
WORKMAN COMPENSATION DECLARATION
1-11m I hereby affirthat I have a certificate of consent to self -Insure, w a
certificate of Workers Compensation Insurance or a mmifled copy thereof(Sec.
3800, Lab C.)
E.IX.Iv�s l'ER TRAP
r1
L
SCHOOL TAX Y_ N_
RECEIPT N
GAS EA. SYSTEM -1 INCA OUTLETS
PARKITL Y N
RECEIPT N
I. p
Com any
GAS EA. SYSTEM.OVER4(EA)
BUILDING DI VISION FEES
ECertNed copy 6 hereby furnished.
FI Certified copy 6 filed with the city inspection division.
GREASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE
GREASE TRAP
CERTIFICATE OF EXEM PHON FROM WORKERS'
PAID
SEWER -SANITARY -STORM EA 200FT
COMPENSATION INSURANCE
(This section need not be completed I( the permit 6 for one hundred dollar
Date Recti t#
WATER HEATER W/VENT/F].ECTR
ENERGY FEE Y N —
(fioollmless.)
Iarifythatl th rf.menceo thewakforwhlchthispenniti, uu d,
WATER SYSTEM/TREATING
I shall not employ e y person In y rave , an .,I. become _ je to the
Workers Co tion so lifomla. Rate
Applicant /tea a4
PAID -
PAID
Date Retxi t#
NEW RESIDENTIAL PLMB. SQ.FT.
NOTICE TO APPLICA Berne gt Certificate of Exemption, you
should become subject to the Workers' Compensation provifimu of the Labor
Code,you =at fort hwith comply with such provisions or this permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
TOTAL:
u;Y
" ekz5A
`
BUILDING FEE
_
SEISMIC FEE
I
I hereby affirenthat there 6 a construction lendingagency for the perform
ance of the work for which this prrmh 6lvwed (See. 3097, Civ. C.)
lenders Name
bender's Address
I certlfythetl have madth sapplicattonand statethat theabove Information
is rrect. l agree to comply with all city and county ordle.remand state laws
TOTAL:
..
ELECTRIC FEEbq—
x
PLUMBING FEE
l77
QTY. MECHANICAL PERMIT
FEE
MECHANICAL FEE
PERMIT ISSUANCE
♦
FEES PAID:
-L-
relating to building construction, and hereby authorize representativea of this
city to enter upon the abovcmen caned property for bepenlon purpo.s.
(We) agree to save Inde an d kap harmless the City of Cupertino
against llabTll Piaci nurt costsand expects.which msyin anywayaccrue
ALTFRORADDTOMECH.
Date Rt'<efpt#
AIR HANDLING UNIT(TO I0,000CFM)
SUBTOTAL:
agai tea Ityi enre the granting of this permit.
' n a_7p_
AIR HANDLING UN'IT(OVER 10000 CEM)
CONSTRUCTION TAX
.i [.t�
Signstvm o(App1i nt/Contractor Date
D(HAUSTHOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (TO 100,000 BTU)
Date Recel t#
Will the a pplicant orfumre wilding occv pant store or handle hazardous
veterlai as defined by the Cupertino Municipal Code, Chapter 9.1Z and the
Health and Safety Code Section 75537(a)?
❑ Yes N No
Will the applicant or mmre wilding occupant use equipment or devices
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
I�
VENTILATION FAN (SINGLE RESID)`
ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management District?
❑ Y. j� No�
BOILER -COMP QHP OR 100,0(10 BTU)
BOILER-COMP(OV[R100,0001N)
?have read the hazardous materials requirements under Chapter6.95 of
the California Health & Safety Code, Seniors 25505, 75533 and 75534. 1
understand that lithe wilding does not currently have a tenant, that it 6my
r.ponsibility, to notify the occupant of the requirements which must be met
/J
NEW RESIDENTIAL MECH. :QXT
prior to issuance of a Certificate of Occupancy.
f
ISSUED BY,
Ownerorauthorlud agent Date
TOTAL:
u
OFFICE COPY