2347APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Bending Pm'aC Identification
BuOding Address:
PERMITNO.
A1*7-11,lell
23477
wn a sure: one
(^�:fa� p��
CITY OF CUPERTfNO-BUILDING DIVISION
APPLICATION / PERMIT
BUfLDINGELECnUIC PLUMBING -MECHANICAL
^�1
paor�mc o 3 DLic No
SS
CATEGORY
CONTROL N
Ar,hiteR/Engineer. Lk. No:
QTY' ELECTRICPERMIT FEE
BUILDING PERMIT INFO
[//
Address .3 Da ��
PERMITISSUANCE
1:1 ❑ ITLICF.NS
ED CONTRACTOR'S DECLARATION
I herertn(hatlam licensedl underr anenc
IngwithS;edton7000)ofDivsion3ofthegusimandPmfeWonsCDde,and my
I efuB forte cites. 3 D
LlmnseC k.pV
AIPLIANCESRESIDENTIA
JOB DESCRIPTION
av N Y 1
PSP
PANFIS
Date Contractor20
201-1000 AMPS
ARCHITECTS DECLARATIO
OVERI"AMPS
SQ. FT. FLOOR AREA
$/SQ.FL.
(understand my plamshall be used as public records.
SIGNS ELECTRICAL
Licensed Profesalanal
OWNER -BUILDER DECLARATION
Ihereby afBnn that l am exempt from the Contractors License Law for the
following reason. (Section 7011.5, Business and Professions Cade: Any city or
countywhich mqulma permitwcomtma, altep impmve, demolish, arrepair
n
LED IN
IPJ
r� UTE R
SPECIALCIRCUIT/MIST
TEMP. METER OR POLE INST.
enystmd mpriorwits6mance,as mquimatheapplleanlforsuchpermltto
file a signed suatereent that he 6 licensed pursuant to the provisions of the
POWER DEVICES -
DATE
,
SWIMMING IDOL ELECTRIC
OUTLETSSW17CiIESHXTURES
ContractorsLicense Law (Chspter9(commencing with Section 7000) of Divi-
cion 3 of the Business and Profeseloro Code) orthal he 6 exempt therefromand
the basis for the alleged exemption. Any violation of Section 70715 by any
applicant fora permit subjects the applicant to a civil penalty of not room than
VAL A ON
/ +T !/ ysO
P
NEW RESIDENTIAL ELECTR _SQ.FI'.
five hundred dollars ($500).'
❑ I, as owner of the property, or my employees with wages as their sole
STORIES
TYPE CONSTRUCTION
compensation, will do the work and the structure Is not Intended or offered for
'
sale (Sec. 7044, Business and Professions Code: The Contractors License Law
,
_
does not apply to an owner of prore
property who builds or improve,theon,and
whodoessuch work himself orlhru gh hlsownempleyees, provided that such
OCC.GROUP
RES. UNITS
Improvements are not Intended uro(fered forsals. 1( however thebullding or
Improvement 6eold wlihinoneyearafCompletion,lM1e owner-bullderwlil have
TOTAL:
t rden of proving that he did not build or improve for purpose of sale.).
4 as mucor of the property, am exclusively contracting with licensed
contractorsct comtcen the am Code:
(Scot appy Business and Iof
QTY. PLUMBING PERMIT FEE
PERMIT ISSUANCE
FLOOD ZONE
APN
w doe
License Law red not apply to an owner of property who
pro
The Contractor's Improve.
Wild. or Improves thereon, and who contrast !or such projccta with a
clip[ dor(s) licensed pursuant to the Contradorb License Law,
Ll l am exempt under Sec B & P C for this reason
ALTER -DRAIN & VENT- WATER (EA)
gA�HpWpROTECT. DEVICE
FEE SUMMARY
DRAINS FLOOR ROOF, AREA, COND.
