20264APPLICANT TO FILL IN INFORMATION WITHIN RED LINES.— USE BALL POINT PEN Ann v
Building Project Identification - -- -
Building Address: _ _
79 s
PE MITN'O.
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G G 64
wn ante: - one:
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION % PERMIT
BUILDINC-ELECTRICALPLIIMBIIV MMIIAMCAL
;
A Yo
on a Lic.No:
CATEGORY
CONTROL p.
Archi ed a Lie. Nm
tQTY'-,� ` } tt EkEHTRICI!ERMIT
s41is • E
!" ,'i s BUIGDIN6 PERMIT -INFO.."�
Address: -
PERMITISSUANCE
(�
-❑
LICENSED CONTRACTOR'S DECLARATION
Ihereby affirm that lamlicensed under provisions HChapter9(commene-
Ingwlth&dion7000)of DtWsion3ofthe BuA.n ,,.nd ProfensionsCode,and my
license Is In full force and effect.
License Claes Lic.p -
Date Contractor
ARCHITECPS DECLARATION
I understand my plans shall be used as public records.
Licensed Pmfessloral
• OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors Llrense Law forthe
following Mason. election 7031.5, Business and Professions Code: Any city or
countywhichrequresapem ttoconstmd,alter,impmve,de=o h,ormpalr
anystructure Pdor in its basno.ce,atso requires theappfiant forsuch permit to
file a signed statement that he Is licensed pursuant to the provisions of the
Conlrad.r§ License Law (Chapter 9 (c m rax, i g with Section 7000) of Divi-
sion 3 ofthe Business and Profession Code).,that he b exempttherefromand
the basis for the alleged exemption. Any violation of Section 7031.5 by any
applicentf.rape, til b)edstheapphcenttoadvllpemityofno=mthan'�
five dred dollars ($500).
vhaa owner .f the property, or my employees with wages as their sole
compensation, will do the work and the strain re Is not intended or offered for
.1. (Sec. 7094. Business and Pro(eeslon Code: The Contractor'.Llcetue Law
does not apply to an owner of property who Wilds or Improves thereon, and
who does suchwork himself or through his own employees, powidecithat such
improvements are not Intended or.ffered forsale. If,howevegthebulldinger
Improvementissoldmthinoneyeamfcompletlorytheowner-WOderwillhave
tFp,purden of proving that he did not Wild orlmpruve forpurpoeeoleale)
Lf L as owner of the property, am exclusively contracting wilt lkemed
contractors to constmet the project (Sec. 7044, Business and Professions Code
The Contradorb License Law does not apply to an owner of property who
Wilds or Improves thereon, and who motraM for such projects with a
mn4actopdrs)) licensed pursuant to the Contractor's License Law.'
Lj I e em)rtr—undefS-ec. B A P C for ehle rcaeom
APPLIANCESRE57DEMTAL
]OB DESCRTPCION
x
Il
PANELS
_-yam
201"1000 AMPS
OVER 1000 AM
-
SQ. FT. FLOOR AREA
_
-$/SQ. Fr,
-
'SIGNSELECCTRI A
SPECIALCIRCUI
T�.(P METGRO LE IN
POWE EW
SWIMM7 G EL
VALUATION. J.
ull D 1-
L/ '
OUTLETS TCHFS ES
p Oct,
NEW RF -41D ALE TR FT,
STORI
TYPE CONSTRUCTION
-
,.
OCCGROUP
'•
RFS. UMTS
- TOTAL:
B-
QTY. ti;',_,t:,, ]aP[JMB1NGtPERMIT t`
PERMIT ISSUANCE
-
ALTER -DRAIN &VENT- WATER (EA)
,;;y r
E•''
'Zs r1m
FLOOD ZONE
APN
BACK FLOW PROTECT. DEVICE
,. :{:i•• :FEE'5UM11'fAR77,
""
Yi.
.
Owner_V/Cf(aa•[�' p "'�)"L��j,'T/r
DRAINS FLDOR ROOF, AREA, COND.
FIXTURES. PER TRAP
2( OQ
SANITARY RECE N
WORKMANCOMPENSATIONDECLAR TIOON---rte-
❑I hereby affirm that I have a certificate of consent to self -Insure, or
certifimwo(Workers'Compemationlmuranmoracertlfiedmpythereof(Sec.
