20573APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
building Project Identification -
Building Address: •;
t5 5��.d�� �>~ C� e y IO.�.'
PERMIT NO.
1. .Y 0 5 7 3
me: e
.E r- k0. eV -L �I^�-C'v.p�,�
or
CITY OP CUPERTINO-BUILDING DIVISION
/ PERMIT -
BUILDINGFLECTRICALPLUMBING-MECHANICAL
A
C • 0
Contractor's No me: Lie. No:
CATEGORY
CONTROL X
ArchltM/Engineer. Lic. No:
-
'.Qtt 1,, ELECTRIC PERMIT +` a 'i'FEC
,.h.�.'�.q BUILDING PERMIT INFO
- - -
Atltlreee:
PERMITISSUANCE '—
0
LICENSEDCONTRACTOR'S DECLARATION.
I hereby affirm that l am llcenmdunder provisions u(Chapter 9(commere
Ingweh infun force and died. o(ihe Buelnenand Ro(naloneCodGand my
license lslnfu8 force and eflmd,
WmnseCbo Lie. #-
Date Contactor
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records. -
Licensed Professional -
OWNER -BUILDER DECLARATION
I hereby affirm that I= exempt from the Contractors License Law for the
following monon.(Section 7lDIS, Business and Pm(esslons Code: Any city or
countywhichrequlresaper ttommmd,alter,impmvgdemolLsh,ormpalr
anystmcture prlorto its bsuance,alaorequlresthe applicant fursuch permit to
file a signed statement that he us licensed pursuant to the provinces of the
Contndorb License Law (Chapter 9(commencing with Section 7000) of Divi-
sion3 villa,Business.nd Pro(ned.m Code)orihat he is exempt there(romand
the basis for the alleged exemption. Any violation of Section 7033.5 by any
applicant fora permit subjecbtheappllcant to a civil penalty elect morethan
five hundred dollars($5M.
❑I,asowner ofthe property, or my employees with
compensation, wllldothe work and the structure Enot intended or offend (or
ended r offered
mp Roes License law
does nor sale (Soc. applyto alnowner and f prupe ons Code: The lds or improves
whodossuchtoanimailofproughhisonemorimprovnthercoryach
whodoementsa nhimselfedoor rwghedowne. If,hc es,provldedild Ing or
Improvement iseold w8hinoneyearafcompletioryihc owner-WBderwlll have
t17,"��,,'rden of proving thin he did not build or Improve for purpose of ale.)..
c)pl Lae owner of the property, am exclusively contracting with Ikended
on666 actors to construct the printed (Sec.7044, Business and Professions Code:
The Contractor's License law does not apply to an owner of property whoALTER
Wilds of improve thereon, and who contracts for such p(ojeda with a
< �t d or(s) licensed pursuant to the C.,ametola License Law.
1ds4' am exempt under Sec. B k P C for this rceson
/7% /
_
APP11ANCES-RESIDENTIAL
U08 DFSCRE'D N
��
PANUS -
ANUS
20140DOAMPS
OERIOOOAMPS
SQ, FI'. FLOOR AREA
`
SVA
B/SQ. IT
"
SIG EEC CAL
LC CUIT/NINC
7EMP.MEIFR OR POLE INST. ,
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS-SWITCHFSFf%TURES
TION
-
-
NEW RESIDENTIAL ELECTR SQFL
RIES
-
TYPE CONSTRUCTION
-
a00Improvemenlsarenoithlooneyearferectforsale,ILhowevmglhebulldingor - TOTAL:
QTY, ",�,' PLUMBINGPERMiT•'.ir,�., FEE 1
'PERMIT ISSUANCE
DRAIN k VENT WATER (EA)
-
C. OUP
UNITS
FLOOD ZONE
APN
-
.... ..
,
',•'`1111, ; FEE.SUMMARY.
BACK FLOW PROTECT. DEVICE
OUTSIDE
DRAINS FLOOR, ROOF, CONTI.
= �-A•
SANITARY Y' N
RECEIPT# .
Owns-�w.�.rw�r 7'I�-�17
AN COMe a cert�cam of consent
hereby
(hare insure, or
Of
mrtifialeo(Workers'CompemationIns nnceoracertifiedmpythereof(Sec.
