24194APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BuildingPm'ect Identification _
B Iding Address:
V
PERMIT 419 4
nets me: one:
• (� —
,
CITY OF CUPERTINOtBUILDING DIVISION
APPLICATION / PERMIT,
BUILDING-ELECTRICALPLUMBING- MFGHAMCAL
p p IL
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C,00nnlrraactor'aNa�/: O /1/� (L \ !_�� LIe.No:
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CATEGORY
CONTROL
A'rc�r(ect� Ic Na:
QTY'S ELECTRICPERMIT FEE
BUILDING PERMIT INFO
Address:qQat,)E -rtG S
❑
PERMITISSUANCEEl❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter 9(commen<
Ingwlthsect.o 7000)of DlvWon3ofthe Buslnemand Pmfe ion$Code,andm
licence b Infyjl- fo;aPnd e. # 5Z * /
License Cl Lie. ��j�.di�F�52
Date �?Qontranor Y�—�UP
ARCHITECTS DECLARA ION
I understand my plats shall be used as public rcmrda,
Licensed Professional -
OWNER -BUILDER DECLARATION
I hereby afllmr that I am exempt from the Contractor's License Law for the
following reason.(Section 70115, Business and Professions Code: Any city or
cauntywhich mqube,a permit towmtron, alter, improve, dermlbh,orrcpalr
anystructure priorto its Issuance, also requlrestheappllcant for such permit to
file a signed statement that he la Ilcensed pursuant to the provisions of the
Contractor's License Law (Chapter9(commencing wlthSM1an 7000)of Divi-
Alan 3 o the Business and ProfesslowCode) or that he is exempt therefrom and
the basis for the alleged exemption. Any violation of Section 70315 by any
subjects the applicant to a civil penalty of nore than
applicant lots permitno m
five hundred dollars ($.500).
1, as owner of the property, or my employees with wages as their sole
compensation, will do the work, and the structure is not Intended or offered for
sale (Sec. 7040 Business and Pmfeuiors Code: The Contractors License Law
does not apply to en owner of property who builds or Improve, thereon, and
.he docssuch work himself or through his own employees, provided that such
Improvements arc not Intended oroffered for sale. If, however, thebuilding or
Improvement6Boldwithinoneyarofcomplmtb theowner-buflderwRl have
t"rden of proving that he did not build or improve for purpose ofsale),
u L as owner of the property, am exclusively contracting with Bernard
contractors to construct the omject (See 7044, Business and Profemiow Code:
The Contractor. License Taw don not apply to an owner of property who
builds or Improves thereon, and,who contracts for such p(ojecb with a
0tt actors) Rcessed pursuant to the Contractor. License Law.
Lf, r am exempt under Sec B & P C for this teasers
APPLIANCESRESIDENTIAL
JOB DiSCRR'110N
n G C
1(�/L
PANELS -
TO 2DOAMPS
201-1000 AMPS
OVER 1000 AMPS
/�SQ. FI. FLOOR AREA
-B.
L E D
I' 666........
/ Q
$/SQ. FT
'
-
SIGNS ELECTRICAL
SPFGIAL CD4CUIT/MISC - -MI/
Tp�p MEfFR ORIOLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
VALUATION
-
OUTLETS -SWITCHES
NEW RESIDENTIAL ELECTR SQ'FT'
STORIES
TYPE CONSTRUCTION
'
_ TOTAL:
(TTY, PLUMBING PERMIT ,FEE
PERMIT ISSUANCE �1
'-
ALTER -DRAIN & VENT - WATER (EA)
OCC.GROUP
R75. UNITS
FLOOD ZONE
`
APN
FEE SUMMARY
-
BACK FLOW PROTECT. DEVICE - '
DRAINS FLOOR ROOF, ARE& CONE.
FIXTURES, PER TRAP
SANITARY Y_ N
RECEDeT M -
Owner Date
WORKMAN COMPENSATION DECLARATION
hereby affirm that I have a artifiam of consent to self -Insure, or a
it ate of Wo ken'Comparriatlonlvurana oracertlfled copyth<rw(�ec.
