22766APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Pro'eat Identification
Buildin Address:
l�
PERMITNO.
- 22766,
ne.
w,� acre: ^^
%�t oCJT'4-41—zu
CITY OF CUPERTINO-BUILDING DIVISION
.APPLICATION / PERMIT
BUILDINGELECTWCAI.PLUMBINGMECHAMCAL
p p IL
CIV d r'sName:
CATEGORY CO OL M
BUILDING PERMIT INFO
Arohlted/Engineer, Lic. No:
QTY ELECTRIC PERMIT FEE
Address .
PERMIT)SSUANCE
❑ 1:1 ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby afflrmthat lam Bcrnsed underprov3slone of Chapter9 (mmmene-
ingwlth Sedl 7000)of Division 3o( eBusimm dProfesslons Code, and my
license is In (uljw[Cpnd effect.
License eA--�L1U LIc.N
Date Contndor
ARCHITE 5 LARATION
I understand my phns ehallbe used mpubtic records _
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
following resson.(Section 7031.5, Business and Professions Code: Any city or
county which requiresa permitmoom4md, alter,improve, demoll,h, orrepalr
anystmd mpriortoibbwancgil mquirestheappllcantforsuchper tto
file a signed statement that he Is Bcensed pursuant to the provislom of the
Contractors License Law (Chapter9(mmmencing with Section 7000) of Divi-
alon3 ofthe Business and Pmfessfuns Code)orthat he is exemp therefromand
the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subject, the applicant to a civil penalty of not more than
five hundred doll.. ($500).
❑ I, as owner of the property, or my employees with wages as their sole
compensation, will do the work and the strucWre b cwt intended., offered for
sale (Sec. 7044, Business and Professions Code: The Contractors License Law
does not apply to an owner of property who build, or improves thereon, and
who does ouch work himself or through his own employees, provided that wch
improv=re are not Intended oroffered forsale. If, however, lhebuilding or
Improvement usoldwithlnoneyearofcompletion,the owner-bullderwill have
tIU,(urden of proving that he did not build or Improve for purpose of sale.),
L,J L as owner of the property, am exclusively contracting with licensed
to construct the project (Sec. 7044, Business and Professions Code:
The Contractor's License Law does not apply to an owner of property who
Wt
builds or I.P.Improve, thereon, and who contracts for such pgojeda with a
co,D.ty'+dor(s)1lcensedpunuanttothe Cmtmdorb Lkenx Law.
LJ I am exempt under Sec B & P C for this reason
APPEANCESRESTDEN7IAL
JOB DESCRIl'IION
J
PANELS
W1'1�AMPS
OVER 1000 AMPS
SQ. FT. FLOOR AREA
1f��... A'
��, !',� ® I ■ -
1
T F.
as
`f/
$/SQ. FT.
SIGNSELECTRICAL
SPECIALCIRCUTE/M
IFMA MEITROR LEINST.
n all
POWER DEVI
SWP{MI POOL ELECTRIC ATE
OUTL SW3TCHESEXTURFS
ATIO
RESIDENTIAL ELECTR SQ.FT.
STORIES
TYPECONSTRUCTION
TOTAL:
QTY, PLUMBING PERMIT FEE
pptM)T ISSUANCE
-DRAIN & VENT WATER (BA)
OCC.GROIIia
RES. UNITS
FLOOD ZONE
APN
FEE SUMMARY
BACK FLOW PROTECT.DE'NCE
OUTSIDE FEES
DRAINS FLOOR A, ROOF, ARECOND
FIXTURES PER TRAP
SANITARY Y_ N_
RECEIPT #
Owner Data
WORKMAN COMPENSATION DECLARATION
hereby affirm that I have a certificate of consent to self -insure, ora
m iflcateofWorkem'C,omple /m�atlpa�nlmuran ora certlfkd mpythemof(Sec.
PoIcy,b C.) 02 WCC-2.��.
Com any
Certified copy) k heed with t ecity
ertBietl copy U (fled with the city Inspection division.
7777 CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Ihlesection need not be completed if the permit Isfor one hundred dollars
($100)orlessJ
( certify
mplo any he nce of In
the forwhkhthbpermit bbo ed the
I shall not employ any person In any manner w m m become subject to the
Workers'Comperuation Lawsof California. Date
Applicant
NOTICETO APPLICANT: If, after nuking this Certificate of Exemption, you
should become subject to the Wmkeri Compensation provisiom of the Labor
Code, you most forthwith comply with such provisions orthis pernotshall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
Ihembyaffirm that there is a comtrudion lending agency for the perform
ance of the work for which this permit 1. issued (Sec.3097, Civ. C.)
lender's Name
Lender's Address
I cer ilythatl have read thisapplicationand statethattheahove infamous.72
Iscorredce
. Iagreetocomplywithallcityand cuomyordlnan, and state laws
relating to building construction, and hereby authorize representativ.......
dtytoenterup theabave-mentlonedpmpertyfwimpedionpurpows.
(we) ogre save indemnify an'keep harMess the Cityof Cupertino
agalnathabil e' t.,rmh..nd expenses hick may In yway cove
against said Ity o u n ( anting this perrr3lt ^ /
1166// .%/�
SCHOOL TAX Y_ N
RECEIPT M_
CAS EA. SYSTEM -1 INC. 40 EI5
PARK FEE Y N
RECEIPT A
GAS EA. SYSTEM-OVE (EA)
BUILDING DIVISION FEES
CREASE/INDUS fR ASIEINTERCEPTOR
PLANCHECK FEE
PAID
Date Rece3 t#
71
GREASETRIP
SEWER -Sp ARY-BTORMEA 200FT
WA TER W/VENT/ELBCTR
ENERGY FEE Y N
PAID
Date Recel t#
ya SYSTEM/TREATING
RmDENDALPLMB. SQFr.
TOTAL:
BUILDING
TOTAL:
SEISMIC FEE
ELECTRIC FEE
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
MECHANICAL FEE
PERMIT ISSUANCE ,5
FEES PAID:
,
ALTERORADDTOMBCH.
Date Receipt#
AIR HANDLING UNIT (3010,000 CFM)
SUBTOTAL;
AIR HANDLING UNIT (OVER 10,000 CFM(
CONSTRUCTION TAX
Signature of Applicant/Contractor Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous
material as defined by the Cupertino Municipal Cade, Chapter 9.1 2, and the
I -lea lth and Safety Code Section 25532(a)?
7411 t --F-1 Yes M No
Will the applicant or foram building occupant use equipment or device.
which emit hazardous air contaminants as defined by the Bay Area Air
'Quality Management District?
Yc, Q1�j No
have read the hazar•Tno material. requirements under Chapter 6,95 of
the Celifomla Health & Safety Code, Sections 25505, 25533 and 25534. I
u orients cad that if the building doe, not currently have a tenant, that it is my
responsibility to not ify the occupant of the requlramcats which moat be met
prior to issuance of a Certificate of Occupancy.
EXHAUST HOCH(W/DUCT)
CONSTRUCTION TAX PAID:
HEATING UMT(T0100,000 BI1n
Date Reeei t#
HEATING UNIT (OVER IDOp00 BTU)
TOTAL
-
VENTILATION FAN (SINGLE RESID)
PIKICBDATE
IY F4 U IU'
�9U 9 1991
CITY UF CU�tI-iIIIVV
ISSUED BY:
BOILER -COMP QHPOR 100,000 BTU)
BOILER -COMP (OVER 100,000 BTU)
NEW RESIDENTIAL MECH. SQ.FT.
Owner or authorized agent Data
TOTAL:
OFFICE COPY