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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES • USE BALL POINT PEN ONLY
CITY OF CUPERTINO "xill" NC-RI:RL°TRRIC.A.
BUILDING DIVISION APPLICATION/PERMIT PING PROJECT IDHANIElC
BUILDING PR03RCT IDEN'ITPIf,A'TION
PERMITNO.
2 C /1 % 7
LJL� r
BUILDING ADDRESS:
SANITARY NO.
APPLICATION SUBMITTAL DAT
f�{�/�
1 LOT#
Lqrq31
OW dKS CK I NAM]?: ` P
Ir r N1-73
CONTRACTOR'S NAME: LIC
NIC
CONIROLN
ARCHITECDENGINEER:
LIC NO
'03t7
AD S:
.S.L
CONTACT: PHONE:
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1! 00 I I IO��Q� 3-7-7--TS-12."'
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QTYn t.,�AL�C'F RIC PERMIT'> REE"
-'BUILDING PE INFO
PLUM
� 1 PLUMB MOH
PERMITISSUANCE
LICENSED CON3'RACTOR'S 611CLARATION
I hereby tiff rm that I am licensed under prov isions of Chapter 9 (commenci ng wi th
APPLIANCES -RESIDENTIAL
JOB DFSCRIPI'ION
Section70BBnf Division 3 ofthe Business and Professions Code, and my ]loan. is in
PANELS
fail force and Li.hcClasseffece
License Class Liak
UP T02tJ0AMPS
Amory /�
,/-3`�ff•�ls �x .IV4_[
Date Contract
201 - I" AMPS
ARCHITECTS DECLARATION
1 understand my plans shall be used as public records.
OVER IDBOAMPS
SQ. FT. FLOOR AREA
$/SQ, IT.
SIGNS ELECTRICAL
Lccnsod Professional
OWNER -BUILDER DECLARATION
SPECIAL CIRCUIT/MISC.
I hereby affirm that I and exempt form the Contractors License law for the
TEMP. METER OR POLE INST.
following reazon. (Section 7031.5, Business and Professions Code: Any city .,..my
which requires x Permit to construct, alter, improve, demolish, or repair any structure
prion its issuaxcC,also maalrea the applicant fnrsuch permit to file a signed statement
POWER DEVICES
that he is licensed pursuant to the provisions of the Convectors License Law (Chapter
9(commencing with Section 9(108) of Division 3 ofthe Business and Professions Cade)
or that he is exempttherefr0m and the basis for the alleged exemption. Any violation of
Smiiat 9031S by any applicant for a pemlit subjects the applicant 0 a civil penaltyof
SWIMMING POOL ELECTRIC
VALUATIO
�• 1 O� �1�
V`,
OUTLETS
not more than five hundred dollar,
❑ I,esownernf thepropeny,0rmyemployeeswithwegexustheirbolecomprnsetifn,
NEW RPSIDFNTLAL ELECTR S .FT.
Q
STORIES
TYPECONSTRUCTION
will do the work, and the structure is not intended or offered for sale (Sec. 7344, Buchem
and Professions Cole: The Cotametors License Law does not apply to an owner of
comedy whobuilds or improves thereon,and who does such workhimselforthough his
own employees, providedthxt such improvements we not intended woffered postale. If,
OCC. GROUT'
RES. UNITS
TOTAL:
however, diebuildifg mintprovement is sold within one yearofcompla ion, Ne owner
builder will have the burden of that he did not build or improve for f
proving P purpose
Qwy o .N, PLUMBING PERMIT' i} FEE;
s)I, un excluslvelycomcting withwm
❑ os Ownendlho property, m licensedntraot
radocci the project (Sec. 7044, Business and Professions Code:) The Convectors
.00DZONE
APN
License Lawdoesnot apply loan ownerofpropeny whobuildsorimpmveathamn,and
PERMIT ISSUANCE
who contracts fnrsuch pmjmts with acenuacians) licensed pursuanun the Communes
License law.
ALTER - DRAIN &VENT-WATFR(EA)
FEE SUMMARY
❑ xm exempt under Sec. , B & P C for thio reason
BACK ELOW PROTECT. DEVICE
Oil IY FEESN
Owner Date
DRAINS-FLOOH,ROOF.ARFA,COND.
