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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Proed ldeNlOcalfon� K J� } r
Building Ad 9.��Fr 4 r Y els v/
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PERMIT NO
. j^{
Y 0. 8 3 3 '
nere ams:_15 '17-05,076CCITY
OF CUPERTINO-BUILDING DIVISION,
APPLICATION/PERMIT
BUILDING -ELECTRICAL PLUMBING -MECHANICAL
Co ractor's,Nlva/ :� , Lie INo:
CATEGORY
CONTVII/a �_ xis
Ar Zy�,ic. No:
QELECTRIC PERMIT FEE
TY
BUILDING INFO
�„I
G/V
Address: � 7
`PERMIT
PERMITISSUANCE
LICE.NSEDCONTRACTOR'SDECLARATION
]hereby affirm that l am licensed under provisions of Chapter9(mmmenc
ingwith Sedion70W)mD1vikoa3 ofthe BusinessandPrafessionsCede,and my
license la In full force and affect
APPUANCFSRESIDENTIAL _
JOB DESCRIPTION
n /� �• ���` d��
PANELS-
Licence Class Lic. p �
Dale - Cordractor
ARCHITECTS DECLARATION
I understand my plans shall be used n public records.
Licensed Professional',
aa��
.. e_0 U Q't
201-1000 AMPS
OVFRIODOAMPS
SQ. FT. FLOOR AREA
Q
14, 2V
/�$/SQ.FL
SIGNSELECTRICAL
SPECIALCIRCUIT/MLSC
' ,OWNER -BUILDER DECLARATION, -
I herebyaffirenthat i am exempt fromthe Contractors License Law forthe
-
_
TEMP MEITR ORPOLE INST.
following reason. (Section 7031.5, Business and Professions Code: Any city or
county which requires a permit to construe, alter, Improve, demolish, or repair
-
any aructure prior toits lasuance,also requires the app8nnt for such permit to
file a signed statement that he is licensed pursuant to the provisions of the
POWER DEVICES
SWIMMING POOL ELECTRIC
'Contractor's License Law (Chapter 9(conmiencing with Section 7000)of Divi-
sloa3 ofthelhudeeae and Profession Code) orthat he iaexempttherefromand
VALUATION!
the basis for the alleged exemption. Any violation of Section 70315 by any
apphcant fore permit sublamthe applicantto a civil penalty of nor more than
OITILEISSWHCIIFSHXTURFS
- '
five hundred dollars ($500).
❑ L as owner of the property, or my employees with wages as their sale
rompensatimwllldothew k,andthesimd misnaintendedor offered for
NEW RESIDENTIAL ELECTR SQ.FT.
7IX&
STORIES
���'P ECON$7 $UCTION
F� 4 ;S 2G
H
sale (Sec. 70K Business and Professions Code: The Contractors Litems Law
does not apply to an owner of property who Wilde or Improves thereon, and
whodoesauch work himeelforthrough his own employees, provided that such
Improvements arenotintended oroftered forsale. 11,however,lhebulldingor
OCG GROUP
IS UNITS
TOTAL: 3306
Improvement Is sold within one yearof completion, the owner-builderwlll have
the nrden of proving'that he did riot build or improve for purpose of sale.).
u L as owner of the property, am exclusively contracting with licensed ."m
contractors to contruct the project (Sec. 7044. Business and Profeelam Code:
'
QTy, PLUMBING PERMIT' FEE
FLOOD ZONE
APN
ISSUANCE
- l ria
The Contractor's License Law don not apply to an owner of property who
Wilds or Improves themes, and who contracts far such paojeae with a
c,,6at{ etor(O licensed ponuent to the Contractor. Lcense Law.
LJI am exempt under Sec: 8 & P C for. this reawn
ALTER -DRAIN &VENT- WATQ4lEA)
FEE SUMMARY
BACKFLOW PROTECT. DEVICE
OUTSIDE FEES
DRAINS -FLOOR, ROOF, AREA, COND.
SANITARY Y_ N_
RECEIPT
Owner - Dae
WORICHAN COMPENSATION DECLARATION -'
❑( hereby affirm that I have a,cerdflcete of consent to self -Insure, ora
certificate of Workers'Compereationlnurance or a certified copy thereof (Sec.
