23934APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
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Building Project Identification
Building Address:
INo $ c4 Viso
-PERMIT NO.
23934
ante:Phone:
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CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
Contractor's Name: Lk. No:
BUILDING-ELECTRICAL-FLUMBING-MECHAMCAL
CATEGORY
CONTROL N '
ArchlteR/Engloeee Lk. No:
QTY ELECTRIC PERMIT I FEE -
BUILDING PERMIT INFO
Address•. N
❑ ❑ ❑
PFRh8TIS5IlANCE
LICENSED CONTRACTOR'S DECLARATION
Ther
70 thet) amlkensedhe under
pmsr9de,and c-
APPL[ANCESRESIDENTIAL
OBD
Sectio
ine.sel bef.117000)ofdeff.on3oflhe8uslnensand Professions Code, end my
Busi emanmoffes
license is In full force and effect.
License Claes Lk.p
PANELS
'1
'7 '
Dale Contractor
LIE TO 200 ANTS
—tell
201-1000 AMPS
ARCHITECTS DECLARATION
I understand my plans shall be used as pubbe records.
OVER 1000 AMPS
SQ. FF. FLOOR AREA
$/SQ. Ff.
SIGNS ELECTRICAL
Licensed Professional
._ _...,p,. •,
SPECIALCUiCUIi/MiSC
TFMp METER OR POLE (NST.
-
OWNER -BUILDER DECLARATION
( hereby affirm that I am exempt from the Contractor's coLicense law for the
following reason. Section 70315, Business and Professions Code: Any city or
countywhich requires a permit tonstruct, alter, improve, demolish, ormpair
Y
t�
D IN ]\'
1�1 �tl1
anystructure priorto its Issuance, also requirestheappBcant forsuch permit to
file a signed statement that he Is licensed pursuant to the provisions of the
POWER DEVICES
POOL ELECTRIC
OU]LE.ISSR,LICHFSFTX.fURFS
Contractors License Law (Chapter 9(cemmendeg with Section 700(8 of Divi-SNrQdMING
s1on3 ofthe Business and ProfesslonsCode)orthat he u exempttherefromand
basbs for the alleged exemption. Any violation of Se tion 7031.5 by any
applicant fora permit subjects the applicant to a civil penalty of not more than
VALUATION
1`zthe
I .'
NEWRESIDENTIALEKEZ7R'-_SQ.Ff.
five hundred dollars ($500).
❑I, as owner oftWproperty, ormyemployees with wages astheir sale
STORIES
TYPECONSTRUCTION
compensation, wllldothe work and thestmcture Is not intended or offered for
sale (Sec.7o94, Business and Profession Code: The ContraRots License law
does not apply to an owner of property who Wilds or improves thereon,and
who doessuchwork himself orthrough hisownemployees, provided that such
OCC. GROUP
RF5. UNITS
improvements are not Intended oroffered forsale. If, however, the building or
T
improvement issold within oneyearofcomplelioo,theowner-builderwill have
rden of proving that he did not build or Improve for purpose ofsale.).
owner of the property, Sm exclusively contracting with licensed
contr cion to construct the project (See. 7094, Business and Pmfr.kms Code:
QTY. PLUMBING PERMIT FEE
HADD ZONE
APN
pp-RMIT ISSUANCE
The Contractor's License Law does not apply to an owner of property who
Wilds or improves thereon, and who contracts for such projects with a
co tt[anor(s)Brenxd pursuant to the Contractais License Law.
LJ 1 am exempt under Sec 'B & P C for this reason
ALTER -DRAIN & VENT WATER (EA)
.FEE SUMMARY
BACK FLOW PROTECT. DEVICE
�1 TTSI OF FEES
DRAINS FLOOR ROOF, AREA, COND.
SANITARY Y_ N_
RECEIPT N
Owner Data
WORKMAN COMPENVSATION DECLARATIONpSppg.1.RAI'
[:]I hereby affirm that I have a certificate of consent to self -Insure, or a
certificate of Workers Campe.Hon Insurance ora certified copythemof Sec.