PER TRAP
SANITARY Y N
a
RECEPrFIXTURES-
Avner Date
WORK MAN COMPENSATION DECLARATION
❑I hereby affirm that I have a of connart to ora
SCI{OOLTAK Y_ N
o Insurance
certificate 8MLab afWorkers'Compensatlon Wuvnce oracertified copy thereof (Sec.
c copy
3800, Lab CJ Ztfi9GG —'2`
Pollry N _ _
-
RECEIPT p
CAS E.A. SYSTEM -1 INCAOUTLETS
PARK FEE Y N
RECEIPT X
GAS EA. SYST'Wd OVER 4 (EA)
Com any '
BUILDING DIVISION FEES
F�Ce Ified copy S hereby furnished,
CEJ coined copy 6 filed with the city lope Non division.
GREASE/WDUSTRL WASTE INTERCEPTOR
PLANCHECKFEE
CREASE TRAP
CERTIFICATE OF EXEMPT ION FROM WORKERS'
COMPENSATION INSURANCE
(Thissection need not be completed lithe permit 6 (Drone hundreddollars
($1p0)or lea.)WATER
l aAifythat in the perfornunce of the work for wN<h (his permn I. issued,
I shall not employ any person In any runner so as to become subject to the
Workers'Compensatlonlawso(Canfom6. Date
PAID
Date Recei t#
SEWER-SANITARY-SMRM EA. 200FC.
HEATER W/VENT/ELTlTR
ENERGY FEE Y N —
PAID
WATER SYSTEM/TREATING
Applicant
NOTICE TO APPLICANT: after making this Certificate pr is Exemption, you
should become subject to the Warken'Compensatlon provlstons o(the Labor
Code, you must forthwith comply with such provisloru or/hls pemdt shall W
revoked.
Date RCCCI t#
NEW RESIDENTIAL PLMB._SQpr.
TOTAL:
s,, --adeemed
U WING
-TOTAL:
SEISMIC FEE
ELECTRIC FEE`
CONSTRUCTION LENDING AGENCY
Iherebyaf,.thatthere 6amnstructlon kndingagenryfortheperform
once of the work for which this permit is Wood (Sec. 3097, CIv. C.)
fender'. Name
Lenders Addrea
nand statethatthe above
I certify(hm I have read fhbth
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
MECHANICAL FEE
FEES PAID:
6correct.lagree to comply with andlyand county ordimncesand mate
allcityd mate laws
PERMIT IBSUANCE
relating ronstruNo,eendherebyauthorize representatives o(th6
terupont
ci (Wellto agree to sae, Indemnify an
property harmless Cit purposes.
(We) agree to ave, Indemnify an d keep harMes the City of Cupertino
against liabilities, pdgmente, emisand expenses which may in anywayaccrue
.g. red vl Try In en rt grantingof �
tM1l. nnit
��� ��
ALTER OR ADD1D METH.
AIR HANDLING UNIT (TO 10,000 CFM)
Date Recei t#
SUBTOTAL:
AIR HANDLING UNIT (OVER 10,000CFM)
CONSTRUCTION TAX
Ignatvre of Applicant/Cehotracior Date
EXHAUST HOOD (W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (TO 100,000 BTU)
Will the applicant the ure budding occupantods, hapten ie hazardous
material as defined by the Cupertino Municipal Coda Chapter 9.12, and the
I and Safety Code SeRioo 25532(a)2
❑ Yes No
Date Reepl
TOTA
HEATING UNIT (OVER 100,000 BTU)
VENTILATION PAN(SINGLE RESID)
ISSUANCE DATE
p
a1
q .SR
�\
'T \/4`eV`/
Clry� NO?
Will the applicant or future building occupant use equipment or devices
which emit havrdoua air contandnante as defined by the Bay Area Air
Quality Management District?
Yesn4 No
have read the bsadrama.ficr66 requiromenb underChapter6.95of
the Ce1Rom6 Health & Safety Code, Sections 25505, 25533 and 25534. 1
u red ersta nd that if the building does not eu mently have a tenan((hat it I, my
responsibility to notify the occupant of the requirements which most be most
prior to exuance of a Certificate of Occupancy.
BOILER -COMP QHPOR 100,000 BTU)
BOILER-C'OMP(OVI➢i 100,000 BIU)
NEW RESIDENTIAL MECH. SQ.17
h 2
ISSUED Bu
Owner or authorlud agent Data
TOTAL:
OFFICE COPY