20017APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building ProjecI Identification
Bunching Addrna:
g35'0o C.aw-Li5o DR VWCvTS y 0 PF fQ
PERMIT NO.,
200
ane.
• if (t G-eaup
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BUfLDINGELECTIUCALI'LUMBINGMF HANICAL
AMIUCA71ON SUBMITTAL
6 —'z 8 -- S
Contractor'. Name: Lc. N.
CATEGORY
CONTROL. Y
ArehLLM/Engineer. I.ic.
6
�-�t�����
QTr ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
/' }{-C-
Address, &01 tt A�Tp bl SFir
❑ ❑ ❑
y�
PFRSMISSUANCE ZW
LICENSED CONTRACFORS DECLARATION
I hereby affirmthet l am licensed under provbaraof Cbapter9(commec
ingwlthSeci n7C=ofavWm3ofineBuMlrc dPmfe maCodgmd cry
license s In full force and dfesL
LicenseChs
Date Controntr actor
ARCHITECT'S DECLARATION
I understand my phvehall be used n public recvds
Licensed Professional
OWI am- a ptfroLDER DECLARATION
Thereby affirm tbatlam earmpt from the CoMractoh Lkerise law (w the
following mason.5trtIon 70715, Busin® and Profnsiona Code: My city or
county which requires a permit tomvtruct, alter, bnpmve, denvlbh orrepair
a nyatvtlunprbrmltatwuncgaborequlm cappb=tfor &pe to
Bk a signed entement that he b lla sed pursuant In the pruvlabm of theDATE
Contractors License Law Chapter 9(commencing with Section 70 W) of Dlvl-
s1cn3ofthe Business and Pmfesebv Cade)orthM he is exempt therefromard
the basis for the alleged uemptlan. My Nolatlon of Section 70315 by any
apph.t fora pemdt subjects the applkant to s civil penalty of not more than
five hundred dollars ($ W).
Fj I, a owner of the property, or my employees with wages as theb aok
mmpamudic , wOl do the work, and the wumnre is not Mended or offeredfor
oak 6ec 7064, Busimat and Pnefesl ms Code: The CoMnctoe. Llmve law
d.notapply town owner d property, who Wildsor Improves therem, and
does such work himself or through M s own employee, provided that such
Improvements are not Intended proffered fee sale. If, however, thebuliding or
Improve MbsoldwfthlnomyurofccmplNomtheowna UderwWhave
B"ardenof pmvingthe he did notbuud orlmpmvefepurposeofsale.).
L_I I as owner of the property, am exclusWely ®stracting with licensed
contncron to construct, the project(Sec. 7044, Buerm and Pmofesbm Code:
The Contractor's Liame law don out apply to an owner of property who
bu0da or improv. th., and who contracts f« auch pAojMs with a
«Wjactw(a) Licensed pursuant to the Contractors Lkxrue law.BACK
L.j 1 am uempt order Sec B k P C for this reason
APPLIANCES -RESIDENTIAL .-
LR-[2g O v�E
pX
I I
PANELS
UP T0200 ANTS
201-1000
OVER 1000 AMPS -
SQ. FT. FLOOR AREA
L 1E D IN
P U T E R
1"
$/SQ.FF.
SIGNSELECIWCAL
SPECIAL CIRCUIT/MISC
TEMP. METER OR POLE MSI'.
POWER DEVICES
SWIMMING POOL ELECTRIC
VALUATION
gyyyl.I.CI �SflXR1RF5 '
NEW RESIDENTIAL EISTR _SOFT'.
STORIES
'
TYPE CONSTRUCTION
TOTAL: 6
QTY. PLUMBING PERMIT FEE
OCC.GftOUP
RES UNITS
.
PERMIT L99JANCE
ALIFR-DRAIN &VENT -WATER (EA)
FLOOD ZONE
'
AI'N
- FEE SUMMARY
FLOW PROTECT. DEVICE
DRAINS FLOOR ROOF, AREA, GOND.
SANITARY Y N
RKEIvr /
Owner Dee
WOR KMAN COMPENSATION DECLARATION
❑T hereby a lrm that I have a certificate of consent to self-loVre, or a
m0
3800, Lab ,Lab of Workers Cwnpansatlonlrusuran. «a ¢rtifkd ropy Nrnrof (Sec.