3 w' Lab C.)
FIX7VRES PER TRAP, "'
SCHOOLTAX Y N_
RECE If
GAS EA. SYSTEM -1 NCA OUTLETS
PARK FEE Y N
GAS EA. SYSTIM-OVER4(EA)- d
ComPolicy
BUILDING DIVISION FE
ES
�any
CertRimd ropy b hereby furnished.
❑ Certified copy Is filed with the city Inspection division.
CERTIFICATE OF E%EMPTION FROM WORKERS'
(This
(This eectlonneed not he completed if the permit ti (Drone hundred dollars
(SI00>orlea.> -
I mrtlfy that In the performance of thework forwhich this permitl> leseed,
I shall not employ any person In any manner an as to become subject to the
Workers'Compensation Lowsof Cafifomia. Date
Applicant
NOTICE co APPLICANT: a after making thinCertificate
pro is Exemption, you
it the ply with..chE mlednprothi, permitsions ofthe Labor
Code,shoulyou at
Code, you must forthwith comply with each provL+lons orchis permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
Ihereby affirmthat them is a conatrudlon lending agency for the perform
once of the work for which this permit is Enamel (Sec. 3097, Civ. C.)
Lenders Name
Lender'. Add
IcertlfythatI%ve readthis application and statelhattheabovelnformmion
bcomed. I agreemcomplywlthallcityand counlyovRnancesand dale laws
relating to building consimctlon, and hereby authorize representatives of this
cityto enterupon the above�mentloned property for inspection purposes..
(We) agree to save, Indemnify and keep harmless the City of Cupertino
against hablBties,judgments, consand expenses which may in anywayacnue
Ins
agi t aald City In consryuenceof the granting of thL permit. .
CARCASE/INDUSIRL WASTE INTERCEPTOR
PLANCHECK FEE
,
PAID—
Date Remi 1#
-
GREASE TRAP , -
•
SEWERSANITARYSTORM EA.200FT
WATER EIFATER w/vaNr/ELECTR
ENERGY Y N
PAID
Date Recel t#
WATER SYSTEM/TREATING -
NEW RESIDENTIAL PLMB. SQFL
- -
TOTAL:
BUILDING • •E
SEISMIC FEE
' TOTAL:
.ELECTRIC FEE
QQ
- I -- ) , ..,-.
QTY. r�',"'MECHANICAL: PERMIT,.�d -.FEES
PLUMBING FEE
MECHANICAL FEE
j
- -
PERMIT ISSUANCE - -"
FEES PAID:
-
ALTTRORADDTOMECH.
AIRHANDLINGUNITfToio, 0CFM)
Date. Receipt#
SUBTOTAL:V
AIRHANDuNGDNrr(ovERlgococrM)
-
CONSTRUCTION TAX
Signature o(AppOcant/Contractor Dale
HAZARDOUS MATERIALS DISCLOSURE
Willthe applicant or future building occupant store or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.12, and then
I leilthand SafetyCode Sect1on25532(a)7
I—]YesM No
Will the applicant or futurebunlding occupant use equipment ordeviers
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management Dis(rict7 -
,?have Yea q.,
read ealth car et mode, erequl 25505, 5under 531 aChapter.1 of
the Code, Sections 25505,25531 a and25534.I
understandtCaliforniHealth building
respontanlityt.hat f t tithe ingdoes not a currentlyhavetenant that Rlsmy
rriort iI, nLonotifytheoccupantofthe iremenbw ichmustbemel
prior to La ice aCerti leans of pan %
IXI1AU5'T FLOOD (W/DUCT) • gp
CONSTRUCTION TAX PA
- HEATING UNIT (TO 100,000 BTU)
.
HEATING UNIT (OVER 100,000 BTU)TOTAL'
Dafe Recei t#
��
VENTILATION FAN (SINGLE RESID) -
ISSUAN DATE
�1> .+' -
JuU .I �l �= IJJ4
'
n• tr 0f "B^efto
J' iHll /
I DBY. N
BOILER -COMP (3lEa OR 100,000 BTU)
BOILER-COMP(OVLR 100,000 BTU)
NEW RESIDENTIAL MECH. SQFf.
- ..
TOTAL: , OO
Owner orawho zed agent Da
'
OFFICE COPY l