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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Pro'ect Identification
Building Address:
PERMIT NO.
23624 3^24
wners mne
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BUILDING-ELILTWCA PLUMBING -MECHANICAL
A A
�✓� � 17 ,Z
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Contractors Nano: Lie. N.
I S .
CATDGORY
CONTROL MIG/f
C V
Ap%rµEm(iL gineer. j 1, was, as Ole. No:
3
Qn. ELECTRICPERMIT FEE
BUILDING PERMIT INFO
Address rad. Z
PFRMITISSUANCE ✓
1�1 I ❑
u `P
LICEN E CONTRACTOR'S DECLARATION
Ihercby affirm that l am licensed under provisons of Chapter9(commenc-
IngwlthSe ion7WD)of DiAsion3oftheBusinessand PmfmimsCude,and my
license is In full force and effect.
Llcenso Clan LIc.N
Date Contractor
ARCHITECTS DECLARATION
I understand my plans shall be used as publle records,OVERT
Licensed Pro(essiovl
OWNER -BUILDER DECLARATION
1 herebyaffirmthat l am exempt fromthe Contractors Limnas Law for the
following ..n. (Section 70315, Business and Professions Cade: Any city or
county which requlres a pemdt to mnatmct, alter, Improve, derenloh, orrepsir
anystructure prior to its lwnnce, also requires the applicant for such Permit to
file a signed statement that he b licensed pursuant to the provisions of the
ContraRor'sLicense Law (Chapter 9(commencing with Section 7000) of Divi-
of the Business end Pmfemlons Code) or that he le exempt therefrom and
the
the bash for the alleged exemption. Any violation of Section 7031.5 by any
zppficnt fora permit subjedsthe appbcant to a dvil pevlly of na more Nan
five hundred dollars (8500).
F]1, as owner of the property, or my employees with wages as their sole
compensation, will do the work and the structure 6not intended Or offered for
sale (Sec 7064, Business and Profsasbns Code: The Contractors Lim. law
docs not apply to an owner of property who builds or improves thereon, and
who does suchwork himself or through hisown employees, provided that such
improvements are not intended oroffemd forsale. If, however, the building or
improvement baold withinovyearofcompleion,then ner-builderwill have
t ,den ofpmving that he did notbulld or improve forpurpossofsale.).
LJ L as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec, 7064, Business and Professions Code:
The Contractors License Law does not apply to an owner of property whg,
Wilds or improves thereon, and who contracts for such pAojeas with a
cg6t.[actor(-) licensed pursuant to the Contractor's License Law.
LJ I am exempt under Sec B & p C for this reason
APPLIANCES -RESIDENTIAL
JOB DFSCR)PTION
0.Q ^n �a�'}.� t
I 00 I I � 6,�J
PANELS
201'1000
AMT'S' "n •�
SQ.FT.FLOOR AREA
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v a v
sm. FT.
G�s'ZQ
OO —av
SIGNSE AL1 11 .) {
SPECIAL CBtCUgT/MIT/MLSC
T�
P,MELI]lGlt f'BL
POWER DEVICES
SWENMING FOOL ELECTRIC
VALUATION
�—�
VV
IJTLETSSWITCHESFIXTURFS
NEW R75IDEhT1AL ELECTR e''QF7.
STOW
TYPE CONSTRUCTION
QTY. PLUMBING PERMIT FEE
rEgMl.I. ISSUANCE
IVALTER-DRAIN &VENT- WATER (EA)
OCC. GROUP
RFS. I1NffS
FLODDZONE
APN
BACK FLOW PROTECT. DEVICE
FEE SUMMARY
OUTSIDE FF
Owner Date
DRAINS FLOOR ROOF, AREA COND.
FD(TURES PER TRAP
SANITARY Y N
RECEIPT N
WORKMAN COMPENSATION DECLARATION
❑1 hereby affirm that I have a certi0cate of consent to self -insure, or a
ccmifimteofWorke Compensationbuuranmoracertifiedropythereoft$ec.
3800,1ab C.)