C3
FTYTlJRES PER TRAP
SCI{ODI TA% Y_ N_
N Y
GAS EA. SYSTEM -1 WC40UTIE15
PAR%FEE Y_ N_
CAS F.A.SYSTEM-OOVER
Co
Co�mparay
DINREctGS IV
EIIILDING DI VISION 4'F.F.9
I ICenNed copy k herebyfurthe cit.
(/tJTP}`�_ .Ned copy la filed with the city lvpMbn division.
CERTIFICATE OP IXIT/PTION FROM WORKERS
COMPENSATION INSURANCE
section need nuthe completed If the pemdt b («cant hundmd dolWn
8110) or«f®J
le pemdt la boned,
I cent employ zany person In anf mew•wk mar s to become
1 ahe0 not empty any La w� f any manner n e to bemma sub}m to the
Wwken Compensation Ewa of California. Dale
Applicant
GRFASE/NDUSIRL WASTE INTERCEPTOR
PLANCHECK FEE '
PAID
Date RCCCI t#
CREASE TRAP
SEWEILSANITARYSIORM FA 2IMPT
WATER HEATER W/VENT/ELDCTR
ENERGYFEE Y N
PAID
Date Re i t#
WATER SYSTEM/1RF ATING
NEW RESIDENTIAL I'LMB. SQFI'. -
NOTICETO APPLICANT: If, after making this Certificate of Eaemo
ptlon, yu
should become subject to the Warken'Compewtlon pvvlsbns of the Labor
Code,yourfMhwthcomplywithouchproali«aorthbpert shank
deemed revoked. .
CONSTRICTION LENDING AGENCY
I hereby affirm that thereb a comtrodton knding agency for theperfomm
once o(the work forwhichthb permit is loved(Sec 309'7, CW. Q
L<rdee. No
Lenders Add ren
I ce.Ilytlut l have read thisapplication and etatethat theabove m(omutlon
Iamrrca. lagreetocomplywnhaBdtyandcountyordinancesandantebws
relating to bollding mrotiuctlan, and hereby authorlae represenntivesof thio
city to enter upon the above-mentbmd property for Inspection purposes.
(We) agrce to save, bdemnify an d keep harmless the City of Cupertino
agalrut liabilities, mets and expenses which may N anywayamue
agalmt said city In comequeore of the graMing or this permit.
-
TOTAL:
BUILDING FEE
SEISMIC FEE
TOTAL:
ELECTRIC FEE
Q Q
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
MECHANICAL FEE
PERMIT L9SUANCE
FEES PAID.
ALTERORADDTOMEC11
Date Recei t#
AIR ANDNG UNIT(TO 10,000 CFM)
HANDLING
SUBTOTAL:
AIR HANDLING UNTT(OVER 10,000 CFM)
CONSTRUCTION TAX
Signature of Applicant/Contractor Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant «future building occupant store or handle halardoua
material as defined by the Cupertino Municipal Code, Chapter 9.1 Z and the
Hearth and Safety Code Section 25533(m)?
Yes No
Will the apphant« tum boilding«cupant use equipment or devices
which emit herardoua air rontambunteas defined by the Bay Area Air
Quality Management District?
Y. No
have read the havmous materials requtmmenb u nder Chap ter 6.95 of
tkC.lifamb FleaHhkSafcty Cad,,Sectlov25505,25533and7S534.I
urdvnnrd that If the louddirgdoes not currently have aknant, that it la my
r.ponsMiry to notify the occupant d the requirements which me he mat
Prbr oLsuanaed a Ce.11.W&O —�_
E%IIAUSF HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HFATINC UNIT (TO 100,000 BT'(n
Date Recei O
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
�s
VENTILATION FAN (SINGLE RESTD)
ISSUANCE DATE
- �"ilL•
♦r?rIH
/M1P�'. •' J IJJV
'
�TyC'ts prf Cljneij^n
ISSUED BY: IXJCi�11', I,w— Y—✓1
BOILER -COMP (3FR' OR 100,0(1. BTL)
HOMER -COMP. (OVER 100,000
NEW RESIDENTIAL MEC}I. SQ.F7
-
ncr«sum«Ixdagent ate
D
TOTAL
OFFICE COPY