19717APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Buuaing Project Identification
Bug' iAddress: _
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: CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BUfLDINGE.ECTRICALPLUMBINGMECHANICAL'
A -.
.2- —D-0 -IF D
co�anor.Name: LIe.No:
CATEGORY CONTROL N
Amhit Fs mer. Lic. No:
QTY ELECTRIC PERMIT' FEE
_
- BUILDING PERMIT INFO
Address:
-
PFRhIITI95UANCE _ U I)
..---Ice.,
IV I �I 5 1
1� L�7 LJ.O-
LICENSED EDCONTRACTOR'SDECns ofChON
I hereby e((irm thatlSm licensed under provisions of Gapter9 (common
ingwithSen1on 7000)ofDiWslon3ofthe Buslnemand Pmfesdom Code, and my
licenu le in Tali (o and dfect. _
Licenu
Date Contractmr �Fi�tll�.mt
ARCHITECTS DECLARATION
AI'I'LIANCESRFSIDENRAL
] OB DFSC ON '
�T�T Ga�I�tj'/
V V I `` \\ 6 Ip
6fLe�ovfGll��l.
-
PANELS .a
- '
AMPS
Z(VER
10
00AM
OVER 1000 AMPS
tQ FTFLODR
S/SQ. Ff.
(understand my pbnsshal be used as public records
SIGNS ELECTRICAL
Licensed Professional -
3 SPECIALCIRCUIT/MISC
OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor'• License Law for the
,
TEMP. METER RI'OL INS..
following Mason. (Section 7031,5, Business and professions Code: Any city or
county which requires permit to construct, alter, improve, demolish, or repair
anystmcture prior to Its Issuance, aLw requires the applicant for such permit to
file a signed statement that he Is licensed pursuant to the pmvlslons of the
POWER DEVICES
SWIPAPVNG POOL C
Off- TC A E J max
Contractors License law(Chapter 9(commencing with Se 7000)of Dlvl-
slon3of the Business and Professions Code) orthat he V exempttherefromand'
the basis for the alleged exemption. Any violation of Section 7031.5 by any
Brans fora mit sub' eta thea Ilcam toss dull It door mare than
fper )) PP Pe"a Y
VALUATI00'
D G
NE WR- LEL}tiC SQ.FL
fivedollars(55(s)).
1, as pro -
❑ I, as owner of the property, or my employees with wage as their suis
STO ES
TYPE CON'STRIKTION
compensation, will do the work and the structure is not Intended or offend for
sale (Sec. 70,14. Business and Pmfenloro Code: The Contractor's License Law
does not apply to an owner of property who builds or improves thereon, and
who doessuchwork himself orthrough hlsownemployees, provided that such
Improvements am not intended oroffered for sale. I(however,thebuildingor
-
OCC. CROUP
RFS. UNITS
'
V TOTAL:,7.0
Improvement is sold within oneyearofcompletion, the owner-bullderwlll have
th,9kurden of proving that he did notbulldorlmprove for purpose of nlc.).
U L as owner of the property, am exclusively contnMng with Ikensed
contractors to construct the project (Sec. 7064, Business and Pmfeabm Code:
Q Pk G ERMIT -FEE
FLOODLONE -
APN
IT E . ll_ DO
The Contractor. Llcense Law don not apply to an owner d property who
builds or Improves thereon, and who contracts for darn p(ojen. wdh a
,,LLt[[actor(s)licensed pursuant to the Contractor. License L.
LJ I am exempt under Sec. B k P C for this rcmonOUTSIDE
TPR DRAT k VENT WATER (EM
- FEE SUMMARY
BA FLOW PRCYiDCT. DEVICE
FEES
DRAIFLOOR ROOF, AREA, COND.
SANITARY Y N_
RECEIPT
Owner Date
WORKMAN COMPENSATION DECLARATIONSCHOOL
❑I hereby affirm that I have a certificate of consent to self-Insureor a
certificate ofWorkeri Compenaatton Insurance or a certi(led copy thereof(Sce.
3800, lab CJ •.