3800, lab C.)
Paltry N
SCItOOL TAX Y_ N_
REr17I'N
S
CAEA. SYSTEM -1 ING40UTLE15
PARK FFR Y N_
RECEIPT It
CAS FA. SYSTEhf-OVER 4 (TA)
Com❑pCany
BUILDING DIVISION FOES
cri fled ropy is hereby furnished.
❑ CertSed copy Is filed with the city inspection division.
GREASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE
GREASETRAP
CERTIFICATE OF EYEM PTION FROM WOR KERS'
PAID
COMPENSATION INSURANCE
(this section need net W completed lithe permit Is for one hundred dollars
sETVER-sANrrAtiY-sroR.M EA.2oopr.
Date Rem!Ij #
WATERHFATERW/VENT/ELECTR
ENERGYFEE Y N
($lW)ntles9.)
I certify that In the performmea.f the work forwhich this pernot is issued,
WATERSYSTEM/TREATING
I shall not employ any person In any manner so as to become subject to the
Workers' Compewtion laws of Califomia. Date
> D
PAID
NEW RESIDENTIAL PLMB. SQ,IT.
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you
should become subject to the Workers' Compensation provblons oRhe Labor
Date Remi t#
TOTAL:
BUILDING FEE
Code, you most forthwith comply with such provisions or this permit shall be
deemed revoked.
SEISMIC FEE
_
CONSTRUCTION LENDING AGENCY
I hereby affil res that there Isaconstructlon leadiagagenry forthe perform
ance of the work for which this permit has Issued (Sec. 3097, Civ. CJ
leaders Name
Lender's Address
1 certifythat I have read thbsappBrationand statethatthe above information
iscorrat l agree to comply with all cityand munty ordinances and state laws
TOTAL:
ELECTRIC FEE
PLUMBING FEE
QTY. MECHANICAL PERMIT FEE
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID:
relating to building construction, and hereby authome, representatives of this
city to enter Pon the above-mentto M property for Inspection purposes.
(We) agree to save, indemnify an d keep harmless the City of Cupertino
agaWt liabilities,j,dgments, cosh and expenses which may in anyway accrue
ALTERORADDTOMECH.
Date Recei I#
P
AIR HANDLING UNIT CFO 10,000 CFM)
SUBTOTAL:
gal said City in ronsaq e re of the granting of this permit.
a �� _r J
MR HANDLING u1.IT'(OVER 1a,0BocT�1)
CONSTRUCTION TAX
ASL � 7��I��
M matureoiRPPi�nt!/ i nY nr Mid
EXHAUST HOOD(W/DUCn
CONSTRUCTION TAX PAID:
HAZARDOUSMATERIAIaDISCLOSURE
EIFATINGUMT(TO100,0001ITU)
RCCfI t#
Will the applicant orfuture building ocvpant store or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.1 2, and the
IkalthandSafiery Code Section 25532(.)?
❑ Yes r] No ,
HEATING UNIT(OVER 1WOM BTU)
—
VENTILATION EAN SINGLE RESID)
ISSUANCE DATE
Will the applicant or future building occupant use equipment or devices
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management District?
Yes No
BOILER -COMP OTB'OR IM f)(D BTU)
BOILER-COMP(OVER I W,1100 BTU)
have read the hazy nus materials requirements under Chapter 6.95 of
the California Health & Safety Code, Section 25505, 25533 and 25534. 1
understand that lithe building does not currently have a tenant, that itis my
Ips q
f
NEW RESIDENTIAL MECH. SQ.FF
to notify the occupant of the requirements which must be rret
Aresponsibility I D
prior to Issuance of a Certificate of Oa panty. '
ISSUED ,,
Owner or authorized agent Date
TOTAL:
�T t t,r
OFFICE COPY rrunvu