20190APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification -
Building Address:
PERMITN'O.
to"/ LeL,nen Dr zss3o63
20190
wM amt: one:
APPL1CATJMTqM9ffrAT =A
1rhyn fjy %{ QPgn p�
'CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION /PERMIT
,Thy ��0
1 D'
conlraeora N�amr Lic.No:
'
BUILDING-ELFCTRICALPLUMBING-MFIHAMCAL
CATEGORY
CONTROL '
Architect/Engineer•. Lic. No:
QTY. ELECTRIC PERMIT
BUILDING PERMIT INFO -
Address:
rFEE
PERMITISSUANCE - I `.�
- ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION'
I hereby affirm that l am licensed under provisions of Chaa erg (oommene
Ingwith infull7000)ofd effect. olthe Buslnessand Pro(esslonaCode,and my
license Is In fuB force and effect.
APPLIANCES -RESIDENTIAL
JOB DFSCRR']lON
PANELS
C. LIL.N
Date
Dale Contractor
_
20140D0 AMPS
- ARCHITECT'S DECLARATION
I understand my plans shall be used as public records
-
OVER 1000 AMPS -
SQ. Fr. FLOOR AREA
b/SQ. FT.
ELECTRICAL n.
Licensed Professional
$TECTAL CIRCUIT/M]SC--'
OWNER -BUILDER DECLARATION
I hereby affirm that l am exempt from the Contractor's License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or
coantywhich requires a permit tocorutruct, alter, improve, demolish, oreepair
anystructure priorto its issuance, also requirmthe applicant forsuch permit to
file a signed statement that he is licensed pursuant to the provisions of the
Comracto/s License Law (CMpter9 (mmnencing with Session 7000) of Divi-
.10e3 ofthe Business and ProfessionsCode) orthat he is exempttherefromand
74,\VY
f-- =.
W
o �i
�f �-
TIMP. M=OR POLE INST. ,
POWER DEVICES
SHIMMING POOL ELECTRIC -E—
V LUATI�
IM Exists for the alleged exemption. Any violation of Section 7MI5 by any
applicant for a permit subjects the applicant to a civil penalty of net more than
OUTLETS -SWITCHES -FIXTURES 141 It
NEW RESIDENTIAL ELECTR SQFE
five undred delta.($SM.
�t I, as owner of the property, or my employees with wages as their sole
STORIES
TYPE CONSTRUCTION
compensation, will do the work, and the structure Is not intended or offered for
-
sale (Sec. 7004, Bustness and Professiom Code: The Contractoes License Law
does not apply to an owner of property who Wilds or impravm tMrmn, and
who doessuchworkhimselforthroagh hisnwnemployees, provided that such
-OCC.GROUP
RES. UNITS
improvements am not intended moffered for sale. If, however, thebuilding or
TOTAL:
improvemnu iesold wilhinoneycarofcompletiontMowner-builderwHl have
thWrden of proving that he did nm Wild or Improve for purpose ufale.).
M 4 as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7004, Business and Professions Code:
QTY, PLUMBING PERMIT FEE
FLOOD ZONC
APNpQtMIT
ISSUANCE
The Contractor's License Law does not apply to an owner of property who
Wilds or improves thereon, and who contractsfee such ts pmojecwith a
tractor(s) licensedSet to the Contractor's License Law.
❑ I am exempt under Sec. ec. B k P C for this reason
.
ALTER -DRAIN & VENT -WATER (G)
.,
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
OUTSIDE FEES
DRAINS FLOOR ROOF, AREA, COND.
- FIXCEURES PER TEAP -
SANITARY Y _ N
RECEIVE N
Owner Date
WORKMAN COMPENSATION DECLARATION
F11 hereby affirm that I have a certificate of consent to Belt -Insure, ora
o(Worken Comperwtion]murance oracertifled copy theree!(Sec.
