21730APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification
Building Acidmss:
PERMITNO.
21730
n one:
G z&Gc/r J
CITY OFCUPERTINO- BUILDING DIVISION
APPLICATION I PERMIT
BUILDINGS].ECTRICA4PLIJMBING-MFLHAMCAL
APPLEcAT07307PTrrAT =A
Cantraaol.Name l Lac. No-
00�j
CATEGORY
CONTROL Y
Aichdted/Frgdneer. Llc. Nm
5 S A/ ✓
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Address
PFRMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION
I hereby ifflrm that l am licensed under rovialmsofCha erg comment
Y P .n f
7000)o( Dlvlalon3ofthe Buslneasand Pro(nelon.Code,and my
Ing with is
l... In (all lq�and dfect. `` 17
Umnse Chse� l Lic.Y 7� �� J /
APPLIANCESRFSDENfIAL
]OB DESCRIPTION
C
PANELS
Date Contractor
UP TO 2DOAMN
201-10DO AMPS
ARCHITECT'S DECLARATION
I understand my plans shellbe used as publierecmda
OVER 1000 AMPS
SQ. Fr. FLOOR AREA -
$/SQ.FT.
SIGNS ELECTRICAL
Licensed Professional
OWNER -BUILDER DECLARATION
( hereby affirm that l am exempt lmmthe Contradoe. License Lw for the
-7336/ /46
SPECIALCIRCUIT/MISC
mfp,METIIiORI'OLE INST.
following reason($enlw 7MIS, Business and Professions Code: Any city or
county which requires m
a permit to Ktruct, alter, Improve, dereolbh,orrc Ir
anystrvctum pmlorto ll, lasaancq al,o rtquirtnhe appeunt (or such permit to
file a shed statement that he is licensed pursuant to the provisions of the
POWER DEVICES
_
SWIMMING POOL ELECTRIC
_
Contractor's License Law (Clapter9(commencing with Section 7000)Of Divi-
slon3 of the Business and Professloro Code) orthat he is exempt therefromand
VALUATION
the basis for the alleged exemption. Any violation of Section 7011.5 by any
applicant lots permit subjects the applicant to a civil penalty ofnn mare than
ave pplicant
OUTLETSSWI7CHE'SFIXIVR
CC
E Is—
I, as ed
of the 00).
1, ae owner of the property, or my employees with wages as their sole
NEW RESIDENTIAL ELECTRrl—
TYPE CONS'ITtUCTION
compensation, wllldothe work and the structure is not intended or offered for
a
sale Sac.70N, BusBmsn and Prdesslom Code: ]Tm Contractola Liame Lw
does not apply to an owner of property who bunds or impme,es thereon, and
whodoessuchwork himselforthrough hdsownemploy es, provided that such
OUP
RES. UNITS
Improvements am not Intended oroffered forsale. If, however, the building or
Improvement viscid wllhinoneyearofcomplebgtheowncr trullderwill have
Ie glen of proving that he did not build or improve for purpose of.ale.).
L as owner of the Property, am exclusively contracting with licensed
contractor to emstruct the project (Sec. 70K Bush. andProfessions Code:
QTY. PLUMBING PERMIT FEE
FLOOD ZONE
APN
PERMITISSUANCE
The Contractors Llaenm Lw dm not apply to an owner of property who��-DRAIN
Wild. or Improves thereon, and who contracts for such piojects with a
rTcI.) Banaed pursuant to the Contractors License Law. am exempt under Sec B & P C for this reason
& VFDTf - WATER (EA)
FEE SUMMARY
BACK FLOW PROTECT DEVICE
iiUTSIDC FEES
DRAINS H -DDR ROOF, AREA, COND.
SANITARY Y_ N_
RECFR'I' Y
Owner Date
WORKMAN COMPENSATION DECLARATION
❑ m, I hereby affirthat I have a certificate of consent to selfdnsure, ora
canifiuteofWorkers'Compemuatlon lrsurmce.r a certlflel copy thereof (Sec.
3800, Lb C.)
