23914APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Proem Identification
Bulldin Add.,:
PERMIT NO.
-r- a^ Vi U cj) �-
23914
Owners Phone:
C d y 33`0
OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
A
Contraoar', Name: L1c. N°:
BUILDING-ELECTRICALMUMBING.MECHAMCAL
CATEGORY CONTROL N
Architect/Engineers Lie. No,
QTY ELECTRICPERMIT FEE
BUILDING PERMIT INFO
Address:
es
❑ IF-� ❑ 1YLICENSED
PERMITISSUANCE
CONTRACTOR'S DECLARATION
TION
herebyafflrmthat 0MINviBcen.edunder pagand ro Chapter9(e,and
It...h Infull force affean3ofthe Buslrassand Pro(esslonsCode, and my
license Is In (uLi fora and affect.
APPLIANCES -RESIDENTIAL
JOB DiEsc
Wtaveta
PANELS
License Clam Lle.N
���
Date Contractor
201.1"AMPS
ARCHITECTS DECLARATION
I understand my plane shall be used as public remnda
OVER 1000 AMPS
SQ. FT. FLOOR AREA
f/SQ. FT.
SIGNS ELECTRICAL
Licensed Professional
9'ECWI. CIRCUIT/MLSC
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License law fee the
following reason.(Section 70315, Business and Profembna Code: Any city or reqes m
county which onto Ince a permit to netrod, alter, improve, demolish, or repair
any atslVeretatemeprior to itahatheis licenedi iresthe pursuant mike rm,ig.peof to
ale a rigned statement that issuance, e, Ilso eed pursuant mike pro.uchp of the
Contractor'sLicense Law (Chapter 9(commencing with Section 7000) of Divi.
slon 3 ofthe Business and Profs. one Cods)orthal he is exempt therefromand
the baste for the alleged exemption. My Wolatlon of Section 7m15 by any
applicant fora permit subject/ the applicant to a civil penalty a naroomrre than
five hundred dollars %W. .
F11, as owner of the property, or my employees with wages as their sole
j'�
I��V9 Ili U If
l L�
TEMP. M= OR POLE INST.
`
POWER DEVICES ^^-E
wt
SWIMMING POOL ELECTRIC
OIITLETSSWITCHESAXTURE$
N
-f
NEW RESIDENTIAL ELlCTR FL.
�'
STORIES
TYPE CONSTRUCTION
compensation, wBldothe work, and thestroctum is not ntended or offered for
sale (Sce.7044, Buslvssand Profasslone Code: TM Contract.es Llmnse law
OY%
does not apply roan ownerof property who builds orimprovm lhermn, and
who doessuch work B hlmssorthrough his awn employees, provided that such
Improvements are not intended proffered for sale. If, however, the bulldingor
improvement issold withlnoneyearofcampldlon, theowner-builderwillhave
tryE.�rlanofprovingthat hedid notbuitorlmproveforpurpossofule.).
U(I L as owner of the property, am exclusively contracting with licensed
tractors to mnetrod the project (Sec94, 70Businessand Profeselons Code:
The Contractor', License Law don sea apply to an owner of property who
bullds or Improves thereon, and who contracts for such IoWjects with a
"glBfa in'(-) Licensed pursuant to the Contractor'. License Law.
LJ 1 am exempt under Sec B k P C for this reason
J(IV .SO A-1OCC.CROIR'
T 1.2
ON. PLUMBING PERMIT FEE
pQthiR ISSUANCE
ALTER -DRAIN VENT -WATER (TA)
__F
RES. UNITS
1)
APN
BACK FLOW PROTECT. DEVICE
FEE SUMMARY
•'^
DRAINS. FLOOR. ROOF, AREA, COND.
SANITARY Y_ N_
RECEIPT
Owner ate
WORKMANC MPENSATION DECLARA 1
Ell hereby affirm that I have a mrtiBote of consent to self
FIXTURESPERTRAP
SCHOOL TAX Y N
-Insure, or a
mrtifivte ofWorkers'Compensztlunlesurance or a certified copy thereof(Sec.
