21417APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification
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CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BUfLDINC-ELECTRICALPLUMBING-MECHANICAL
cnntr or'aName: ,�A W �iY Uc.No:
A a 'S 71
CATEGORY
CONTROL p
Archhect/Engmeev Lk. N°:
QTY ELECTRICPERMIT FEE.
BUILDING PERMIT INFO
Address:
PERMIT ISSUANCE
LP ❑ O ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provlstneof Chapter 9(commenc-
ingwith5 ton90W)of Divigoo3 ofthe Biagnsssand Penfessi°nsCode,and my
I.hi 11 effort.
(cense Is in fuB (fix and rife', e� /),
I
APPDANCFSRESTDENTIAL
JOB DESCRIPTION
` C
PANELS
Lirenx J J �I
� J L
Date
AWS
JI
L
ARCHITECT DECLARATION
(understand myplartashallbeusedaspublierecords
OVER1000 AMPS
SQ. rr.HAOR AREA
S/SQ. FT.
SIGNS ELECTRICAL
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License law for the
following reason. (Section 90315, Business and Professions Code: Any city or
county which requires a permit to construct, alter, Improve, demolish, or repair
any stmcram prior to its Issuance, also requires the applicant for such permit to
Ile a signed statement that he h licensed pursuant to the prove iom of the
Continder'.License Law (Chaptsr9(commencing with Section 70 W) of Divi-
'on 3 of Business and Professhms Code)'rthat he is exempt therefrom and
the bash for the alleged exemption. Any violation of Se tion 7031S by any
applicant for a permit subjects the applicant to a civil pvmlty of not more than
SPECIAL CIRCUIT/MLSC
TEMP. METER ORM3LEM4T,
POyypg DEVICTc5 (Y
\ n IR
SWIMhRNG ELCTRIC
- - -
I 1 R
0UTLETSSW1Wi2SRXTURE5
VALUATION
`WJTob
sn n n a n
N'EW RESIDENTIAL IALM SQ.FL
five hundred dollars (¢500).
❑ I, as owner of the property, or my employees with wages as their sole
compensation, will do the work and the structure h not intended or offend for
.Is (Sec. 9014, Business and Professions Code: The Contractors License Law
does not apply to an owner of property who builds or improves thereon,and
who docesuch work himseUorthrough his ownemployees, provided that such
STORIES
TYPE CONSTRUCTION
`t/
_
t, �•� A
v
OCC.GROUP
RES. UNITS
Improvements are not Intended or offered for sale. If, however, the building or
TOTAL:
improvemcnthwid within°neycarafcomplNlon,theowner-bullderwill haveon
tbg,t;urden of proving that he did not bund or improve for purpose ofsale.).
LJ 6 as owner of the property, am exclusively contracting with licensedde:
ors to construct Business and Professions Code:
project (Sec. 70Kapply
QTY. PLUMBINGPERMIT" PEE
FLOOD ZONE
MIN
PERMIT ISSUANCE
The Co Lice'the
License Law does nor applyto an owner d property who
The Contractor's improves
bull2s or Int roves thereon, and who contram (car such
p p(ojeta with a
co[nI amenamedpursuant to the Contractor's License Law.
J m exempt under Sec. B k P C for thin reason
ALTER -DRAIN VENT -WATER (EA)
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
OUTSI DE FEES
DRAINS FLOOX ROOF, AREA, COND.
FIXTURES- PER TRAP
SANITARY Y N
RECQPT N
Owner Date
WORKMAN COMPENSATION DECLARATION
❑I hereby affirm that I have a certificate of consent to self-insureor
certificate of Workers Comref
ponsinlon Insurance ora unified copy theo(Sec.
MOD, Lab C.)
Polity N
SCHOOL TAX Y N
RECEIPT M
G AS LA.SYSTEM-]INC.40ITILET$
PARK Y_ N
p
RECEIPT
GAS EA. SYSTEM -OVER 4 (EA)
Com any
BUILDING DIVISION FEES
ffmlflM copy h hereby furnished.
❑CeniBed copy h filed with the city Inspection division.
GREASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE
GREASE TRAP
CERTIFICATE OF EXEMPT ION FROM WORKERS' -
PAID
SEWERSANTTARYSTORM FA 200ET
COMPENSATION INSURANCE
omp "'the permit isforeme hundretldollars
(This s"Ac,,
Date Recei t#
WATER liEATLTt W/VENT/FI.ECTR
ENERGY FEE Y _ N _
(SID') or l
]comfma ftheworkforwhichthlapennltisissued,
I shall noon manner so leer to the
Workers s f f'rn1a. Date
WATER 51,5141/TRFAlING
PAID '
Applicant
NOTICE , aft r ng this ertiflate of Exemption, you
should become subject to the Workers Compensation provisions of the Labor
Date Remi t#
TVLW RESIDINTIAL PLMB. SQ.FT.
TOTAL:
BUILDING FEE co
c
Code, you must forthwith comply with such provisiore orthh permit shall be
dunad revoked.
SEISMIC FEE 1
consraumoN LE.Nlnlvc ACTacY
' Ihereby affirrnthat there In a construction Tending agency for the perform
arm of the work for which this permit h issued (Sec. 3097, Civ. G
Lender'.Name
Lenders Address
I mrtifythat I have mad thbappliati°n and statethatthe above information
mcarma.1jil,extocomplywith city and county ordinance and gate Taws
TOTAL
ELECTRIC.FEE
PLUMBING FEE
QTY. - MECHANICAL PERMIT - FEE
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID:
relating it Sconatrution lierebyauthortoomprcxntativesofthh
,
city to en rupthe above -mc ed property for inspection purposes
(We) ct save, IndemN dkeep harmless the City of Cupertino
ALTER OR AOD TO MILH,
Date Recei t#
P
PTR HANDLING [AIT (TO 10,030 CFM)
SUBTOTAL:
against[ illt jadgmenb, expenses which maylnanywayar°rue
against tlCi In mnaequen ( egranting&this permit.
' aRTiwNDUNc 11Nrr (ovFR la,o"cFM>'
.
CONSTRUCTION TAX
ignatu of at Dnte
EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (TO 100,000 IlM
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 Cod ion ZS53E(a)7
Date Recei t#
HEATING UNIT (OVER 100,(00 BTU)
TOTAL:
❑ Yes j NO
VENTILATION FAN (SINGLE. RESID)
ISSUANCE ATE
1� �• R�
U 19�Q�
1 4,)� V MW
Will the applicant yFfuYtsrc buildingompara use equipment or devices
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Marugcmcnt District?-
4Y °
vcrc d ealth-a rials requirements under Chapter 6.95 of
the iforni Healt,Z fety e, Seom. 75505,25533 and 25531.. 1
BOILER-COMPOHPOR 100,0(9 BTU)
BOILER-COMP(OVER1(0,000 BTU)
NEW RESIDENTTALMECH. SQ.FT
and ands atifthebuildin a currently have a tenant, that iti my
resp `Snit to nosily the a the requirements which must be rmt
Erici4ua cc of a CertlOc of panty. -
/aa�
� y-yPaw
` h1 r,
ISSUEDBY: V Y-I-fA 1 n t(t,(
Owne o oriu a t Date
TOTAL:
OFFICE COPY