23705APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
Building Project Identification
.W
PFRTNO.
11han/OZ o 6� . O /
23705
w er amc-/� one:
A A A
AKe Wo�V QF� 2 F`
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BUILDING-ELECTRICAL-PLUMBING-MECHAMCAL
c
Contract r'sName: Gc.No:
CATEGORY
CONTROL#
Architect/Engineer. Lie. Na
.QTY ELECTRICPERMIT FEE
BUILDING PERMIT INFO
Address:
PERMITISSUANCE
❑
LICENSED CONTR ACTOR'S DECLARATION
lh mbyaffG thatlamlkmwduMerpro Wonsof Chapter9(mmmmo-
APPLIANCESRESIDENTTALJOB
DFSCF MON
ig witeion 7000)of Division 3 ofthe Business and RcfessionsCode, and my
... is in fall force and affect,
PANELS
-7 tri
j-7
Yf�.C"� 1'T' Kr
��
License Clam —Lt. If
Date - Contractor
UP TO 2DOAM5
201-100DAMPS
ARCHITECTS DECLARATION
I understand my plans shall be used m public records.
\ �is:QOw
OVERI000AMPS
SQ. Fr. FLOOR AREA S/SQ. FT.
SIGNS ELECTRICAL, Al
Licensed Professional
n r f l
II
SPFGIAL CIRCNi/MISC
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt fro m the Contractor's License Law for the
�—A h—'
FZ'
TEMP. METERORPOLEINST.
. following reason: (Section 7031.5, Business and Professions Code: Any dtyor
county which requires a permit to construct, alter, improve, demolish, or repair
�A P �� ....e j
anystmu mprlorto Jts smancGal mqulrestheappliantforsuchpermitto
file a signed statement that he k Bernard pursuant to the provisions of the
-POWER DEVICES
,'/� g•
.
SWIMMING POOL ELECTRIC -'
Commana's License law (Chapter 9 (commencing with Se tion 7000) of Divi-
sion3ofthe Business and Profeulons Code) orthat he is exempttherefromand
VALUA'j](fi [
the basis for the alleged exemption. Any violation of Section 7031.5 by any
appHard for a permit subjects the applicant to a civil penalty of not more than
01 M E7SSWITCHESFIXTURES �,.
^ �� V VV
(�
five hundred dollars ($500).
1, as owner of the property, or my employees with wages as their sok
NEW RESIDENTIAL ELECTR SQ'FT:
STORIES
TYPE CONSTRICTION
compenaatlon, willdothe work, and thestruclare is not intended or offered for
sale (Sec. 7014, Buslnrm and Profemloro Code: The Contratoti License Law
does not apply to an owner of property who builds or improves thriven, and
who does such work himself orthrough Ms own employees, provided that such
OCC.GROUP
RFS. UNITS
improvementsare not Intended oroffered forsak. I{howevegthebuildingor
TOT L.
improvement issold within oneyeam(completlon,theowner-builderwill have
th�rden of proving that he did not bund or improve for purpose ofsak.).
{ as owner of the property, am exclusively contracting with licensed
contractors to construct the projct (Sec. 7014 Business and Professions Code:
QTY.. PLUMBING PERMIT FEE
FLOOD ZONE
APN.
1 pFRM1T ISSUMCE
The Contractor's License Law does not apply to an owner a property who
Wild. or Improves thnven, and who contracts for such piojets with a
Iraat r( I ncensed pursuant to the Contractor's License Law.
I am exempt under Sec. i B & P C for this reason
ALTER -DRAIN& VENT- WATER (FA)
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
-OUTSIDE FI;Lb
DRAINS FLOOR ROOF, AREA, COND.
SANITARY 'Y N
RECEIPT If
Owner Data
WORKMAN COMPENSATION DECLARATION
�I hereby affirm that I have a certificate of consent to self -Insure, or a
certificate of Workers' Compensation Insurance or a certified ropy thereof(Sec.
3800, Lab C.)