FIX, PFR TRAP b
TAX Y- N_
RFGm NN
CAS EA. SYSTEM -1 INC.40UILETS
PARK FEE Y N
RECEIPT#
I'mliryp
C,.mmpany s - N
GAS EA. SYSTFT4.OVER 4(EAI
_
BUILDING DI VISION Fr. ES '
.�Ur'crtified copybhercby famished.
. ❑ Certified appy V ❑led with the sty Inspection division.
GRFASE/NDUSIRL WASTE INTERCEPTOR
PLANCHECK FEE
GREASE TRAP
CERTIFICATE OF IXEM PTION FROM WORKERS'
PAID
SEWER -SANITARY -STORM EA. fiOFT.
COMPENSATION INSURANCE
'(This seMon need not be completed lithe permit is for one hundred dollars
Date Remi t#
WATER HEATERW/VENT/ELECTR
ENERGYFEE Y_ N_
-
($100)orless.)
I certify that In the performance of the work forwhich this permit Is Issued,
WATER SYSTEM/TRrATING
1 shall not employ any person In any manner eo as to become subject to the
Worken'Compcnsution Lawsd Cahfomla. Date
PAID
NEW RESIDENTIAL PLMB. SQ.FT.
Applicant
Date Recci til
NOTICETO APPLICANT: If, after nuking this Certificate of Exemption, you
should become subject to the Workers' Compensation provisions of the Labor
TOTAL:
BUILDIN
• Q O
Cade, you most forthwith comply with such provisions or this pevnit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
SEISMIC FEE
I hereby affirm that there is a construction lending agency for the per(ormry
ante of the work for which this permit is Issued (Sec. 3097, Cls. QI
Iendar. Name
Lender's Address
IcenRythatIhave read thisapplicaNmnand Yetethat theabove Information-
Iscomen. l agreeto complywith all city and county ordinances and Yate laws
7 TOTAL: v
ELECTRIC FEE
.O
PLUMBING FEE
- a,
QTY. MECHANICAL PERMIT FEE
MECHANICALFEE
PERMIT ISSUANCE -rip
FEES PAID-
1
relating to building construction, and hereby awhon representatives ofthis
cyto enterupon the above-mentioned property for inspection purposes.
(We) agree to save, indemnify an d keep harmless the City of Cupertino
agar Ilablllties,judgments, coatsand expenses which may In any wayamue
ALTERORADDTOMECH.
Z— ].�"t_
_ —=S-1i
Date Receipt#
AIR IiANDENG UNIT (TO 10,00(1 CFM)
SUBTOTAL:
aga said City In roes the granting d this permit. -
-
AIRxnNDUNcI)NIr(OVER lB,aoocFM)
CONSTRUCTION TAX
nature of Applicant/Contra r 'Date
( EXHAUST HOOD(W/DUCT( 6 , $-'p
CONSTRUCTION TAX PAID:
IF ZARDO MATERIALS DISCLOSURE
Will the applicant or future building occupant store orhandle havardom
HEATING UNIT OD 100,000 BTU)
Date ReceI t#
material as defined by the Cupertino Municipal Code, Chapter 9.17, and the
Ilealth and Safety Code Section 25537(a)7
❑ Yea No
Willtheapplicant Awn, building occupant use equipment or devices
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
I . Dp
- VFN'DLATION rAN(SINGLE MID)
-
ISSIO) 6.DATE
which emit haundous air contaminants as defined by the Bay Area Air
Quality Management Dut 7
_
,
BOILER -COMP OFT' OR 100,000 BTU)
yeso .
have read the Fara smatedab requlrcmcnb underChapter 6.95 of
, v _ ;, 199U
BOILER-COMP(OVEt 100,OWN
B)
the Glifornla Iiczlth k Safety Codq Senloras 75505, 25533 and 25534. I
understand that tit he buildingdoes"otcurmntlyhavcatenangthatitismy,
responsibility to notify the occupant of the requirements which must be met
prl texuanceu(a Ce' Blum Occopanry.
City of bin IRA
NEW RESIDENTIAL MECH. SQT.
ISSUED BY:_ -
raw d gent Data
'
-
TOTAL: /g. �%
OFFICE COPY V