Policy k
SCHOOL TAX Y N
RECEIPT
GAS EA. SYSTEM -I INCAOITTLETS
PARK FEE Y N
RECEIPT p
Co any
GAS EA. SYSTEM -OVER 4 (EA)
BUILDINGPTVISION FEES
scertlfled copy b hereby furnished.
❑Certified copy b filed with the city inspection division.
CERTIFICATE OF D(EMITION FROM WORKERS'
COMPENSATION INSURANCE
(This season need net be completed B the Fermat b I..rel utdreddollars
(SI comlyss.) in work
Iceran employ
thenner.asto become
an perm, In esubjepermit sbmed,
I shall net employ any person in any manner ao ns to 'seroma subject to the
W an Compensation Gwa of Grn
lBoia. Date
Applicant
hODCETOe,subpAM:IL filr�orken'kCrg ompe Ceronipro ofoscmpteLabor
shouldou most forth to the ply with such prsauonprovhiovrmit of s Labor
Cade, you most forthwith comply with such provblons or permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
L+amnstmctlsn lending agency for the perform.
Ihercby orkfo which
Lend Lender'. Name for whkh Nb permit u timed (Sec. 3097, CN. CJ
Lenders Nacre
lander'spthatI
I rerti(ythntl have readthlsappBcatbnand &atethalthe above information
Is correct. l agree to comply with all cityand county ordlnanres and slate lawsPERMIT
relating to building construction, and hereby authorize representatives of this
city to enter upon theabovomenboned mperty for Inspection purposes.
(We)agr as", Inde Ify an keep harmless the City of Cupertino
against] Bit s,judgment astsa ex seawhicherayinanywayacerue
agar acid rty lnronm enceo egr ting of this permit.
Z' /L
P/DDum
CREASE/INDUSIRL WASTE INTERCEPTOR
PLANC14ECK FEE
PAID
Date Recei t#
GREASE TRAP
SEWER -SANITARY -STORM EA. 2DOFT
WATER HEATER W/VENT/ELECTR
ENERGYFEE Y N_
PAID
Date Recef t#
WATT=SYSTEM/TREATING
NEW RESIDENTIAL PLMB.__�,Ff.
TOT d�
TOTAL:
B ILDING , E
SEISMIC FEE
ELECTRIC E i�
QTY. MECHANICAL PERMIT FEB
ISSUANCE
PLUMB
ME -IA LFE
FEES D.
Date Receipt#
ALTERORADDTOMECH.
AIR HANDLING UNIT (T010,ODOCFM)
BTOTAL'
AIR HANDUNG UNIT(OVER 10,000 CFM)
CONSTRUCTIO TAX
Signature of Applies, or
HAZARDOUS MATERIALS DISCLOSURE
Will the appBcant.,future WHeling occupant store or handle hazardous
material as de0ned by the Cupertino Municipal Code, Chapter 9.12, and the
I lealth and Safety Code, Stolon 25532(a)7
❑ Yes � No
Will the applicant or future building oeropant use equipment or devices
which emit haz Moos air cont amivnts as definedby the Bay Area Air
Quality Mavgement District]
Ya �Nm
4 of
haverthehazar Safety
materassercons 255nb5533 and 25534.
the Californiau Health &Safety Code, Sections 5505, 75533 and 25539. ]
understand that lithe building does not currently have. tenant, that it is my
responsibility to notify the Occupant M the requlremenls which must be met
Prior to issuance of. Certificateof Ocmpanry.
EXHAUST HOOD(W/DUCT)
CONSTRUCTION AX PAID:
Date eeei t#
HEATING UNIT (TO 100,000 BTU)
_
HEATING UNIT (OVER 100," BTU)
VENDLATION PAN (SINGLE RESID) -
ISSUANCE DATE
Rr
mai E
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dt
C%ty v
V Uhr.. _
y ^9/ffYU
SSUEDB .
BOILER -COMP OHPOR 100,0(10 BTUs
BOILER-COMP(OVQt 100,000 BTU)
NEWRESIDENTIALMECH. SQ.bT.
_
Owner or authorlud a gent Dae
OFFICE COPY