Policy Y
FIXTURES PER TRAP
SCHOOLTAX Y_ N_
RECEIVT Y
GAS F.A. SYSTEM -1 IC.IOUTLEIS
PARK FEE Y N —
RKL= Y
GAS G.SYSPFA7.OVER�(FA)
Com anv i_,-4 rI PC. F,L
BUILDING DIVISION FE IS
�CenlOed copy l, hereby furnished.
[ CenlRed copy is filed with the city inspection division.
CREASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE
CREASE THAT,
CERTIFICATE OF EXEMPTION FROM WORKERS'
' COMPENSATION INSURANCE
(fhdssedlon need not be completed if the permit l+ forone hundred dollars
PAID
Date Remi t#
S a.iU
SEWER-SANIT'VZY-STORM 1N.200FI.
WATER FiFAT,, W/VFN'T/FLECTR
FEE Y N —
(SI00) or lean.)ENERGY
Iasify that In the performance of the work for which this permlt is Issued,
I shall not employ any person In any manner so as to become subject to the
Workers Compensation Lwsof CalBomla. Date
WATEE SYSl77.1/TREATING
PAID
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you
Date Remi t#
NEWRESIDFNTIALPf.MB. SQA.
TOTAL:
should become mbjed to the Workers Compmsatlon provl,iov of the Labor
Code, you Most fart hwlth comply withauch provisions ar this permit shall be
dmmad revoked.
BUILDING •E
SEISMIC FEE
D
CONSTRUCTION LENDING AGENCY
I hereby affnrmthat then l, a xiaatmnion lending agency for the perform
etof the work for which this permit is issued (Sec. 3097, Clv. CJ
ia endae. NameI.�L�
1<ndal.Addres. r /
I unify thatl have read this app) tlonand state lhattheabove information
Iscomed. I.grmtocomplywdthalt, tyandcountyorellnanmandslatelaw.
misting to building comuuction, and hereby authorlas representatives of this
TOTAL:
ELECTRIC FEE
QTY., MECHANICAL PERMIT FEE
PLUMBING FEE
-
MECHANICAL FEE
J
PERMITISSUANCE
FEE
Lf
city to enter upon the abavementlonad property for inspection purposes.
(We) agree to save, tndemN/y an d keep harmless the City of Cupertino
against hishillttes, ydgments, costsand expenses which may In any way aarue
againstid CltyIn mnsaryena�f y,e gr.nting of thio pemmlt 2_
i71,..J- /
Signature of App ant/Contraactor / Date
HAlARDOUSMATERIA DISCLOSURE
ALTERORADDTOMECH.Date
Ri t#
eec
- P
AIR HANDLING LNITT170 10,0DOCIM)
SUBTOTAL:
IMR
AIR HANDLING(OVFR IO,000CFN)
CONSTRUCTION TAX
,�/
EXHAUST HOOD(W/DIX:T)
C�O•A/p�$T CTION TAX PAID`:
—-/-�L
HINTING UNIT (TO I00,000 BTU)
Will the applicant or future buildingo ant store or handle hazardous
asteria) as def ned by tM Cupertino Munldpal Cad, Chapter 9.12 and the
Date Recel 1#
HEATING UNIT (OVER 100,000 BTU)
TOTAL: ,
Ilealth and Safety Code Seddon 25532(a)?
❑ Yea No
VENTILATION FAN SINGLE RESID)
ISSUANCE DATE
Wlllthcappllcant or hours building occupant use equipment crdevices
which emit havnd... air contamdvus as defined by the Bay Arca Air
Iity Mugemcnt District?
ye, [7 No
shave aread
BOILER -COMP MIT OR 100,CM BTU)
50RER-COMP(OVER100,000 BTU)
the haaa�ous material, requirements under Chapter 6.95 of
the Glifornia I lealth & Safety Code, Sections 25505, 25533 and 255M. I
FEB 141991
NEWRESIDENTIALMECH. SQ.17T.
understand that lithe bulidingdocs not comenlly have atenant, that It is my
mporability, to notify the occupant of the requdreaenls which most be met
priorto Lsuan¢da Certilicatcof .P.any. /
G
red i�11n-�'-'3
ISSUE
Owner or author' gent Date
TOTAL:
OFFICE COPY