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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PENT ONLY
Building Project Identification -
BuildingPERMIT
Address:
q ,1A� v
NO.
22639
ners arse:
��P�hIor.nn3e:
DSM '�C]J 4
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION /PERMIT
rador's Named un. No:
CV
BLnDING-ELECTMCAL PMUMBINC-MECEIANICAL
ArcMt /Englncen Lic. No:
C
CATEGORY
CO N
f
QTY ELECTRIC PERMIT -FEE
BUILDING PERMIT INFO
-
Address
PERMIT ISSUANCE
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirenthot l am licensed under provislonsof Chapter 9(commenc
II maiSed1ollf.meafd effeon3oflhegusinemand Pro(esslonaCade,and my
ligwith dion7orceand Asi.
License Clam LIC#
Date ContARCHITECT'S
APPLIANCES RESIDENTIA
PANELS
JOB DESCRIPTION
l
S'LMU 6 D J
ARCHITECTS DECLARATION
(understand my Plans shalbe used As public records.
-1 AMPS
�?� .
_ 1000 AMPS
, SO. gl'. F{rQQR�gEp S
FT,
SIGNS ELECTRI
-
Licensed Profembnsl
''
ALE D
OWNER -BUILDER DECLARATION
I heorwing axon. (S at l am exempt .InA the Contractor's Llrenm Gw for the
bllowingrehrnquiedion7n Htw Bmtmdandr, (pmve, emlCode h,ydtyor
anystm hkhrequlresapeame,coonqu stheaplimntfmollsh,orretto
any stsucturetatemelfshat heeq licensedPursuant to cant(w suions of lte
floe a signed statement that he b Ilcensed pursuant to the provisions of the
Coni ofthe License Law (Chapter9 (commCode) ncingrthd with xSection
mpttheID)of Divi-
f exempt therefrom and
tis basis for lh;N Ie ed Professions Any
the lash for the alleged exemption. Any vlolacivi of Section 70315 by any
app hundred.Nt for aollarsroombjectseheappllcant toadvll penalty of not more than
live hundred dollars %he pr .
❑I, ate owner of /be property, or my employees with wages r thele sole
compensation, rk,Pr fe the o. Cocture is e:TheC Intended Licence d for
ask (Sac. 7(194, Bu siness andf property Code: The Contractors Licence Law
Law
does not apply to an owner or property who Wilds or improves thereory and
who does
mentsa not Intended gh owns. If,ho evert ded that suchthe building
or
Improvement to Auld within earotredtarsale. the however, deer ilingor
improvementbwldwlthln oneyearofcomple(too,theowner-bullderwill have
ttlgjiurden of proving that he did not build or improve for purpose of sale.).
L,f L as owner of the property, am exclusively contracting with licensed
contractors to coot trod the project (Sec. 70K Business and Professions Code:
TheCont actor's Llcenm I.A. does not apply to an owner of property who
Wilds or Improves thereon, and who contracts for such plo(ecta with a
<qt t�actor(e) Bceneed pursuant to the Contractors Llrenm Law.
LJ I am exempt under Sec. g & P C for this reason
I� A T
M
SPECIALCI2CUIT MLSC
' -
TFMP.METERORPOLEINST.
POWER DEVICES T
SWIdwNG POOL ELECTRIC
Q �yVALL ATION
/ ,3 •� F.
OUTLETSSWITCHE&FIXTURE9
NEW RESIDENTIAL ELECTR -c'Q
STORIES
TYPE CONSTRUCTION
`
OCC. GROUP
REq. UN'rIS
TOTAL:
QTY, PLUMBING PERMIT FEE
PERMIT ISSUANCE
ALTER -DRAIN& VENT- WATER MM
FLODDZANEr
APN
BACKFLOW PROTECT. DEVICE
FEE SUMMARY
OUTSIDF
Owner Date
DRAINS FLOOR ROOF, AREA, COND.
