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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Ym'ed Identification LOT 3
Building Addau:
e -� PI ni t �a,��'� G ,�� e ��
PERMIT NO. 175 3
neva ams: one:
('LiMrGQ-,moi �j-N•u� int_. 5C\$-Ztoo
CITY OF CUPERTINO-BUILDING DIVISION
- APPLICATION / PERMIT
A A A
— Z — C
Conlractoes Name: Lie. Nes
G C4 t
- BUTLDINGELFGIRICALPLUMBINGMfECHAMCAL
CATEGORY CONTROL N
Architect/Fsglnnr. Lk No:
S `•- fo. 'LPC a--\
QTY ELECTRICPERMIT FEE
BUILDING PERMIT INFO
Address:
1-A
�1
PERMIT]%UANCE
LICENSED CONTRACTOR'S DECLARATION
I Habyi70 that lama.A3 dunder pnwi.nd olChapter9(mmmm
lice with Section 7000)of Dlvlelon3 ofthc Buslnevand ProlessloneCody+nd my
license le In a fa d affect.
Cuss_ ,LION l-4�C�0��-
APPLIANCES -RESIDENTIAL
JOB DESCRIPTION
S 1- O
• PANELS
Dance
Data Contractor
IM TO 200 AbQS
201-1000 AMPS
ARCHITECTS DECLARATION
I understand my plans shall be used as public records.
OVERI"AMPS
SQ. Fr. FLOOR AREA
S/SQ. FT.
SIGNSELECTRICAL�
Licensed Professional
q q S
SI'ECIALCIRCUIT/M15C
OWNER -BUILDER DECLARATION
I hembyarBrmthat i am exempt from the Contractor's License LAW for the
m
following reasen.(Sood.n7WIS, Rinesiand Profesebna Code:AnyntyM
countywhich requires a permit tocomm ct, alter, Improve, demolish, ormpalr
LlJ
kz'U-L ED
TEMP. METERORPOLE INST.
any strueu re prior to its Issuance, also requires the applicant for such permit to
file a signed rtatrmam that he is Bansed pursuant to the provubrs of the
POWER DEVICES
SWIMMING POOL ELECTRIC
Contranoh License Law (Clupler 9(commencing with Semon 7000) of Dlvl-
sbn 3 ofthe Bidets. and Immaalons Code) Mthat hely exempt thercfmmand
VALUATION
d exemption. Any violation of Sen 7031.5 by any
the Hsu for the allegenb
applicant fora permit subjects the applicant to a civil penalty or no rnoethan
OUTLETS-SWIICRE -FUTURES
^
1 (.� -2v'S '1 C1
NEW RESIDENTIAL ELECTR SQFP,
five hundred dollarsofthe pro employee with wages a thele sole
❑Las owner of the property, or
STORIES
TYPECONSTRUCTION
compensation, will d he intended or for
the work, and ihestmds:
BusinessThe Ct
ando
alnow and Professbns Code: The License
Llaron law
(AM
doed
or improves
don not apply to an owner of property who builds or improve thereon, and
app). to
who doeseucM1 work himself athrough his own emplgee, provided that such
OCC, GROUT'
RES. UNITS
improvements arc not intended oroffemd forsale. If, however, thebuilding or
TOTAL:
improvement umld within one yearofcompletbM the owner-Wilderwill have
lh rden of proving that be did not build or improve for purpose ofsals.).
L as owner of the property, am exclusively contracting with Bansed
contractors to construct the pmjcd(Sec. 7044, Business and Professions Code:
QTY, PLUMBING PERMIT FEE
FLOOD ZONE
APN
PERMIT ISSUANCE
The Commotors License Law does not apply to an owner of property who
builds or Improves thermrt and who contracts for such prpjrcts with a
c9alE+ctor(s) Hormed pursuant to the Contr+ctors License Law.
U I am exempt under Sec. B & P C for this reason
ALTER- I A
BACK P
FEE SUMMARY
OUTSI DE FEES
DRAIN
SANITARY Y_ N_
RECEIPTN
Owner Date
WORKMAN COMPENSATION DECLARATIONFIX
❑I hereby of i. that 1 have a certlBate of consent to self -insure, a a
to ifiateofworY Comperuationlnsuranamaartifiedmpytheeof(Rec.
3800, Lab C.)