38lic Lab C.) rrrr���--'�
1'o11ryM� �l_
P 4, Fv ��!!
SCHOOL TAX Y N_
RECEIPT N
GAS EA. SYSTEM -1 INCA OUTLETS
PARK FEE Y N
INGDIM
GAS PA. SYSI}Tt-0VER 4 (EA)
BUILDING
BUILIIINC DIVISION FEES
ertified mpyla a mbhed.
Certified copy iefiled with the city Inspection division.
CERTIFICATE OF"EMPTION FROM WORKERS'
' COMPENSATION INSURANCE-
(This section need not becompleted lithe permit Isfor ane hundred dollars
(s10B)wlese.)
I certify that In the perforeance of the work forwhich this permit 1. Baued,
I hall not employ any person In any manner an as to become abject to the
Workers' Compensation Lawn of Cahfomfa. Data
E
Applicant
NOTIC
NOAPPLICANT. If, after making thisCertifla/a of Exemption, you
should became subject to the Wodere' Cmnpa... it.. provisioro of the Labor
Code, you at forthwith comply with such provisions or this permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY,
I hereby affirm that there la a constmctlon lending agency for the perform
arm of the work for which this permit Is lsacd (Sec. 3097, CIv. C.)
]enders Name
Lc.dcr'a Address
Irenifylhatlhaversadthbappliationandgatelhattheabmelnformatlon
Is correct. Iagree tocomplywllhall cltyand coantymello.nceaand Matti..
relating to building construction, and hereby authomea rcpresentativn of thls
city to enter upon the above-mentioned property for Inspection purposes.
(We) agree to save, Indemnify an it keep harmien the Clty of Cupertino
aBaisutllablii e, jadgmenro,cona.rdexpAmeswhich may inanywayaceroe
aga .ts ily In ren once ming ofthls permip .s/�
/O 'W
�zn
GREABE/INDUSTRL WASTE INTERCEPTOR
PLANCI-IECK FEE
PAID
Date Recei t#
GREASETRAP
SEWER -SANITARY -STORM EA. 200FI'.
WATER HEATER w/ulcer/F1.EcrR
ENERGYFEE Y N _
PAID
Date Remi t#
WATER SYSTEM/TREATING
NEWRESIDENTIAL __SQ.FT.
PLMB.
TOTAL:'
BUILDING FEE
SEISMIC FEE
'
ELECTRIC FEE
-
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID:
'Date Receipt#
ALTFRORADDTOMECH.
AIR HANDLING UNIT (to 10,000 CrM)
SUBTOTAL:
PIR HANDLING UNIT (OVFR10,000CFM)
CONSTRUCTION TAX
401021
rco Appilan /Contract r I Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applies est or future building occupant store or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.12 and the
Health and Safety Code Section 25532(.)1
Ye, No
Wlllthe applicant or store buildingoccupant use equipment ordevices
which emit hazardousair contamimnts as defined by the Bay Area Au
Quality Management District?
Yea Q No
4 have read the haus mus mawriala requirements under Chapter 095 of
the California Health & Safety Code, Sections 75505,25533 and 25534. 1
understand that if the building does not currently have a tenant, that it is my
responsibility to notify the occupant of the requirements which must be met
prior to Issuance of a Certificate of Omrpanry.
D(HAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HEATING UM'I(TO 100,000 BTIp
Date RCCei t#
HEATING UNIT (OVER 100,00(i BTU)
TOTAL:
VENTILATION PAN(SINGLE RESID)
ISSUANCE DATE
^T
OV 1
urcnAs"
v'r-YW
ISSUED DBY BY: fSa� CCClll
BOILER -COMP QHP•OR 100,000 BTU)
BOILER -COMP (OVER 100,000 BTU)
NEW RESIDEN7INrr
7AL ME. _- SQ.
Owner or authorized agent Data
TOTAL:
OFFICE COPY