21906APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project IdentificationPERMIT
Building Add2.o�35, ^ .g
NO.
21906
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�7x,a�ciQ�
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BUILDINC-ELECTRICAL-PLUMBING-MECHAMCAL
y actoe.N me:'I - Lt.Na
CLUK• 2
CATEGORY
CO.-/
N'Bfl71 _YS
zs
/ n
Architect E e Llc'No:.
e&U �' "�'GLC7SG�
Address: •-5 '� 3
QTv ELECTRICPERMIT FEE
BUILDING PERMIT INFO
PERh17T ISSUANCE 1SLUG
CO
U�l PLUMB M�H„
LICENSED CONTRACTOR'S DECLARATION
I herebyatfbeethat l amllcensed under provhlonaof Chapter9(commenc.
ingwith SMton7000)of DtAsion3oftheBuslnemand Profesma Code, and my
license le In (u and disci.
License CJa�Llctl 2 17 I
APPOANCESRESIDENTIAL
JOB DFSCKE'TION
�+
PANELS
_'
Date F Contractor
1014000 AMPS
ARCHITECT•, CLARATION
OVER 1000 AMPS
SQ. Fr. FLOOR AREA
' LOU
7� $/SQ. Fr.
I understand my place shall W used as public records.
Licensed Professional
SIGNS ELECTRICAL
SI'ECL1LCEtCIRT/MLSC
OWNER -BUILDER DECLARATION
I hereby of irmthat I am exempt from the Contractor's License Law for the
T
TEMP. METER OR POLE INST.
following meson.(Section 7031.5, Business and Professions Code: Any elty or
countywhichmqutrsapermittommtmct,altegimpmve,den lish,orrepair
anysmmmpdortoltalawance,aLwmquirestheappllonlfwsuchperMtto
file a signed statement that M ie bcemed pursuant to the provisions of the
Contractor'sLlceree Law (Chapter 9(commencing with Section 7000) of Divi-
sion 3 ofthe Businessand Profeeslare Code) orthat he is exempt there(romand
the bash for the alleged exemption. Any violation of Section 7031.5 by any
applicant fora permit subjects the applicant to a civil penalty of not more the
five 1, as demodollarIhepr.
I, at owner of the property, or my employees with wages thele sole
POWER DEVICES
SWIMMING POOL ELECTRIC
LUATION
`L"1 „CNO
UTLETSSWITCEIFSFIXTURFS Q
a
NEW RESLDENTIAL ELECTR SQ.ET.
ES
TYPECON51RUCHON
compensation, I do work and r
or...Loffered for
sale (Sec. Business ions Codurehnaintended
Business and Code: The Law
apply to f property uilds or impctols theme
does whodotapply torn owner otp rough who nempINmprowes ovided thatsu h
himself or
wprove,
C.GROUP
RES. UMTS
ort.uch cr theedlhalsuch
improvementsarenm Intended earodco for sale. If, however, flder ldingve
improvement b sold within one yeara(compldlon,the owner -W Bderwlll have
TOTAL: -60
_
tlr�urden of proving that M did not build or improve for purpose attests.).
L,J L as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 704,1, Business and Professions Code:
QTY, PLUMBING PERMIT FEEGgNR
PERMIT ISSUANCE
z V
ra
ppN
The Contractors Limose law does not apply to an owner of property who
Wilda or improves thereon, and who contracts for such pIpjects with a
cgp(Tactor(s) licensed pursuant to the Contractors License Law.
I am exempt under Sec B & P C for this reamn
ALM -DRAIN &VENT -WATER (Full
BACK FLOW PROTECT. DEVICE
FEE SUMMARY
DRAINS FLOOR ROOF, AREA, OOND.
pLYTVRFSPERTRAP 4-06 6
SANITARY Y_ N—
RECEIPIN
Owner Date
WORKMAN COMPENSATION DECLARATION
❑I-hareby'afr6m that I have a certificate of comers mself-Insure, ora
certificate of Worken'Compeeeatton Insurance ora certified copy thereof(Sec.