Policy I
/"//1 /
TOOL TAK Y_ N_
RECEn r I
GAS LA.SYSTFM-1 INC.40UlT.ETS
Tg Y N
RFCF3PTI
CAS FA. SYSTEM -OVER 4 (EA)
Ce ansa l t� ^.E PC.L Fsr
B UILDING DI VISION FE ES
ECertlfled copy u heebyturnuhed.
i� c,Ailed copy ufiled With the my Inspection division. �T•
GREASE/INDUSTRL WASTE INTERCEPTOR
PLANC14ECKFEE
I GREASE TRAP
CERTIFICATE OF Ei(EMITION FROM WORKERS'
PAID
COMPENSATION INSURANCE
(1'Msneed nnorbe compacted lithe permit uforonshundred dollars
Date RCCeI [#
IS.50
SEWER -SANITARY -STORM EA. 20oFT.
W,A,1.ER�,�W/YEN./E.E_.R
ENERGYFEE Y N
a1 N)afessIcas.) 3 I
lanot that an tm cb penNtbuued,
WATER SYSTEM/TRLATINC
anyhe
emin ploy person i
1 .r1uhall not employ any person m any runner m u to become subject to the
mannworker sc, as t co
Workers' Compensation IAws el Cali(arnl+. Data
PAID
Appliant _ rv.ase
Date Remi t#
NEW RESIDENTIAL pLMB. gQ FT.
NOTICETO MPLIC¢NT: If, after ng this Certificate of Exemption, you
-
TOTAL:
should become subFn to the WCrken Comprruatlon pmvuionsof the Labor
Code, you nest forthwith comply with such provisions orthu permit shall be
dremad revoked.
vo
CONSTRUCTION LENDING AGENCY
BUILDING FEE
9l2 u u
SEISMICFEE
,
73.15
I heebyafgrenthat there is amnstrunlon lendingagency forthe perform,
anaoflhe workforwhichthts emit is issued (Sec. 3097, Civ. C.)
Lender. Namep) �[•.
Lenders Addau
I artilythat I have read thuappliation and stmethatthe above Information
is mrnxl. lagree to comply with all my and countyardtn+nasint state lawn
TOTAL:
ELECTRIC FEE
13.. ?'
QTY. MECHANICAL PERMIT IEE
PLUMBING FEE
MECHANICAL FEE
—7 5, t 3
PERMIT ISSUANCE
FEES PAID:
relating to bullding construction, and hereby authorise rtpresemstwas of the
city to enter upon the above-mentioned property for inspection purposes.
(We) ages to save, Indemnify an d keep harmlem the City of Cupertino
ALTEtORADDTOMECH.
Date Reeei [#
P
SUBTOTAL:
against liabWlee,/rdgmenta,consand a.,rc swhicE mayln anywayamue
against said City in consequence of the granting Militia permit.
AIRIEANDLING UNIT (TO 10,0)0CFhI)
AIR HANDLING UNIT (OVER 10,000CI1,I)
CONSTRUCTION TAX
signature of 1Ate
EKI3ADST HOOD M(W/DUCT)US
CONSTRUCTION TAX PAID:
HAZARDOUS MATER
MATERIALS
IiFATIRG UNIT CTO 100,000 BTI))
_
pantDISCLOSURE
Will the applicant the futurebuildingngamupa Code, Chapter 9. haand the
material as defined by the Cupertino Municipal Code, Chapter 9.12 and the
Date Recef [#
]ELATING UNIT (OVER 1W," BTU)
TOTAL:
4 i 41M,3 5
I I❑ Yesnd Safety Code, Section 75537(a)7
VENTILATION FAN (SINGLE RESID)
ISSUAAUATE
Will the applicant a future building occupant use equipment or devices
Which emit hua Nom air .M,,mi.nt ii, defined by the Bay Arca Air
I�°�j
BOILER -COMP OH POR IM000 BTU)
Quality Management District?
Yes ❑ No
Mavicea ANousnut underChapter of
�(V�
1 A 1991
BOILER-COMP(OVER 100,000 BTU)
Ht .Ith
ted Glifornu Heabh&Safcty Coda Sections 5505, 25533 and 25530.1
,S d2S534.I5
t'
1 LV ♦'i v
NEW RESSI DENTIAL MECH. SQ.11
understand that it the building dues not currently have a tenant, that it Is my
responsibility to not lfy the occupant of the mquimments which must be met
priorttlo Nuance da Certificate C(Occupaney.
^ ^
11l ,I,If�t_ •Till
ISqUT
O.vner or au hariud ageNI Data
IOTA L:
OFFICE COPY
_I