23610APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project identification
Bufidm Address: . .
P TNO.
23610
r. ane:
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION if PERMIT
BUILDINGELECTRICALPLUMBIN~UMEC AL
Itect r. L
CATEGORY '. CO
QTY ELECTRIC PERMIT V 171.,E
BUILDING PERMIT INFO
Addmse I /
'�j ❑ ❑ ❑
PERMITISSUANCE 1, J
PPLANCESRE L
AP
IC S DCONTR S CLARATIO
ffern r ro1[viA eplo
Inss I • Iherebyn�d
n (dB fa haatnf seen
Ingwlth&con7000)ofDiWsion3oftheB"sandPm(eWoneCodendmy
,
lcen . s/
D�ESCR�B'TION
_u
lfcf.eMct�Licensed
"n/�
'�✓
LDate
��JOB
-e
Can or f
ARCHITECTS DECLARATION
?tall
SQ. FT. FLOOR AREA
5/SQ. FT.
I understand my plan shag be used es public records..
GNS ELEC A
Licensed Professional
SPECIAL CIRC M(SC
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor. License Law for the
TEMP. METER O POLE ST.
following reason. (Section 70315, Business and Professions Code: Any city or
county which requbn a permit W construct, alter, Improve, demolish, or repair
any.truclure price to its Wunece,alsor•quires the a ppllcent fm..uh permit to
file a signed statement that he Is licensed pursuant to the provislom of the
EOW'FR DEVICES
SWIMMING LELECTRTC
OUTLE SWITCIffSHXTTIRES
Contractor's License Law (Chapter 9(commencing with Sen1on7000) of Divi-
Mon 3 o the Business and Professions Code) or that he Is exempttherefroma ed
the basis for the alleged exemption. Any violation of Stolon 7031.5 by any
applicant for a permit subjectstheapplicant to a civil penalty of net more than
_
VALUATION ieTTJ
/ / _ fO LL—S
I DC7 CXD
fiv^e,rundrtd aolho (5500).
Lf I, as owner of the property, or my employees with wages as their sole
R�DPNTIAL ELECTR SQ.I•T.
STORIES
TYPE CONSTRUCTION
competsation,will do the work and the strueturc Is not Intended or offered for
sle (Sec 7064, Bustrss and Professions Code: The Contractor's License Law
does not apply loan owner o! property who Wilds or improves thereon, and
whodo owchworkhir lforlhrooghhisuwnemployees,provldedthaleuch
OCCGROUP
RES. UNITS
Improvements are out intended or offered for sale. If, however, the building or
TOTAL: -
improvement Is sold within oneyearofcomplefionth, ownervbuilderwill have
dia.fl vden of proving that he did out WOd or Improve tar purpose of sale.).
LJ
Lcommucter owner of the property, em exclusively contracting with licensed
to the project (Sec. appy Business and Professions;
rt Code;
QTY, PLUMBING PERMIT FEE
FLOOD TONE
APN
PERMIT ISSUANCE
The Contractors
acts rs License
The Caor lonpr'e Llcene Law don not apply to an owner of property who
property
Wild. or Imprwn thereon, and who wntncts ice such p(okcts with a
Mfflctor(eexempednder Set to the Conlnrtors License Law.
LJ I em exempt under Sec B k P C for this reason
ALTER -DRAM k VENT- WATER CEN
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
DRAINS FLOOR ROOF, AREA, COND.
SANITARY Y_ N_
RECEIT M
Owner Date
WORKMAN COMPENSATION DECLARATION
~I hereby affirm that I have • ceHficele of consent to se161nsum, ora
cert orate ofWorkers' Compensation Insurance or a certified copy thereof (Sec.
lab C.)
Policy
FIXTI7RF- PER TRAP
SCHOOL TAX Y N
RECEIPT 0
GAS EA.SYSTEM-I INCA OUTLETS
PARK FEE Y_ N
RECRIPT p
ollry N
Com any
GAS EA. SYSTEM.OVER d (EA)
BUILDING DIVISION FEES
Certified copy Ish I., famished.