MW,ateCJ
Policy
Policy p N
SCHOOL TAX Y_ N_
RECEn'f M
S
GAEA. SYSTEM -1 INCA OUTLETS
PARK FEE 'V N
RECEIPI'N
GAS PA. SYSTEM -OVER 6 (EA)
Com any
BUILDING DIVISION FfliS
Certified copy is hereby furnished.
F-1 Coddled copy is filed'entle the city inspection division.
GREASE/INDUSIRL WASTE INTERCEPTOR
PLANCHECIC FEE
GREASE TRAIT
CERTIFICATE OF EXEMPTION FROM WORKERS'
PAID
COMPENSATION INSURANCE
(This section need not be completed if the permit Is tome hundred dollars
SEArp-R-SANITARY-yTORN EA. 2WFT.
Date Remi t#
WATER HEATER w/VEM/ELECTR - -
ENERGY FEE Y N_
PAID
,
($100)orles.)
I certify that in the performance of the wmk for which this permit is issued,
I shall of employ
I shave not employ any person in any manner so u to emrye suby,c�lo the
any
Gov l o Date S 7T/
WATER SYSTEM/TREATING -
NOTIApplicant_ �
NOTICETd APPLICt to the rim' Co this Certinprois Exemption,you,
shwldWcome subject to the Workers'Compensation provisions of the Labor
Date Remi t#
NEW RESIDENTIAL PLMB. SQ.FT..
TOTAL:
BUILDING FEE
Cade, you most forthwith comply with such provisions or this permit shall be
deemed revoked.
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lendingagency forth¢perform
anecof the work for which this permit is Issued (Sec. 3097, Civ. C.)
lender'. Name
Lende.snddrm.
I ceditythatl have readthis applicationand statethattheabove information
1100100 I agree to comply with all cityand county ordinanm and state laws
TOTAL:
ELECTRIC FEE
PLUMBING FEE
QTY. MECHANICAL PERMIT FEE
MECHANICALFEE
PERMIT ISSUANCE
FEES PAID:
relating to building construction, and hereby authodu representatives of this
city to enter upon the above-mcntioed property for inspection purposes.
(We) agree to ave, indemnify an d keep harmless the City of Cu ped Iran
against liabilities, costs and expenses which may In any way acerue
ALTER OR ADD TO MECH.
Date Receipt#
AIR HANDLING UNIT (TO 10," CFM)
SUBTOTAL:
gaimt said City in conseegquuenn�e of the gir otthis permit
L/C lJ�a. �f-Z3-9�
MR HnnmuNC Darr rover 10,000 CM
CONSTRUCTION TAX
gmtnree t/cemrselm Date
EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (TO 100,000 BTU)
-
Date R cel t#
Will the a pplla rat orfuture building occupant store or ha exile ha>anlous
material as defined by the Cupertino Municipal Code, Chapter 9.1 2, and the
Hes lthandSafeyCcde ion 25532(.)?
F71 Yen CANo
HEATING UNIT (OVER 100,000 BTIE,
TOTAL:
VENTILATION FAN (SINGLE RESID)
ISSUANCE DATE
Will the applicant or future Wilding occupant use equipment or devices
which emit haranloes air cents mimnts as defined by the Bay Area Air
Quality Management Dist et? -'
ppNo
,
BOILER.COMP QHPOR 100,000 BTU)
MOILER-COMP(OVER 100,000 BTU)
4Ym
havereadtheh.,(MmsmaterialsrequirementsunderChapter6.95of
the Glifrnla Health k Safety Code, Sections 25505, 25533 and 25531. 1
understand that lithe Wilding does not currently have a tenant, that itis my
-
NEW RESIDFN TIAL MECH. SQ.FI'.
responsibility to notify the omupant of the requirements which most be red
-
prior to Issuance of. Certificate of Om p. racy.
iSSUEDBY: vY N ""^'xO--L�'s'�x•
Owner or authorized agent Date
TOTAL:
OFFICE COPY