23645APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Project Identification
Building Address:
PELMITN'O.
10-3ke$ D
236 4
wiV Wils,1DOOL4` inane:
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
n AL VA IE
J L
Contractors Name- Lie. Net
O W
BL7LDING-ELECTRICA PLUMBING -MECHANICAL
CATEGORY
CONTROL #
Architect/Engineer. LI, No:
.... . , ..r .. µ .. .. -. ..
,Qrt,t ., t sELECTRIC PERPoIIT ;•� ,' � , "FEE �-'
- 'BUILDING PERMIT INFO -',:= <;'
Address:
PERMITISSUANCE ��
J
❑ Y ❑ ❑
R
LICENSED CONTRACTOR'S DECLAATION
I hereby affirm that l am B[ensM under provisions ofChapter 9(commere
N7PUANCFS-RE5IDENIAL
JOB DESCRIPTION
rANfES
in in,ei in fall force d Division 3o(the BusinessandProlessionsCode,acid my
license Is in full force andc.
License Cl.. N
UP TO 209 AMPS
N
Date CControntiactor—
201-1OW AMPS
AACHITECPS DECLARATION
I understand my plans shallbe used as publicrcmrds
OVER I()X AMPS
SQ.FT.FLOORARFA
S/SQ. FT'
SIGNS ELECTRICAL
Licensed Professional
SPECALCIRCUI7/NLSC
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
TEMP. METER OR POLE INST.
following reason.(Section7MI5, Businessand Professions Code: Anycity.r
countywhich requires a permit reconstruct, alter, improve, demolish, orrepair
anystm=mpr rtolb Issuance,alsorequimtheappecantforsuNpermftto
file a signed statement that he is Breneed pursuant to the provisions of the
POWER DEVICES
SWIMMING POOL ELECTRIC
Contractor's License Law (Chapter 9 (commencing with SeeHen 7000).( Divi-
slon3 olthe Businessand Professions Code) or Nat he Is exempt therefromand
VALUATION
basis for the alleged exemption. Any violation of Section 70315 by any
tapplicantfora permit subjects the applicant to a civil penalty of not more than
OUTLETS -SWITCHES -FIXTURES
five hundred dollars($500).
�¢jll4 as owner of the property, or my employees with wages as their sole
NEW RESIDENTIAL ELECTS SQFT.
STORIES
TYPE CONSTRUCTION
mppensatfon, will do the work, and the stru mem u not Intended or offered for
k (Sec. 7044, Business and Promse iom Code: The Contractors License Law
T
does not apply to an owner of property who builds or imprmm themen, and
does such work himadforthrough his own employees, provided that such
improvements are not intended oroffemd foraale. If. howevemthe building or
OCG GROUT'
RES. UNITSwho
improvement usoldwmhinoneyearofcompletion, the owner-builderwdl have
trys$nellen of proving that he did not hued or Improve for purpose of sale)
contractor to rammed the project (Sec. 7014, Business and Professions Coder
LJ L as owner of the property, am exclusively contracting with licensedgAL=-DRAIN
The Contractor's License Law does not apply to an owner d property whoN
Wilds or Improves thereon, and who contracts for such Ptoje sta with a
Bcanaed pursuant to the Contractor's License Law.
u I am exempt under Sec B & P C for this reason
-
QTY. ,-PLUMBIN G PERMIT -r. .v *j'FEE `=
FLOODZ
APV
ANCE
& - hTEi (EA)
y
Z,6t,actor(a)
PROTECT. D CE
-OUTS] DE FEESOwner
OR ROOF, A COND.SANITARY
ERTRAPI L)NlG
RE�ID'I pWORKMAN
Date
COMPENSATION DECLARATION
hereby affirm that I have a certificate of consent to self -Insure, or a
tertillcste ofWorkx Comperxdtlon Wurance ora certified copy thertrofexec.TEh1-1P
3800, Lab G
OOL TAX- N_❑1
RECET T N
UTLETS
PARK FEE Y N
RECEE'C p
Com N
Com any
GAS EA. SYSTEM -OVER
BUILDING DIVISION FEES
died copy Is hereby furnished.