3800, Lab C.)
SCHOOLTAX Y_ N_
RECEIPT, p
S CAEA INCA C.40UTLETS
PARK FEE Y N
Policy N
ftF-CC0'CM
GASYSTEM-OVER 4 (EA)
S F.A.ity
^Y
�Cenlflad
BUILDING DIVISION FEES
copy h furnished.
❑CertlRed appy h flied with theccity inspection division.
GREASE/fNDUSTRL WASTE INTERCEPTOR
PLANCHECKFEE
GREASETRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
need rad M completed tithe permit h /Drone hundred dollars
Rl
PAID
Date ReCel t#
toll 2-6
SEWER-SANITARYSTORM PA 200FT
msection
�140ertifyhperncework
I certify employ any person In any reanner so ast to b this pesubjecrmit Is hound,
I shall not employ any Uwe In any manner w as to become subject to the
Applicant ompensatlon lJws of Calitomla. Date
NOTI E
NOTICE TO APPLICANT:him to
te orkmakingthio ationleateat Exemption, you
Labor
shoulddou aforth ttothe Workers' such provisions
his permit shall
Code, you must forthwith comply with each provisiav Dentis permit shall be
deemed revoked.
WATER HEATER W/VENT/ELECTR ,OD
-
ENERGYFEE Y N —
PAID
Date Rece1 t#
1'6
em
WATER SYSTEM/TREATING
NEW RESIDENTIAL PLMB. SQF7.
TOTAL:
BL21LDING ELEz5
�
TOTAL:
�O-
SEISMIC FEE
ELECTRIC FEE
RIC EEE
a
_ (�
CONSTRUCTION LENDING AGENCY
I herebyafRrmthat there Is a construction lending agency for the perform-
erform
...
anre of the work forty ish this permit h isrond(Sec. 3097, C1v. C.)
Under'.Name I
Lenders Address
I mel ify that have read this application and nate that the above inforces'tion
Iscomet. l sgreeto comply with all city and county ordinances and state laws
QTY, MECHANICAL PERMIT FEE 'MECHANICAL
PERMITISSUANCE G(7
PLE
0_Q
FEE
FEE$PAID:
relating to building construction, and hereby authorize rcprcsentadves of this
city to enter upon the above-mentioned property for I peatlonpurposea.
(We) agree to save, Indemnify an d harmless the City of Cupertino
against lhblittle., mems, costa d sea which may l^ any weyacaue
against said Cl n sequence t .tis of thispermit
I ALTER OR ADD TO MFGH. - OD
Date Receipt#
AIR HANDLING UNIT CIO 10,000 CFM)
ATRHANDLING UNIT (OVER 10,MOCFM)
SUBTOTAL:
CONSTRUCTION TAX
t-/1
SkmatureskarrPheant ntrador Date
EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
HFATINGUMT(TO100,000 BTU)
Will the applicant orfutum building occupant store or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.12, and the
Health and Safety Cada Section 25532(a)?
❑ Yrs �jJo
Date ReCei f#
HEATING UNIT (OVER 100,000 BTU)
TOTAL • '
VENTILATION FAN (SINGLE RESID)
ISSUANCE DATE
Will the applicant orfutvrc building occupant use equipment or devices
which emit hazardousair contami areas defined by the Bay Area Air
BOILER -COMP OHPOR I0e0W BTU)
Quality Management District?
a Yes No
� �/�
6'AM
RAM
BOILER-COMP(OVER 100,000 BTU)
rd
heveread the haze ow materials mqulmmenh under Chaptec6.95of
the Califcmia Health & Safety Code, Sections 25505,25533 and 75534. 1
understand that tithe building does not currently have a tenant, that it is my
i 19 1
NEW RESIDENTIAL MEOL SQ.Fr.
responsibility to notify the occupant of the requirements which most W met
prior to issuance of a Certificate of Occupancy.
x
ISSUEDBY:
Owner or authorized agent Date
TOTAL:
OFFICE COPY