20975APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Protect Identification -
Build ing Add rets:
53 1 �o
PERMIT NO.
/1 0 (� 1")
G .9i I
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CITY OF CUPERTINO-BUILDING DIVISION�J6
APPLICATION I PERMIT
BUILDING-ELI)CTRICALPI.UMBINGMECHAMCAL
ATr
l `t
c°ErstlaN me; ,� 3J y
CATEGORY
CONTROL a
Architect/Engineer. Tic. No:
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Add..
Ly ❑ ❑ ❑
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION
Ihth Syioflrmdut I am fDivik 3o(theBuMnmandsed under soffhon,Codmmdmy
Ingwlih SecfunLarma(Divifixt. the Bupnessand ProfeselonsCodgand
license le in (uB roe and d(.01 '3�((A/, y,
LlcenxC Llc M r_
Date Contnnor —IG�I P r
ARCHITECTS DECLARATION B—
I understand my plans shall be used as public rerorla
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirmthal I. exempt from the Contractor's License law for the
following reason. (Section 7071.5, Business and Profeasbne Code: Any city or
cuuntywhich requlma permit tucomuHuct, alter, Improve, demoli,h,orrepdr
anystmetumpdortoitel mance,ala mquim.theapphnnt(orsuchper tto
file a signed statement that M Is licensed pursuant to the provisions of the
Contractor's License Law (Chapter 9 (commencing with Section 7000) of Dlvl-
sion3 ofthe Business and Professions Ccde)orthat he b exempt therefrom and
the basis for the alleged exemption. Any violation of Section 7071.5 by any
apphcent for a permit subjects the applicant to a civil penalty of not more l ban
five hundred dollars fi;SM.
❑ L as owner of the property, or my employees with wages as their wk
compensation, wllldothe work and the slmclure is not Intended or offered for
aale (Sec. 7064, Business and Prof°asloru Code: The Contractor's Licensee law
does not apply to an ownerof property who builds orlmprovnlhereon,and
who dexasuch work himsel(orthrough his own employees, provided that such
improvements are amIntended oroffered formle. If, however,the buildingoi
improvementhsold withinoneyearofcompletion,lheowner-bullderwillhave
tlW.kurden of proving that Mdid not build or improve for purpose a(wlc.).
Lj 1, as owner of the property, am exclusively contracting with licensed
contractors to mmlmct the project (See 7064, Business and Professions Code:
The Conteactor's License Law don not apply to an owner of property who
or Imprwee thereon, and who contracts for such plu)ecis with a
cgB(�actor(s)licensed pursuant to the Cormactot's License Law.
LJ I sm exempt under Sec R h P C for this reason
APPLIANCFSRF.SIDEMTAL
]pis DESCRIPTION
_
PANELS
$_-
201 -IOW AMPS
OVER1000AMPS ly I
SQ. Fr. FLOOR AREA
'
$/SQ. Fr.
SIGNSE CAL VAI K/
SPECIALC T/M
TEMP. Kf.p�
POWER
SWIf.1MI
OUBLE
L ELE C
I XTIJRFS
VALUATION
1 �x ` eco.,
l V �-ll
W R M. TR SQFr.
STORIES
TYPE CONSTRICTION
TOTAL:
Qty, IrL[JMBj IT FEE
OCC. GROUP
HIS. UNITS
,-
PERMITISSUANCE
ALTER -DRAIN VENT- A (FATbuild,
FLOODZONE
APN
FEE SUMMARY
BACK FLOW PROTECT. DEME
_Q_QTS_1DE FEES
DRAINS FLOG ROOF,
R AREA,
SANITARY Y N
RECFR'Ta
Owner Dale
�a...�AWORKMAN COMPENSATION DECLARATION
Lfy! hereby affirm [hal I have a certlflrate of concent to self -Insure, ora
c iflCb C.Work°rs'ComperwHonlmuranceoramrtl/led copythemf6ec.