DE
SANITARY
RECEIPT
WORKMAN COMPENSATION DECLARATION
SCHOOLTAX Y N
❑ Thereby affirm tbmlbave acefifica¢of consent to sel4insore, orucenificae of
Workers'Compensntion Insurance ora certified copy thereof(Sm. 3800, Luh C.) which
FIX3'IJRES-PER 3'RAP
RECEIPTN
PARK FEE Y N
covers all employee's under this permitW�jRECEIPT'
1,T
Palsy N
GAS - EA. SYSTEM -1 INC,d OUTLETS
N
OUILDING DIVISION REPS
Company- �ib�.(-
E]DC111 ICd Copy I.e hereby lumtahed.
Certified copy is filed with the city inspection division.
GAS -PA.SYSTEM-OVER 4(EA)
PLcNCHFCK FEE
GRfiSWINDUSTRI, WASTE INTERCEPTOR
GRADING PER
CERTIFICATE OP EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GREASETRAP
SOILS FEE
SEWER - SANITARY - STORM EA. 2001§'.
ENERGY FEE
(Elis section food not be completed ifthe permit is foronalandreddollms($100)
or]Css.)
WATER HEATER W/VEW/ELECTR
I certifythm in the perfotronmof the work forwhich this permit is issued,]shall
not employ any person in any manner an as to became subject to But Workers'
PAID
Compensation Lewsnf California. Date
WATER SYSTF:M/HREATING
Date RmciptN
Applicant
NOTICE TO APPLICANT: If, after making this CevNcate of Exemption, you should
become subject to the Worker's Compensation provisions of the labor Code, you must
NEW RESIDENTIAL PLMB. SQ. FT.
TOTAL:
forthwith comply with such provisions or this Permit shall be doemW revoked.
BUILDING FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that them is o construction lending agency for the performance of
SEISMIC FEE `
TOTAL:
ELECTRIC FEE
the work for which this permit is issued (Sec. 3099, Civ. C.)
lender's Name-
Lcndet'sAddress
Q'I'IY,++. '3 -', NCCIIANICALPHRIMIT�r„ "Flat, -
PLUMBING FEE
I certify that I have read this application and state Had the above information is
correct. I agree to comply with all city and county frdsinaossand slate laws m1ming to
PERMIT ISSUANCE.
MECHANICAL FCE
building construction, and hereby authorize repreunatives of this city to enmruport the
above-mentioned property for inspection puryoses.
AIA ER OR ADD TO MECH.
CONSTRUCTION TAX
(We) agree costive. indemnify and keep churchless the City of Cupertino against
liehilities,jodgmente,costs andexpenseswldch mayin any way accrueagainst said City
AIR HANDLING UNIT ITO 10.000 CFM)
mvequenmof -g ting of this permit /�
V'
AIR HANDLING UNIT (OVER I0.00) CFM)
Signaareof Applicullcishowwr ])me
EXI MUST HOOD(W/DUCT)
PAID
HEATING UNIT (TO 100,000 RTU)
HAZARDOUS MATERIALS DISCLOSURE
Date Rxeipt N
Will the applicant or cache building chapant stare or handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
VEN'ULATION FAN (SINGLE RFSID)
Code. Section 25532(10'!
11 Yes ❑ No
Will the applicant or future building occupant sex equipment or devices which emit
BOILER - COMP (3HP OR 100,000 BTU)
ISSUANCE DATE
BOILER - COMP(OVER 1110,000 BTU)
hxznrd0ux air cmilwhinums sex defined by 0he Day Area Air Quality Management
District?
❑ Yes 11 No
pp�� w
P A
NEW RESIDENTIAL MECH.—SQ. FT.
I have read the hazardous mamms, requirements under Chapter 6.95 of the
undempard
not cyColy has afinnew.that itis my nd
if building does 1itytontif that
if thebuildingdoesnot currentlyhave tist thallus my responsibilityenotify the
���
O8 199
�i/
occupant0mupo of the requirements which must be met prior m issaan¢ of a Cenif to of
thea
occupancy.
ISSUED BY:
Owner 0r emh0rized agent Dae
TOTAL:
vr'rllat