3800, Lab C.) -
F0(NRES PER TRAP
SCHOOL TAX 'Y_ N_
RECEIPTV_
GAS F.A. SYSTEM -1 INC.4OUTLETS
PARK FEE Y ,N
PT
RECEIPT p
Policy If
Co any >
GAS F.A.SYSTEM-OVER 4 (EA)
- -BUILDING VISION FE ES'
Certined copy is filed w tamished. city
�CertBied ropy is filed with the cttyirupection division
r CERTInCATEOFEXEMPFIONFROMWORKERS'
GREASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE
,9J
PAID '
GRE -ASE TRAP
SEWER -SANITARY -STORM EA 200Ff
COMPENSATION INSURANCE
(Hit ... diov need not becompleted lithe permit is forone hundred dollars
($10()orlea.)
I certifythatin<he penormanceo(the work (orwhlcfi this permit is blued,
Date - Recei [
MATER BEATER W/VENT/ELEC7R
ENERGYFEE Y_ N_ G. 7,0
.
WATER SYSTEM/TREATING
I .haH not employ any person In any manner so as to become subject to the
• Workers Compensation Laws of California. Date
PAID /y
Applicant -
NEW RESIDENTIAL PLMB. SQFT.
Date Re t#J
NOTTCETO APPLICANT: If, after making this Certificate of Exemption, you
should became evbfectto the Workeri Compenatlon provisions ofthe Labor
Code, you must forthwith comply with each provisions orthis permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
Iherebyaffirmthat there is a mstruction pending agency for the perform-
anon of the work for whlchthes permit is Issued 05w. 30W, Civ.C.)
Lender's Name
Lenders Address
lmnlfythatIhavereadthsappecatlonan katethattheabove in forrruHon
Iscorreci agree to comply with all cityand countyordlnanceserd statelaws
TOTAL: 8 �-
21 (15
BUI 'E q ,�
SEISMIC FEE
TOTAL: a] (Z
3
ELECTRIC FEE s�
PLUMBING FEE
QTY. MECHANICAL PERMIT
MECHANICAL FEE C�O
.•FEE
PERMITIRsUANCE .Y,�
FEES PAID: '
relating to building construction, and hereby authorize representative of this
city to enter upon .above-mentioned propenyforimpenknpurpoxea.
Me) agree to ve, indemnity and keep harmless the City of Cupertino
agaimtliabiut '. dgmean, costs and expenses which may in anywayamme
Date Receipt#
ALTERORADDTOMECH.
AIR HANDLING UNH (TO 10,000 CFM)
SUBTOTAL:
against Bald Ci In mneequence of the granting of this permit
MR HANDLING UNIT (OVER 10,000 CPDD
CONSTRUCTION TAX
Si��pl�nC/Contractar • Date Date
EXHAUSTHOOD(W/DUCA
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
the ppllcantorfuture building occupant store or handle hazardous
Date Recel t#
HEATING UNIT (TO 1 M,00081” -
materia de fined by the Cupertino Municipal Code, Chapter9.lZ and the
Health and Safety Code Section 75532(a)?
❑ Yrs r! No
Will the applicant or turn building occupant use equipment or devices
HEATING UNIT (OVER 100,000 BTU)
TOTAL: 1
VEMIILATION FAN (SINGLE REBID)
- ISSLI940JWTE
which and hazardous air contaminants as defined by the Bay Area Air
Quality Management District?
4YesNo
haveread the haxaQ Amaterials requirementsunder Chapter 6.95of
SEP 13 1990
BOILER -COMP AHP OR 100,0(10 BTU)
BOILER-COMP(OVER 100,000BTU)
the Calife role Health & Safety Code, Settlors 25505, 25533 and 25534. 1
understand that ltthe building does not Currently have atenangthat it is my
responsibility to notify the occupant of the requirements which must be met
priortolss anceofa Certlficateof Occupancy.
,,��,�4
_
PRY
NEW RESIDENTIAL METH. AFLriltyF•QIIC9)���
ISSUED 9Y: Nie.%
Owner or authorized agent Data
a
TOTAL:
OFFICE COPY