WkylbC.) )�„_ I i/O
Pollry M_/ [ /7
FO(Tl1RFS PER TRAP
SCHOOL TAX Y N
RECEIPT M
C C. O
G VU�U
PARKFEE Y N
RECENTM
C.�. p�ny
BUILDING DIVISION FEES
UCertiffeedi copy is filed hereby
the city
' Certified copy b (fled with nis city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Rhlesecllon need nU M completed i(thepermit b for on hundred dollars
(91 I0)orless.)
Icertilythat in the perfomunceo(the work for which
ch this permit is Issued,
1 shall not employ any person in any manner so as to become subject to the
Workeri Compensation Laws of Call(orela. Date
NOTICE
NOTICE co APPLICANT: the after making this Certificate is Exemption, you
ComOenationprovisionofthe Labor
Code,shoulbecome sforth to the ply with
Code, you oket(orthwith comply with such provbloro or this permit shall be
domed revoked.
CONSTRUCTION LENDING AGENCY
Iherebyafti mn thatthereba mmtmalonlendingagencyfortheperform-
ante of the work for which this permit 1, Issued (Sec. 3097, Civ. C.)
Lender's Name
Lenders Addms
I certifylhat I have read this appBCtlonand stalelhalthe.bona IEornution
Iscorrect. i agreeto comply with all city and county ordinance and pate laws
relating to building construction, and hereby authorize repmentativn of fhb
city to enter upon the above-mentioned property for Inspection purposes.
(We) agree to save, Indemnify and keep harmless the City of Cupertino
age til IWke,judgrjteet copeandexpenmwhichmaylna"ywayaccrue
Ityi
Inst sal mnxq o(Ihe granting of thla�mnif.
�=_�QT�
SlgruEraof AppHCnt/Contractor i` Date
HAZARDOUS MATERIALS DISCLOSURE
Will fheappllCnt or future building occupant store or handle hazardous
material a, dented by the Cupertino MunlelpaI Code Chapter 9.1Z and the
Hca lth and Safety Codg Byctlo"75532(.)7
fly. o
Will rheapplkant ofuture building occupant use equipment or device.
which emit hazardous air contaMoanu as defined by the Bay Area Air
Quality Managementict7
4Yo s No
havercadthehaz r ousm terialsrequirements underChapterg.95of
the .Health building
Code, not currently have
understand
underslandyton that fly the oocupaes of therequirmves which that It Is
ve a tenant,it
7 ability Ion fly the occupant of the requirement which =at be tnE
JgSpan Cert c cofoccup.ncy.
Ownerrrorxuthorladagent 1D
GR I L
PLANCHECK FEE
Date Recei t#
GREASERAlir,PAID
SEWER -SANITARY- FA.iOo
WATER HEATS w ENT/m Ec TR
ENERGY FEE Y N
PAID
Date Remi t#
WATIR SYSTPM/TREA77NG
NEW RESIDENTIAL PLMH.SQ.FT.
TOTAL:
U G
FEE
SEISMIC FEE
TOTAL:
ELECTRIC FEE
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
MECHANICAL FEE
PERMITISSUANCE
FEE$PAID:
ALTER OR ADDTO MECH.
Date Recei t#
P
AIR HANDLING UNIT TO 10,ODO CFM)
SUBTOTAL:
AIR HANDLING UK7T(OVER IO,ODOCEN)
CONSTRUCTION TAX
EKFUUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HFATING UNIT DO IOO,ODO BTT!)
Dale Reeei t#
HEATING UNIT (OVER 100,000 BTU)
TOTAL
1♦ 6
VFNDLATION FAN (SINGLE RESID)
ISSUANCE DATE
���
�^^t4,
SEP L990
U
ISSUED BY: ri L
BOILER -COMP OHPOR 100,000 BTU)
BOILER -COMP (OVER 100,000BTU)
NEW RPS[DFN77AL MECH. SQ.FT
TOTAL:
OFFICE COPY