3800, Lob C.)
Poll It
TAX Y N
RECEIPT M
GAS FA. SYSTEM -1 INCA OUTLETS
-
PARK FEE Y N
'
pA.SYSTFM-OVER4(EA)
Com any
Certified copy is hereby tcity
❑ Certified copy V filed withh the the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATIONINSURANCEbf
(TNssMi.n need not W completed If the permit V (Drone hundred dollars
($1ID)orfy that
Illrouehatoyan performance.!emanhe ner was tfor obecons,h this b)it is issued;
] shall rs Cempen any person In any manner co n to become eubjM t. the
Workers Compensation Laws o(CallfomW. Date
Applicant '
NOTICE TO APPLIGM:IL after making this Certlfkate.f Exemption; you
should becorre subject to the Workers' Compensation provisions of the Labor
C.de,youmustf.dhwithcomplywithsuchproN lonorthiaper tehallbe
revoked.
CONSTRUCTION LENDING AGENCYE1hereby a(firenthat there b a construction lendingagenry for the perform
ance of the work for which this permit V lssued(Sec. 3097, Civ. C.)
-
certitythatI have readthisapplicationandstatetht... above Informationiscomect.I agree to comply withaB dtyand munty Ordinances and state laws
to building construction, and hereby authorize representatives.(thiscitytoemerupon theaWva-mentloned property for Inspection purposes.
agree to save, indemnify an d keep harmless the City of Cupertino
against liabilities,judgments, mks and expenses which may In anyway accrue
against said City consaryence of the granting .(this permit.
CAS F.A.ECEIPT
WASTE INTERCEPTOR
BUILDING DIVISION FEES
PLANCHECIC FEE
PAID
Date Recei pt#
'
GREASE TRAP
SEWER-SANITARY-STDRM FA. 200Fr.
WATER HEATER W/VENT/ELECTR
ENERGY FEE Y N
_ —
PAID
Date Recei t#
' WATER SYSTEM/TREATING
�a OD
NEW RESIDENTIAL PLMB.__SQ.FT.
TOTAL:
TOTAL:
.l)0Lc.Le.dcr'aName
EE
Qa
QTY; MECT'IANICALI3ERIN[T`""
PERMIT ISSUANCE -
ALTER OR ADD TO MECH,�'(We)
AIR HANDLING UNIT(TO 10,000 CFM)
i ,'FGe'•t.''AL
FEE'Lender'sAddre.a
MBUILDINGFEEEdeemed
FEEI
'relating
Receipt#
SUBTOTAL•
AIR HANDLING UNIT (OVER 10," CFM)
CONSTRUCTIONTAX
SI a reof Applicant /Contractor Date
HAZARDOUS MATERIALS DISCLOSURE -
illtheappIluntorfuture building occupant store or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.12, and the
Health and Safety Code Section 25532(a)?
❑ Yes M No
Will the applicant or future building occupant use equipment or devices
which emit haeardom air contaminants as defined by the Bay Area Air
Quality Management District? -
�i�j Yes ❑No
]have read the hazardous material. requirements under Chapter 6.95 of
the CalifernW Health A Safety Code, Sed Ions 25505,25533 and 25534. 1
undcratandthatifthebuifdingdoes notcomently have a tenant, that It is my
responsibility to not lfy the occvpaa, of the requirerramts which must be met
prior t. issuance ola Certificate ofOmpanry. _ -
EXHAUST HOOD (W/DUCT)
CONSTRUCTION TAX PAID:
-
HEATING UNIT (TO 100,000 BTU)
-
Date 'ROCt#
ei
HEATING UNIT (OVER 100,000 BTU)'
.•
TA
TOL•
trh
VENTILATION PAN(SINGLE RESID)
ISSUANCE DATE
/�
PAID
,( -
U l�sU
pita of Cupertino
ISSl1ED'BY: l a H Il J,
BOILER -COMP QHPOR 100,0W BTU),
BOILERCOMP(OVER 100,000 BTU)-„w1AY
"" •'
NEW RESIDENTIAL MECH. SQ.FT.
'
Owner or aulhorlud agent' Date
' 1
.TOTAL:
OFFICE COPY V