23394APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification
Building Address:
5"t S't�e.�Fa �—
PERMITNO.
23394
_
en a one:
A,✓,I/ Sof c��� u�gfc 7SI.10993
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BUILDING-ELECTRICALPLUMBiNGMMC LAICAL
Conmome.Natre: Lie. Na:
CATEGORY
CONTROL p
Archltett/Engineer. Lie. No:
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Add.
L�J
❑ ❑ ❑
PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION
I hereby.!@m that l am licensed under provisions of Chapter 9(commenc.
lngwitbeen. affeon3ofthe Bu.InmsandProfessionsCotle,and my
license Is In full force and effect.
.fell form
License Class LILg
Date Contractor
ARCHITECT'S DECLARATION
I understand my plans shall be used ss public records.
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt fromthe Contractor's License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or
countywhich requires a permit to construct, alter, improve, demolish,orrepalr
anystructure printer, Its Lssuance,alsorequires the applicant for such percutto
file a signed statement that he it licensed pursuant to the provide. of the
Contractor's License Law (Cha pter 9 (commencing with Section 7000) of Owl.
due 3 ofthe B.Ane.. and ProfesalomCods) or that he Is exempt therefromand
the basis for the alleged exemption. Any violation of Section 7031,5 by any
fora permit subjects the applicant to a civil penalty of net more than
evens,mill of ars
pr).
owner of the property, or my employes with wages r offered
llon,wBldothework andtheseructurc Is sat intended or r,!(ered for
fo
197044,
In Business and Professions Code. The Contractors License law
does not apply to an owner of property, who Wilds or Improves thereon, and
whodoessuchworkMmself orthrough Nsmenemployees, provided thatsuch
improve.n ets am not intended oroffered for sale. If,howeverthebuildingor
improvement issold within oneyearofcomplctlon, the owner-bullderwlll have
the*rden of proving that he did not build or improve for purpose of sale.),
I, as owner of the property, am exclusively contracting with licensed
contractors to occulted the project (Sec. 7014. Business and Professlor�s Code:
The Contractor's License Law does net apply to an owner of property who
Wilds or Improves thereon, and who contracts for such jewi cts with a
&,tBI, cnor(s) licensed pursuant to the Cenmarme. License Law.
LJ I am exemp ndar S.V_ B k P C for this reason
Owner :727 6Date /
ORKMAN COT ATIC9� D[CLAR ION
❑I hereby affirm that I have ace 1Be4c of consent to Alf-Inwre, ora
cortlficam.fWorkers'Compevatlon lvuranme, certified mpythereof 6ec.
3800, L.b C.)
Policy p
-
APPLIANCFSRESIDENHAL
JOB DESCRIFHON
PANELS
— UP TO 2DOAM
101-IODDAMPS
OVER 1000 AMPS
SQ. FT. FLOOR AREA
Pea
SM. FT.
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC
TEMP. METER OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETSSWITCHESHXTURES
VALUATION
/
NEW RESIDENTIAL ELECTR S,FF.
TYPE CONSTRUCTION
TOTAL
QTY, PLUMBING PERMIT FEE
OCC. GRONP
RL'S, UNITS
PERMITISSUANCE I
ALTER -DRAIN k VENT -WATER (EA)
FLOOD ZONE
APN
FEE SUMMARY
BAIX FLOW PROTECT. DEVICE
OUTSIDE I
DRAINS. FLOOR ROOF, AREA, CONT.
SANITARY RFCEIRp
FIXTURES PER TRAP �1
5C1100L TAX V N
RECEIPT Y
GAS EA. SYSTEM-11NC<OUTLETS
PARK FEE Y N
RECEIPT k
CAS EA. SYSTEM -OVER 4 TEA)
Com any
BUILDING DIVISION FEES
MCertlfled copy b herebyfurnished.the cit.
�Certl(Ied copy V filed with the city ivpmlan division.
CERTIFICATE OF EXEMPTION FROM WOR KERS'
COMPENSATION INSURANCE
RFlsaese.) need not be compldedif the permit V(Drone hundred dollars
(a10o)rtifyt .)
I certify that In the person in an tm workmanner w ex twhich co permit I.wbJec Issued,
manneratesto become aub�ect to the
I shall notemploy any Laws of
Workare'Compensation Lova of Gllfmnb. Date
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you
should become subject to the Worker.' Compamtion provisions of the Labor
Code, you must forthwith comply with such provisione, or this pemNt shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby afflrenthat there V a constmciion lending agency for the perform-
ance of the work for which thl. permit Is Issued (Sec. 3(%7, Civ. C.)
lander. Name
Lendcr'.Addmss
I certlfythat I have read this application and sesta that the above Information
iscorred. I agree to comply with all city and county ordinances and state laws
relating to building construction, and hereby authorize representatives ofthb
city to enter upon the above-mentioned property for Inspection purposes.
(We) agree to save, tedemNfy an d keep herMess the City of C. portion
against liabilities, P dgemet., cossass.. and expenses which ymay 11. any way..a
ag�alost
/said Clty�I�n[/[/°��}M° gra in of this It, ee /
__Ma'�E�x/—MAIt.
,ii1�ofApp
GREASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE
PAID
Date ReCei t#
GREASE TRAP
SEWERSANTTARYSTORM EA 2DOI•T
WATER HEATER W/VENT/ELLCTR
ENERGY FEE Y N
PAID
Dale Revel IN
WATER SYSTEM
NEW RESIDENTIAL PLMB. :OFT.
TOTAL:
BUILDING FEE
SEISMIC FEE
ELECTRIC FEE
QTY. MECHANICAL PERMIT .FEE
PLUMBING PEE
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID:
ALTER OR ADD TO MFCH.
Date Receipt#
AIR FTA NDENG EMT PO I O,ODO CFM)
SUBTOTAL:
AIR HANDLING IIM7(OVQ210,000CFM)
CONSTRUCTION TAX
Sig eaB cit/Contractor II
HA ZAR DOLS MATERIALS DI SC SURE
Will the applicant or future building occupant store or ha ad le hazardous
material as defined by the Cupertino Mu Ncipal Code, Chapter 9.1 1, and the
Health and Safety Code Section 25532(a)7 -
❑ Ye. Na
Will the applicant or inure building occupant use equipment or devices
which eMt hazardous air contaminants as defined by the Bay Area Air
Quality Management D❑isirld7
4 Yes rd No
have read the hazy ou. material. requirements under Chapter 6.95 of
the Califon la Health building Code, etcuw25505,rrently ve a t and8534. I
that it mete my
ruspunderstandlhat lithe ntifytheoccupant note mquirments which
responsibility to notify the occupant of the requirements which must be met
prior to Issuance of a Certificate of Oreupa acy.
EXHAUST HOOD (W/D[7CTI
CONSTRUCTION TAX PAID:
HEATING UNIT (TO l 00,0DO BTU)
Date Recel Iq
HEATING UNIT (OVER 100,000 BT U)
TOT
VENTILATION FAN (SINGLE RESID)
ISSUANCE DATE
P
PAID
MAR 10 �[]
�i
CITY V:• currr, /
ISSUED BY. r
BOILER -COMP (3HPOR 100,0W RTU)
BOILER -COMP (OVER 100,OW BN)
NEW RESIDENTIALMECH. SQ.IT.
Owner or authorized agent Date
TOTAL:
OFFICE COPY