23770APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALLPOINT PEN ONLY
Building Project Identification
feuding Address,: ys1r /J /
C%v / C ✓
PERMIT NO.
f/�
Y 770
ners are: one:
%J
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BUILDINGELECTRICAGPLUMBINC MECFfANICAL
A
� m
�^3qZ
cnn nr.Na LIc.No:
C S
CATEGORY
CONTROL N
Archlted/Engineer. - Lic. No:
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO '
Address: me I/' -lle
�tj 1 s�
, PERMITISSUANCR
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter 9(mcumme-
Ing with Section 7000)of Division ofthe Business and Professions Code, and my
Bronx is in tel orm and affect.
Llanx Clam 4A Lmura
Data Contractor
APPLIANCESRESIDENTIAL
Jp@DfSCRfI'fION
GG`
�
PANELS
201-1000 AMPS
ARCHH'ECPS DECLARATION
I understand my place Shall be used as public records.
OVER 1000 AMPS
SO. FT. FLOOR AREA
$M.Fr.
I SIGNS ELECTRICAL
Licensed ProfesslmW
SPECIAL CIRCUIT/MLSC
OWNER -BUILDER DECLARATION
I hereby affirmthat I am exempt fromthe Contractor'sLicense Law forthe
_
TEMP METER OR POLE INS T.
following reason. (Section 70313, Business and Professions Code: Any city or
eountywhich requires a permit tocommact, alter, Improve, demolish, ormparr
anystmdurc priorto Its Issuance, also rcqulrestheappllrant forauch permitto
file a signed Statement that Is Is licensed pursuant to the provisions of the
Contractors License Law (Chapter 9(mmmendng with Section 7000) of Divi-
Mona ofthe Business and Profearaos Code)orthat he is exempt iherefromand
the basis for the alleged exemption. Any violation of Section 7131.5 by anyI�
(ora permit subj Lathe applicant tlWi penalty of na more thanEI'SSWITCIiESFIXTUAES
POWER DEVICES
SWIMMING POOL ELECTRIC
VALUATION
I'� 600appilcant
NEW RESIDENTIAL ELECTR SQ,FT,
five hundred
owner ofthepm
I, as owner property, or my employees with wages as [herr sole
STORIES
TYPE CONSTRUCTION
will of
compensation, on, Bus doihe work and the Structure V cwt Intended or offered for
,
sale (Sec• Business, andf Code: The Contractors License !mow
applT44,y
to
does nonsuch torn owner ofpropertyhisoWilds nemorlmprovesthereoryand
property
who does hleownemployees,provided that Such
OCC.GROUP
RES. UNITS
ants amrnhlmxBorihrwgh
Improvementsarenot Intended oroffered pletio.the cam r -b deer ldingoe
improvement beold wlthinoneyearofcomplMlon,theowner-bullderwlll have
7p
the rden of pmAng that he did not build or Improve for purpose ofsale.).
Lj L as ..or of the property, am exclusively contnMng with licensed
contractors to construct the project (Sec. 7044, Business and Professions Code:
Q'ry. PLUMBING PERMIT FEE'
PERMITISSUANCE
FLCODZONE
APN
The Contractors Llcenx Law does nM apply to an owner of property who
Wilds or Improves thereon, and who ccm ra; for such pto(ects with a
cq=aeor(s)licensed pursuant to the Contractor's License Law.
-U I am exempt under Sec. B k P C for this reason
ALTER -DRAIN &VENT - WATER (Ek)
�.�
RACY FLOW PROTECT. DEVICE
FEE SUMMARY
OUTSIDE FEES
DRAINS FLOOR ROOF, AREA, COND.
HS PER TRAP
SANITARY Y_ N_
RECEIPT N
Owner Date
WORKMAN COMPENSATION DECLARATION
❑1 hereby affirm that I have a cese
rtl0caie of consent to se141nsure,
SCIMOOL TAX Y N_
or a
reMfioate o1 Workers'Comperuation Iesursnce m a ceriflW ropy thereof (See.