FliCTURES. PER TRAP
SANITARY Y_ N_
RDC LIT B
WORKMAN COMPENSATION DECLARATION
❑I hereby affirm that I have a cort(Rrate, of consent to self-ine re, or a
=skitiwteo(Workere'Compec time mnmwamdified pythemof(Sec.
3800, Lab C)
Policy p
SCHOOL TAX Y_ N_
RECEIPT
GAS FA. SYSTEM -1 WC.4OUTLETS
PARKFEE Y N
RECEIPT p
• Com any
furnished.GREASE/INDURRL
Certified copy h herebyhcity
❑ CertNed copy b filed withhthe city Inspection division.
GAS FA. SYSTEM -OVER 4(EA)
WASTE INTERCEPTOR
BUILDING DIVISION FEES
PLANCHECK FEE
76r OK'
C
GREASETRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
frhissection need not becompleted ifthe permit leforonehundred dollars
(81I comlessd
o the performanceny work for to b this permit b blued,
I ll am employ
I shall not employ any person In any manner m es to become subject to the
W plica' Compenm(bn Laws of Call(omla. Date
Applicant
NOTICE TO APPLICANT. If, after making this Certificate of Exemption, you
should become subject to the Worken'Compenaa(lon provl.ions of the Labor
Code, you must forthwith comply with such provisions or this permit shall be
deemed revoked.
PAID ! `
Date Retxi t#
SEWER -SANITARY -STORM EA. 2001rr.
WATER HEATER W/VENT/ELECTR
Y E.
t 6
pAlp
Date Recei t f7�
WATER SYSTEM/TREATING
NEW RESIDENTIAL PLMB. SQ.Fr
B FEE
CONSTRUCTION
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the perform
ance of the work for which this permit is issued (Sec. 3097, CIv.C.)
Lender. Name
Lender'.Addrem
Icertifythatl havemadthis appliestbnandetain hattheaboveinformation
TOTAL:
SEISMIC FEE a.
ELECTRIC FEE
QTY: MECHANICAL PERMIT FEE
PLUMBING FEE
MECHAN L FEE
Is correct. I agree to comply with all city and county ordinances and state laws
relating to building construction, and hereby authorize representatives of this
city to enter upon the above-mentiomd property for inspection purposes.
Me) a o save, Indemnify an d keep harmless the City of Cupertino
against 11 les,ju gments,m& expenses which may In anywayaceme
against. Ci i uenc a noting ofthls Permit.
PERMTTISSUANCE
FEES PAI : iI • I.q LI
'
Date. Recei f#
ALTERORADDTOMECH.
AIR HANDLING UNIT (TO 10,ODO CFM)
SUBTOTAL:
AIR HANDLING UNIT (OVER IO,OXCFM)
CONSTRUCTION TAX
EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
treo Appllcent/Contractor Data
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT 100,000 BTU)
Will the applicant building occupant store or handle haeaMous
material as defined by the Cupertino Municipal Code, Chapter 9.1Z and the
I lealth and Safety Code Section 25532(a)7
❑ Yes ON.
Date Recei f#
HEATING UNIT (OVER 100,000 BTU)
TOTAL•
•
VENTILATION FAN (SINGLE RESID)
.ISSUANCE DATE
0
UU9
19aa1
�®d. .
Will the applicant orfulure building occupant use equipment or devices
which emit haeardous air roots mlo..O m deftned by the Bay Area At,
Quality Management District?
Yes jj''�� No
havenia teeth& Safer materialsium 25505,255derChapterA95 of
the understand
to Health & Safely Code, Sodium25505,25533have
a to nd , that I I
. understand that if thenote the occupant
not the
avea tenant, that It mat
responsibility iniss to notify the occupant of the requlrementa which must be met
prior to Issuance cafe Certificate o(Occvpancy.
BOILFR-COMP (3HP OR 100,00) BTU)
BOILER-COMP(OVER 100,000 BTU)
NEW RESIDENTIAL MECH. - SQ.FT
_
�Nu
Owner orauthorized agent Date
1DTAL:
ISB[!B
OFFICE COPY