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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Profen identification
Building Ad a.:
PER.wT NO.
xa—
23225
nm. C eA
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CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BULDINGELECTRICAL-PLUMBING-MECHAMCAL
A A
connay�od.N me: Lic.No:
.30MZZ=
CATEGORY
CONTROL#
ArchI1M/Lngineer. Lic. No:
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Address
PERMITISSUANCE
El
LICENSED CONTRACTOR'S DECLARATION
I MrSectioi000).DiA.io3.fthunder provisions oftChapter
APPLIANCFSRESIDENTIAL
JOB DESCRIPTION
PANELS
..Cd(,..mc
l'ngwlthSMbn 7000).( Dlvislon3ofthe Businessand ProlesslonsCode,and my
icense I In to o I'd affect 77'�
LlcenseC ss LIc. M„�]�
>a
`LSV\
Date' Contractor
`
701-IODOAMPS
ARCHITECTSDE IARA
I understand mry pbru shallbe used as public records.
OVER 1000 AMPS
SQ. FT. FLOOR AREA /SQ. Ff.
SIGNSELRCTRICAL
Licensed Professional
i\9{��AAp LED 9
SPECIALCItCUIT/ME3C
OWNER -BUILDER DECLARATION
I hereby affirmthat I am exempt fromthe Contractor's License Law for the
,V, P U E
TEMP. METER OR POLEINST.
POWER DEVICES
following reason. (Section 70D5, Business and Professions Code: Any city or
muntywhichrequbeapermitbmmtmd,alter,impmve,demolbh,orrepair
anystruct re imarto its lsataance,also aequirestheapplicant for such permit to
Ole a signed statement that MIs licensed pursuant to the provisions of the
(/ 6
T6 of
—I
SWIMMING POOL ELECTRIC
Contractor's License Law (Chapter 9 (commencing with Section 7000) of Divi-
sion3.f the Business and ProfessionsCods) orthat he is exempt therefrom and
VALUATION
the basis for the alleged exemption. Any violation of Section 70115 by any
applicant fora permit subjects the applicant to a civil penalty of not more than
OUTLETS-SWITCHESH%TURES
five hundred dolls. ($500).
M 1, as owner of the Property, or my employees with wages as their sole
NEWRFSIDENITALELECTR SQFT.
STORIES
TYPE CONSTRUCTION
compensation , will doth work, and the structure Isnot intended or offered for
sale (Sec. 7064, Businessaha Professions Code: The Contract.(. License Law
does nes apply to an owner of property who builds or improves thereon, and
whodoessuchworkhimseUorthmigh Msownemployces, provided that such
OCC.GROUP
RFS. UNITS
TOTAL:
improvements are not intended oroffered for.ele. IL however, thebuilding or
improvement bsold withinoneyearofcompldion,theowner-bulMerwlll have
itrden of proving that he did nes build or improve for purpose of sale.).
tyI, a. owner of the property, am exclusively contracting with licensed
contractors to construct the pmjed (See 70K Business and ProfessionsCode:
QTY. PLUMBING PERMIT FEE
FIAODZONE
APN
PERMIT ISSUANCE
The Contractor's License law does net apply to an owner of property who
builds or Improves thereon, and who contracts for such p(ajects with a
Mlicensed pursuant to the Contractor's License Law.
al
LJ I am exempt under Sec. B & P C for this reason
ALTER -DRAIN &VENT -WATER (FA)
FEE SUMMARY
gACg FLOW PROTECT. DEVICE
OUTS] DF FELS
DRAINS FLOOR ROOF, AREA, COND.
SANITARY Y N
RFCEPTN
Owner Data
WORIONAN COMPENSATION DECLARATION
❑I hereby affirm that I have a certificate of consent to self -Insure, ora
mdiflateof Workerd Compensationlnsuranremamrtifiedmpythereof(Sec.
