23463APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Prom ldentmratlon
BuBdi.g Add 5
PERMIT NO.
2346 3
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CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BUILDINGS.ECIMCAI PLUMBINC-MECHANICAL
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CATEGORY
CONTROL.
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Aichi a/Engles.r --7-- Lk.No:
QTY ELECTRICPERMIT FEE
BUILDING PERMIT INFO
Address:
PERMITISSUANCE -
❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that lamsi.3 licensed fth.Buir salonsof ChaTax., 9msCommmm
Ingwlth 1.f.I effort ofthe Buelnessand PmfeulonsCade,and my
license le In (u 1 ores e tl cited.
Limn la 0 Lk.N
Date 115
ARCHITECTS DECLARATION
I understand my plans shall b, used as public rem,d&
Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I amexempt from the Contractor's License law for the
following reason(Section 70115, Business and Professions Code: My city or
county which requires a permit to constructalter, improve, demolish, or repair
any structure prior to Its Issuance, also mqulres the applicant for such permit to
file a signed statement the he h licensed pursuant to the previsions of the
Contractor's License Law (Chapter 9 (commencing with Section 7000) of Divi -
.1.. 3.( the Business and Profeaderes Code).,that be k exempt therchorna d
the bask for the alleged exemption. My viohtion of Section 70115 by any
applicant fora permit subjectsthe applicant to a civil penalty riroom om than
fit�undred dollars(SSDO).
I, as owner of the property, or my employees with wages as their sok
mmp.nudon, will do the work and the structure h not Intended or offered for
gale (See 70K Business ami Professions Code: The Contractors License Law
does not apply (o an owner of property who bullas or Improves thereon and
who doessuchworkblelf orthro sigh Msown employees, provided thatsuch
ms
improvements are not intended or offered for sale. If, however, the building or
Impmvementhsold wlthlnoneyearofcompldlon,the owner-bullderMll love
tl)L,¢vaenof pmving that he did nmbundorlmproveforpurpoacafuk.).
LI 1, as owner of the m licensed
property, and Cole:
Business and Pf property
TheconCo we to mruwd the pm)M (Sec. 70"apply who
The Contractor's Licence law does not apply tct an owner d property with
c Ods t r Improvse thereon, and who contracts for such plv)ects with
cg0lrado,exem t Pursuant to the Contractors License Law.
LJ I am exempt under Sec B 6 P C for this reason
APPLIANCES -RESIDENTIAL
JOB DESCRIPTION
/VI
PANELS
UP TO 200AMRS
2I1-1000AMPS
OVER)ODOAMPS
SQ. FT. FLOOR AREA
NLicensed
LED ''
P R
♦ / i
$/SQ.Fr.
SIGNS ELECTRICAL
SPPCLILCD2CUIT/MLSC
pMEfER OR POLE INS,.
POWER DEVICES I TE
OUILETSSWITCHESFD(TURF5
VALUATION
oO
NEW RESIDENTIAL ELECTR SQFr.
STORIES
TYPE CONSTRUCTION
TOTAL:
QTY. PLUMBINGPERMIT FEE
OCC. GROUP
RES UMTS
pFRM1T LSSUANCE
ALTER -DRAIN A VENT- WATER (EA)
FLOODZONE
APN
FEE
BACK FLOW PROTECT. DEVICE
OUSUMMARY
EFEES
DRAINS FLOOR ROOF, AREA, COND.
SANITARY Y N
RECEIPT p
Owner Date
WORK MAN COMPENSATION DECLARATION
rad hereby affirmorkers that I have o certificate of moment to sdf-Imre, ora
3800 Late.floorken'Compematlon/ilrounnmorasxrtlfied copy, thereof (Sec.
3800, lots CJ 29,93' i� 92
Policy p
FD(TURES PER TRAP
SCITOOL TA% Y N
RECEIPT Is
GAS EA. SYSTEM -I WU OUTLETS
PARK FEE Y N
RECEIPfg
CAS EA. SYSTEM -OVER 6 (EA)
Cam aey TMT' Al
BUILDING DIVISION FEES
�__. C�d copy k herebyfamished.the
eAlkd copy h filed with the city Inspection diWtlon.
city
CERTIFICATE OF M'MPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need rad be completed if the permit hfor one hundred dollar
(Sim itifyt.)
I cent anplohat the person In anye of exameriework so an to b ca Berm jestt is to he
I .hail not employ any person In any manner so as to become subject to the i Compensation Lawao(Califomla. Date
Applicant Applicant
NOTICETO esubjeAM:IL aftermaking
penCertificate .(EvempteLyou
should become subject to the Workers' Campewtlon provhIs p of the Labor
Cale, you must forthwith comply with such pmvhbm ortM1h pemdt shall be
deemed revokes.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there Is a construction lending agency for the perfarm�
arm of the work for which this perrNt h taxied (See. 3097, Civ. C.)
Lender. Name
Lenders Address
1 omilythat I have readthk eppllcatlonand natethat theabove Information
hcormet. l agree to comply with all city and muntyordinances and gate laws
relating to building commatorm, and hereby auth.mes repr.eentatives.( this
city to enter upon the abovemvmloncd property far inspection purposes.
(We) agree to save, Indemnify an d keep harmless the City of Cu pert Ino
against llah llIas,pdgmenimmar, expend wlit hmaylnanywayaccrue
agalm tr in cons quonce gra oft permle
�g u ppuont/Q nva .r Date
NA RDOUS MATERIALS DISCLOSURE
Will the applicant ,future building occupant store or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.73, and the
Hcalt homed SafetyCode, Sectio..75533(.)7
❑ Q
Will the applica rat or future building occupant use equipment or devices
which et hazardous air contaminants as defined by the Ray Area Air
mi
Quality Management District?
Yea j''j No
have read the haz2ous materials requirements under Chapter 6.95 of
the Callfe rala Health h Safety Code, Sections 75505, 75533 and 75539. I
and creta no that if the building does not currently have arena nq that it Is my
responsibility to net lfy the occupant of the requlr.ments wh lch must be met
prior to lssuanre of a Certificate of Oca'u parry.
CREASE/INDUSIRL WASTE INTERCEPTOR
PLANCHECK FEB
PAID
Date Recei t#
GREASE TRAP
SEWER -SANITARY -STORM EA 700Irf
NATER HEATFRW/VENT/ELECTR
ENERGY FEE Y N
PAID -
Date Recei t#'
WATER SYSTEM/TREATING
NEW RESIDENTIAL PLMB. SQ.Fr.
TOTAL:
BUILDING FEE
SEISMIC FEE
TOTAL:
uu
ELECTRIC FEE
r(,O
QTY. MECHANICAL PERMIT FEB
PLUMBING FEE
MECHANICAL FEE
PERMIT ISSUANCE
FEE$PAID:
ALTERORADDMMECH.
Date Rf#
eCel P
AIRHANDLINGUNIT(T010,0DOCFM)
SUBTOTAL'
AIR HANDLING UNIT (OVER 10,000CFM)
CONSTRUCTION TAX
IXHAUg'r HOOD (W/DUCT)
CONSTRUCTION TAX PAID:
HEATING UNIT (TO 100,0DO BTU)
Date RCCeI t#
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
I
VPN'II LATION FAN( SINGLE RESID)
ISSUANCE DATE
f,�p B
if" ,y)
N
Pii,I1!
,/s 799a/g®
Coy! `
ISSUEDBY:
BOILER. OMP Of OR 100,Om BTU)
BOILER.COMP(OVER 100,000 BT U)
NEW RES] DENTIAL MECH. SQ.Ff
Owner or auihorlud agent Data
TOTAL:
OFFICE COPY