3800, Lab C.)
RFLFR'T N
GAS G.SYSTFM-I INC40UTLETS
PARK FEE Y N
PoliComryan
RECEIPTDI p
GAS G. SYSTEM -OVER 4 (FA)
BUILDING DIV] FEES
[�y
Certlflcd copy is hereby dwith the cit.
❑Certified copy V filed with the city im)xchon division.
GREASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECKFEE
CREASE TRAP
CERTIFICATE OF EXEMPTION FROM WOR KER S'
COMPENSATION INSURANCE
(This section need not becompleted BIM permit V (Drone hundred dollare
PAID
Data Rec01 I#
SEWE&SANITARY-STORM FA. 20OFF.
(5100)orlm.)
Icertify that in the performance of the work for which this permit la issued,
I shall not employ any pereon In any manner So as to become abject to the
Workers Compensation Laws of Calif.U. Date
WATER HEATER W/VENT/ELEGTR
ENERGY FEE Y N
PAID
WATER SYSTEM/TREATING
AppliNOIICant
ellermakingthis Certificateof Exemption,you
ShoulNOTICEca eaubjC 1. the
mthe Work err' Compensation Labor
it
Date Recei t#
NEW RESIDENTIAL PLMB, SQ.FT.
TOTAL:
Code, you forth Ins isinprovbiorer
Cade, you must forthwith comply with such provbiom orchis permit shall be
s
deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a commadion lending agency for the perforce,
ance of the work for which this permit is blued (Sec. 3097, Civ, C.)
T
7ER
Lender's Name
Lessers Addre„
I certify that lhave re.1this applicatlonand Statethatthe above Information
Is corned. I agree to comply with all cit and county ordinarme and elate laws
relating to building mmtrucilo rcpresentalives of this
QTY. MECHANICAL PERMIT ' •E
E
FEE
PERMITISSUANCE I
at y the nmeM perry for pectlot purposes.
(We) agree to a fy an ep harmle the City of Cupertino
ALTQr ORADDTOMECH.
Date ReCCI f#
P
agalast Ila 11ties,j, rats, ca pensesw may m eitywayacerue
agalrot dCity in o mai gnntl this Pe L
_ _ qj
AIR HANDLING UNIT ITO I oalcrM)
SUBTOTAL:
AIR HANDLING UNIT (OVER 10,000CFM)
CONSTRUCTION TAX
cant rano Date
IXHAUS'r HOOD(W/DUC'D
CONSTRUCTION TAX PAID:
HA RDO USM RIALS DISCLOSURE
W huapplican orfutumbuildingo antstoreorhandleha rdous
mat las dean y the Cupertino Municipsl Code, Chapter 9.12, and the
Date Recei t#
I'RiATING UMT(TO 100,00007W ��•
-
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
Heall Cade+- Section 23532(1)7
❑ Yes No
Will the applicant or future building ocvpant use equipment.,devices.
which emit havantous air conmmmenta as deflmA by the Bay Area Air
VENTILATION FAN (SINGLE RFSID)ISSUANCE
DATE
BOILER -COMP OW OR 100,0M BTU)
Quality Management District?
Yea n❑ No
have read the hazardousouterlals requirements under Chapter A95 of
g.� A
P M
BOILER-COMP(OVER 100,000 BTU)
the Celifernia health k Safety Code, Sedlons 2550.5, 25533 and 25534. I
understand that if the building does not currently have a tenant, that it is my
respomibility to notify the occupant of the requirements which must be met
?JUN -'S 1rr�r�
,`l{(,�a�J�CJ/l
NEW RESIDENTIAL MECH. - SQ.FT
prior to issuance of a Certificate of 0empancy.
Cit i Vh c�ury
ISSUED BY:
Owneror mthori>ed agent Data
T L
OFFICE COPY