Lob C)
lit.
pD(NRES PER .IAAF
SCHOOLTAX Y N
RECEIPT B
GAS EA, SYSTEM -1 INC.60UTLETS
PARK FEE V N —
RECE3800,
I'ollryp
Com anv
IrLt�,ed.
GAS EA. SYSTEM-OVER6(FA)
DING DTR
BUILDING DIVISION FEES
GREASE/INDUSIRL WASTE INTERCEPTOR
PLANC IECK FEE
certined p Is re
CertlOed copy b flied with the city InspMlon dh I.I...
GREASETRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
PAID
COMPENSATION INSURANCE
(ThbsMion need nes be completed if the permit is forone hundred dollar
SEWER-yVM.1.ARY-yTOgM FA POET
Date Recd ted
WATER HEATER W/VENT/ELEGTR
ENERGYFEE Y_ N_
($IW)orless.)
I comlythat in the performance of the work for which this permit b issued,
WATER Sl'SIFN./TREATI N'G
I shall not employ any person in any manner so as to become subject to the
Worker Compensation Laws of California. Date
PAID
NEW RESIDENTIAL PLMB. SQ.FT.
Applicant
NOTICE TO APPLICANT: If, after nuking this Certificate of Exemption, you
should become subject to the Workers' Compensation provlalav of the Labor
Date Remi I#
TOTAL:
BUILDING FEE
Code, you must forthwith comply with such provisions or this permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
SEISMIC FEE
TOTAL,
ELECTRIC FEE
I hereby affrmthat there b a construction lending agency for the perform-
anceof the work for which this permit b issued (Sec. 3097, Civ. C.)
Linder'. Name
Lender'. Address
Icertlfythat l have read this application and stmmhatthe above Information
is correct. la to omply with all city and county ordinances and gate laws
PLUMBING FEE
QTY. MECHANICAL PERMIT FEE
MECHANICAL FEE
r�
/ PERMIT ISSUANCE rl
FEES PAID:
relating to ildln construction, and reby authorize representatives of this
dtytoen . heabove-menti. ropertyin' WpMbnpurpose.
(We) agree .ave, Indemnify keep harMess the City of Cupertino
agalnstllab e, pd rent met n expenses which may in anywayaccrue
AL7E2ORADDTOMECH.
Date Receipt#
AIR HANDLING UNIT (IO 10,000 CFM)
SUBTOTAL:
against ui Byln ce ( granting of thio pemnIt.
' (J
/
AIR HANDLING UNIT (OVER 10,010 CIM)
CONSTRUCTION TAX
Signaturi o(AppEam/Contractor Date
E%HAusr How (W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous
I HEATING UNIT (TO 100,000 BTU)
Date Recel t#
material as defined by the Cupertino Municipal Code, Chapter 9.1 7, and the
I lealth and Safety Code Section 2S533(a)?
n YeM No
HEATING UNIT (OVER 100," BTU)
TOTA
VENA IATION FAN (SINGLE RESID)
ISSUANCE DATE
Will the a ppiicant or future building occupant use equipment or devices
which chat hazardous air contaminants as defined by the Bay Area Air
Qua hMa ragereent District?
Yrs No
BSl A
P PY 8ty
BOILER-COMP(3HP OR 100,0(0 BTU)
BOILER -COMP (OVER I W,WO BN)
have read the haze ous materials requirements under Chapter 6.95 of
the Caufcrnla Health&Safety Code, Sed ions 25505, 7sSt3 and 75534. 1
understand that if the building does nes currently have a tenant, that It is my
7{1V1 gn(Ia)
��•_ �� 1x992
NEW RESIDENTIAL MECH. SQFf
responsibility to notify the occupant of the requirements which must be met
prior to isauance of a Certificate of Occapanry.
. a^/
'I Ur i:UPtnunu
ISSUEDBY. /lis/1/1
a'-----a�1
Owner or authorized agent Data
as=S4 F
TO
OFFICE COPY