3800, Lb C,)
RECEB'T N
GAS EA. SYSTEM -1 TNG OUTLETS
PARK FEE Y N
poney Y
RECEIPT Y
Com any
GAS F.A. SYSTEM -OVER 4 (FA)
B U ILDING DI VI SION FEES
furnished.
❑p Certified ropy is hereby h(hcity
❑ Certified copy is (clod with the city Inspection division.
CREASE/INDUSTRL WASTE INTERCEPTOR
PLANCI-IECK FEE
GREASE TRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
ITMarealon need net be completed B the permit is(prone hundred dollen
(EPI undifmss.)
] .net that employ
I shall not employ any person In any manner so u to become subject t° the
anyhe arnout in an tmanner so as to b co permit is to the
Workers' Compen,atlon laws of GIIlomia. Data
PAID
Date Recei t#
SEWMSANO'ARY STORM EA 20EFT
WATER HFATERW/VENT/ELECTR
ENERGYFEE Y N
PAID
WATER SYSTEM/TRFATTNG
Applicant
NOTICE TOAPPLICt to orkmeklnm ensationis kro is Exemption, you
Compensations Labor
shouidou=atforthwit the ply with
Code, you moat forthwith comply with each proal Ione orth4 pertNt shall be
och provlonp Orth Is permit
deemed revoked.
Date Recei t#
NEW RESIDENTIAL PLMB. FT.
°�
-
TOTAL:
BUILDING
TOTAL:
SEISMIC FEE
. CONSTRUCTION LENDING AGENCY
I hereby affirm that there iso construction lending agency for the perform,
ance of the work for which this permit is Issued (Sec. 3097, Civ. C.)
Lender's Name
Lender'. Address
I cemlythatl have madthis appliationand gate thattheabove information
le cornea. l agree tocomply with all city and county ordinances and gate laws
ELECTRIC FEE
QTY. MECHANICAL PERMIT FEE
PERMITI.SSUANCE
PLUMBING FEE
MECHANICAL FEE
FEES PAID:
mating to building commuction, and hereby authorize representative, of this
city to enter upon the above-mentioned property for Inspection purposes.
(We) agree to save, Indemnify an d keep harmless the City of Ce pertirw
ALM OR ADD TO MECH.
Date RCCCI t#
P
SUBTOTAL'
agalvl BabNtlee, jadgmenh, mgsand expenses wMch may In anywayaccrue
again IF na,quenceof he granting of this permit.
^(I-
AIR HANDLING UNIT (TO 10,000 CFM)
AIR HANDLING UNIT (OVER IQ OOOCFht)
CONSTRUCTION TAX
ppllcant/Contractor Date
ExHAUS'T HOOD (W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT CFO 100,000BTU)
illtheappRuntorfumu Wildin8o pantstoreorhandle hanrdous
material as defined by the Cupertino Municipal Code, Chapter 9AZ, and the
Date Recei #
HEATING UNIT (OVER 100,000 BTU)
TOTAL
��
Health and Safety Code Section 25532(a)7
❑ Yes �i No
VENTILATION FAN (SINGLE RESID)
ISSUANCE DATE
A r
a V
Will the applicant or future building occupant use equipment or devices
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Mavgoomea District?
Yen ❑❑ No
BOILER -COMP ORP OR 100,000 BTU)
BOILER -COMP (OVER 100,D00 BTU)
have read the has .amaterials requirements under Chapter 6.95 of
the California Health k Safety Code, Sections 25505,25533 and 25534. 1
AUGY'1
NEW RESIDENTIAL MECH. SQ.FT
understand that ifthe building don not currently have a tenant, that It is my
responsibility to rally the occupant of the requirements which most he mel
prior to Lssuance of a Ccrtlfiam of Omn parry.
14
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/Sa7I[
S
Ui-I'UrctT
,"Ty
—
IV
ISSUED BY: I
Owrcr m authomxd agent Date
TOTAL:
OFFICE COPY