F-1 Certified copy is filed with the city Inspection division.
GREASE/INDUSiRL WASTE INTERCEPTOR
PLANCHECKFEE
GREASE TRAP
CERTIFICATE OF IXEMPTION FROM WORKERS'
PAID
SEyyER-SANITARY-STORM EA 2WFr.
COMPENSATION INSURANCE
(Thissectlon need not be completed B the permit Is forooe hundred dollars
($100)or less.)
I cartify that in the performance of thework fmorhich this permit Is Issued,
Date Real t#
WATER HEATER W/VENT%ELECTR
ENERGY FEE Y_ N_
WATER SYSTEM/TREATING
I shall not employ any person In any manner so as to become subject to the
Worken'Compe.sztionlawsof California. Date
Applicant
PAID
Date Recti t#
NEW REIDEMTALPI-MB. SQFT.
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you
should become sub)# to the Workers' Compensation provisions of the Labor
TOTAL:
BUILDING FEE
Cada you must forthwith comply with such provisions or this permit shall be
SEISMIC FEE
deemed revoked.
CONSTRUCTION LENDING AGF CY
TOTAL:
ELECTRICFEE
I hereby affirm that there Is a construction jendlngagenry forthe perform
ante of the work for which this permit b, Issued (Sec 3097, Clv. CJ
Lender'a Name
Lender's Address
PLUMBING FEE
QTY. C n MECRANItAU'PERMIT... " ..' FEE'_
MECHANICAL FEE
I mrtlfythatl have readthleapplicationand statethatthe above Information
bmrmct. I agreeto comply with all city and county ordinances and state Paws
PERMIT ISSUANCE
FEES PAID:
ALTER OR ADD TO MECH.
rehttng to building consmuctton, and hereby authorize representatives of this
city to enter upon the atwemtentioned property for Inspection purposes.
(We) agree to save, indemnity and keep harmlm the City of Cupertino
against liabilities, judgment, mite a and expenses which may In anywryaccrue
Dale Receipt#
AIR HANDLING UNIT (TO 10,000 CFM)
SUBTOTAL:
AIR KANDE NGIMR(OVER 10,000CIM)
CONSTRUCTION TAX
againstsailfityinconsequene fthegrantingo hlaperrt'
EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
Sigtihimof AppBcant/Contractor Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfuture building occupant store or ha fid le hazardous
Date Recel t#
HEATING UNIT (TO 100,OW BTU)
-
material as defined by the Cupertino Municipal Code, Chapter 9.1 2, and the
Health and Safety Code Section 25532(a)?
❑ Yes M No
Will the applicant or future building occupant use aqulpnment ordevices
which emit hazardous air cora morsels as defined by the Bay Area Air
Quality Management District?
Ycs No
have read the Nazar ease matcriaLs rcqulrcments under Chapter 6.95 of
the California I Ic.1th & Safety Code, Sections 25505, 25533 and 2-55M. I
understand that it the building docs not currently have: teranl thatitIs my
responsibility to notify the occupant of the requirements which'. tbemet
prior to Lssuancc ofaCerti(i<ue o(Occvpanry.
HEATING UNIT (OVER IM(Ml BTU)
IOTA
VEN ILATION FAN (SINGLE RESID)
ISSUANCE DATE
Z'
�1
,(lrj'J
rr/y rJr JJJ[, /w\
'„(J/] �J
BOILER -COMP QHP OR IOQDW BTU)
BOILER -COMP (OVER 100,000 BTU)
NEW RESIDENTIAL MECIL SQ.FI
illy
ISSLTiD BY: \ls�sa/l
Owner or authorized agent Date
TOTAL:
OFFICE COPY