Carolled copy Is filed with ted city Inspectiondivlelon.
GREASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECKFEE e-2:04
O
GREASE TRAP
CERTIFICATE OF O(EMPTION FROM WORKERS'
PAID
COMPENSATION INSURANCESEWER-SANITARY-S10RM
(Eu.sectlon need not becompleted Bthe pemdl leforors hundred dollars
Date Recei tp
E.A.210Ir1'
WATER HEATER W/VENT/F1.ECTR
ENERGYFEE Y_ N_
($101)arless.)
I mrtify that In the performance of thework forwhich this permit Is issued,
-
WATER SYSTEM/TREATINGWorkeri
I shall not employ any person In any manner se, u to become subject to the
Compensation Lawsof Callfornla. Date
PAID
NEW RESIDENTIAL PLMB. BQ.FT.
Applicant -
NOTICEco APPLICANT: If, after makingthisGartmore ofExemption,oft the
should become subject to the Worken'isiCompensation provisions althe Labor
Date Recei til
TOT
pi
deemed ymaud ou forthwith comply with such provisions or this permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
BUILDING
SEISMIC FEE
Iherebyaffirm that there Is a construction lending agency for the perform-
ance of the work for which this permit Is Issued (Sec. 3097, Civ. Cd
1e.der'. Name
Lenders Addres.
I certllythat I have readthis applicetlonand slatethattheabove Information
iscom't.I agree to comply with all city and county ordinances and Mate laws
TOTAL:
ELECTRIC FEE
PLUMBING FEE
QTY. MECHANICAL PERMIT FEE
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID:
relallog IoW Tiding comlroHan, end hereby authmoce representativesof this
city to enter upon the above-mentloneci property far Inspection purposes.
(We) agree to ave. Indemnity and keep harmless the City of Cu part
iudgmequencecosts and expense which may In any way accrue
acerve
against hail
Date Recei tN
JALTERORADDTOMECH.
AIR HANDLING UNIT (TO 10,000 CFM)
SUBTOTAL:
agahut old City in consequence of the granting of this permit.
City
14r
AIR HANDLING UNIT (OVER lO,WOCIM)
CONSTRUCTION TAX '
natureof Appeont/Contrector .' Date
F7(HAUSTHOOD(W/DICT) -
CONSTRUCTION TAX' PAID:
HAM RDOUS MATERIALS DISCLOSURE
HEATING UNIT (ED 100,000 BTU)
WIIl the applicant orfuture building omapant store or hand Is hazardous
nstertil as defined by the Cupertino Municipal Code, Chapter 9.1 7, and the
Health and Safety Code Sedion 75S32(a)i
❑ Yes MN.
Date Rete'
JL
HEATING UNIT (OVER 100,000 BTU)
'FO
VENTILATION FAN(SINGLE RE5ID)
ISSUANCE DATE
WIII the applicant or &tore building occupant use equipment ordevices
which emit harardous atr contaminants m defined by the Bay Area Air
(Nailty, Management District?
I-1 No
F-1 love
`T'�verthe tavr�oetyComaterials,Sectiquiremenh5533 aChapter. 1 of
the Californiaandt Health and 25534. I
Code, Sectiomntly
PAID
BOILER -COMP OHP OR 100,000 BTU)
BOILER -COMP 100,000 BTU)
NEW RESIDENTIAL MECH. SQFf
building h ve ate that itIsmy
not mrrendyhcritsw
understand that if thenosily
responsibility to of the rementswhich must be met
the occupant which
prior to issuance ofeCedlticete o(Ompanry.
WAY27
ff��}}I/IH
ISSUED$S•MWj&! �A"
Owner or authorized agent Data
- TOTAL:
—"va+P"""e'c I-It'ttY
OFFICE COPY