Policy
FIXTURES. PER TRAP' _�
SCHOOL TAX Y_ N_
RECEIPT #
GAS EA. SYSTEM -1 INCAOLTLETS
PARK FEE Y N '
RECEIPT #
GASEA.SYSTEMOVER4(EA)
aY
Co�cn
BUILDING DIVISION
ISION FEES
craftedcopy is hereby furnished.
Candied copy V filed with the sty inspection division.
GREASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECK PEE
GREASETRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
PAID
COMPENSATION INSURANCE
(This section need not be completed If the permit la for one hu nd rcd dollars
SEWER-SANiTARY-STORM EA. 20017.
Da[¢ RCCeI t#
WATER HEATER W/VENT/EL[CTR
ENERGY FEE Y_ N
($100)orlem.)
I certify that in the performance of the work for which this permit is issued,
WATER SYSTEM/TREATING
1 shall not employ any person in any manner so as to became subject to the
Workcrs'Compenmtionlawsof Califomla. Date
PAID
NEIN RESIDENTIAL PLMB. SQFT.
Applicant
NOTICETO APPLICANT: If, after making this Certificate of Exemption, you
should bemmeaubjct m the Workeri Compernation prov.1%a ofthe Labor
Code, you most forthwith comply with such provisions or this permit shall W
deemed revoked.
' CONSTRUCTION LENDING AGENCY
Date Rcaei t#
TOTAL:
BUILDING FE'
G._7
SEISMIC FEE
I hereby affirm that there ts a construction lending agency for the perform
ELECTRIC FEE
ance of the work for which this permit 0 imued (Sec. 3097, Civ. C.)
Leaders Name
LeMers Addrem
I rertilythm I have readthbappliathm.nd state lhatthe above information
iscortect. l agree to comply with all city and county ordinances and state laws
-
_
PLUMBING FEE Is
QTY. MECHANICAL PERMIT FEE
MECHANICAL FEE
PFRMTI ISSUANCE
FEES PAID:
relating tobullding mmuutlon, and hereby authorize representatives of this
city to enter upon the abow,micatimvd property for inspection purpose.
the City of Cupertino
(We) agree a, save, Indemnify and keep harmles which
against llabilitiea,p rats, carts and expenses which yin anyway accrue
Date Receipt#
ALTER OR ADD TO MUCH.
-
AIR HANDLING UNIT (TO 10,000 CFM)
SUBTOTAL: '
against a Ci of the granting of 1 pertnl�,
J
AIR HANDLING UNIT (OVER IO,000 CFM)
CONSTRUCTION TAX
ignalumof Applicant/C Tato
IXHAUS'r HOODffV/DLCT)
CONSTRUCTION TAX PAID:
HA OUSMATERIA SCLOSURE
HEATINCUNT OPO IWX)0 BTI)
Wilithrappn rfuture building occupant store or handle havarchms'
Date Recei
material as defined by the Cupertino Municipal Code, Chapter 9.12, and the
Ilealthaad Safety Code Section25532(a)i
F1 Yes M No
WilltheappBant orfutvrebuildingoccvpant useequipment ordevices
HEATING UNIT (OVER mom BTT)
TO -
VEN71LATION FAN (SINGLE RFSID)
ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
Quality DistriNo
p
-COMP QHP OR I00,IXq BTU)
Management BOILER
PO '
BOILER -COMP (OVER Iffl," BTU)
4havercadthe haarams materials requirements under Chapter 6.95of
the California Health & Safety Code, Snt1om 25505, 25533 and MM. I
understand that if the building does not currently have a tenant, that it is my
MAY lx y
NEIN RESIDENTIAL MECH. - SQIT
responsibility to notify the occupant of the requircments which most be met
L (_ _ l
prior to Issuance of a Certificate of 0 ropancy.
�/ '
CIIT Ur GUrcr-t,,,
ISSUEDBY:
Owner or authorized agent - Data
TOTAL:
OFFICE COPY.