24862APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY 5031_7 V f OR549,
OFFICE
CITY OF CUPERTINO BUILDING-ELECI'HICAL
DUILDING DIVISION APPLICATION/PERMIT PLUMIHNG- MECHANICAL
BIIILDNG PROJECT IDEN EFICATION
PERMIT NO. /� /y��
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BUILDI G DU S.
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SANITARY NO.
APPIJCATIONSUHMB7ALDA'IE
PONE: —3z
MOE
GINEER: LIC NO:
A'1'ORSNAME�, 1/'
„^rte II/l 1~//yM, l �l ✓
N/C
❑
CONTROL.#
CONI'ACI': PHONE:
QTY. ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE, ii5.
❑ V ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under pmvisimmofChawith
Section eland e f Division 3 of rhe Business and Pmfcssions lode, add my licenx is in
full force andeffect. S�LI`h
APPLIANCES -RESIDENTIAL
/]pere)(commencing
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JOB DESCRIPTION
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License lass hic.p .�/- /.
Date — Contractor
UPT02W AMPS I ti/,/s�)��pyY1
201 1000AMPS
J1�✓MHgV
ARCHFI'ECI'SDECLARATION
I understand my plans shall be used as public remn8.
-
SQ. IT. FLOOR ARTA
IJ o V
- C1P111
Il LE
0 LZ
$ISQ. FT.
OVER I" AMPS
SIGNS ELECTRICAL.
Licensed frofesomal
OWNER -BUILDER DECLARATION
hereby affimn mm 1 xm exempt from 0e Cpntrazwrs License law for rhe
following reason. (Section 7011.5, Business and Professions Code: Any city or county
which requires a permit to construct, alter, improve, demolish. or repair any structure
Prionnits issuunce,xlso requitxa tM1enpplicam fnrsuch #stenion Ne usignW smrement
that he is licensed pursuant the provisions or the Contractors License Law (Chapter
9(commencing with Section 7") of Division 3 of the Business and Professions Code)
or mat he is exempttherefrom and me basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects tire applicant to a civil penalty of
mm ore than five hundred dn1lars($500).
A n p
SPECIAL CIRCUIT/MISC. n 14'I
TEMP. MBTER OR POLE INST. C -
POWER DEVICES �. .I I-1
SWIMMING POOL BLE IC _
VALUATION
OUTLETS-SWRCHES- RES
NEW RESIDENTIAL BLECTR 5 I. -F
D'
lz
C.
❑ oche wok, add
will do thework,ands: The tune is...not .a enense, offer ed Toro, .,ec.]0in Business
forsthc(Sce. comrynsiness
and Professions Code: The Commcton, License Law does not apply lf an owner of
STORIES
TYPE CONSTRUCTION
�- 5
property who builds or improves rhereon, and whodoes such work himxlfnr through his
�empbyces.pmviJed lhm such improvemems are norimended proffered founle.If,
OCC. GROUP
RBS. UNITS
however. the building or improvement is sold within nae yearofcompletion.the owner
builder will have the burden of proving ma he did not build or improve for purpose of
TOTAL:
TY. PLUMBING PERMIT
Q FEE
s0 ).
❑ Las uwnerofthepfopeny,mnesinssand contractingwith licensed contractors to
FLOOD LONE
pPN
onetmn the pmjcct (Sec. 7044, Business and Professions Code:) The Commnor's
License Law docs not apply loan ownerofproperty who builds or improves minicar, add
PERMIT' ISSUANCE
whocnmmcrs for such projects with aconracmov) licensed parsulam to the Contractor's
License taw.
❑ I um exempt under gee. , B & P C for mis reason
DRAIN EA
M -TER- 1 )
FEE SUMMARY
BACK IT.OW PROTECT. DEVICE
OUTSIDE plips
SANITARY YN
Owner Data
DRAINS- FLOOR. RODE, AREA, COND.
RECEIPT#
WORKMAN COMPENSATION DECLARATION
❑ Thereby affirm thaslhaveacenificam pf <onrem to self -insure, oracenifipte of
Worker' Compensaion lnsurmttoracenifiW copy therepf(Sec. ]800. LaACJ which
covers all employee, under this permit. �!-" 1\�
Policy V VV
SCHOOLTAX YN
RECF.IPFN
FIXTURES - PER TRAP
PARK FEB Y_N
RECIiIna
GAS -IA. SYSTEM -I INC.40UTLErg
BUILDING DIVISION FEES
Comport, --------(A
ed
Certificopy is hereby fumishW.
GAS- FA. SYSTEM OVER 4( EA)
PLANCHECK FTE
Ccnified cagy is filed with the city inspection division.
GREASILINDUSTRL WASTE INTERCEPTOR
GRADING IEE,
C17RI[FICATE Op EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GREASETRAP
SOILS FTE
flttisxction ncednot lueompleted ifma permit's faronehundraddellam($108)
or less.)
SEWER - SANITARY - STORM EA. 200FT.
ENERGY FEE
D
I certify that in the perfornance of the work for which this Permit is issued, Ishort
not employ any person in any manna as m become subject to the Workers'
CAumpv.mIipm Lewsof Califomia. Date so
Applicant
WATER IHIATER W/VFNT/ELECl1
PAID
Date Receiprp
WATER SYSTEM/TREATING
NOTICB TO APPLICANT:If, after making this Certificate of Exemption, you should
bocomesubject join, Workers Compensation pravieimo.fthe Labor Code, you must
NEW RESIDENTIAL. PLMB. SQ. ff.
TOTAL:
forthwith comply with such provisions or this Ismail shall be deemed revoked.
BUILDING FEE
a
CONSTRUCTION LENDING AGENCY
1 hereby affirm that men: is a cansovaiod lending agency for the peAomnnnce of
the work for which this permit is Lsucd (Sea 3097, Civ. C.)
Lender', Name
SEISMIC FEE
TOTAL:
Lender. Address
c 1 certify tha I lave read this applicaion and arae ma me above information is
contact. (agree to comply with ell city and county oMinances end stere laws relating to
buildingcnnstmctingaW humby:alhorize repmacnalives pf mis city tocnterupon the
QTY. MECHANICAL PERMIT FEE
E
PERMIT ISSUANCE.
FEIJ
OR ADD TO MECH.
N I'AX
ahwememioned pmpeny for inspection puryosa.ALTER
(We) agree to save. indemnify add keep harmless Ne City of Cupertino againstliabilitiea.judgmems,lost and expenses which may in my way acme against said City
in consequence of the granting of this permit.AIR
AIR HANDLING UNIT(TO 10,OW CFM)
!FR
HANDLING UNIT (OVER IO000 CFM)
Signature of Applicant/Contractor Dae
EXHAUST FOOD W/DUCO
HEATING UNIT(TO 100,000 BTU)
IIA9.ARDOUS MATERIALS DISCLOSURE
Will the applicant nr future building occupant score or handle hazardous material
e Receipt#
AL:
as dellund by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 25532(x)?
HEATING UNIT (OV ER 100,000 BTU)
VENTILATION FAN (SINGLE RESID)
11 Yes 0 N
,
BOILER - COMP 3HP OR I00,(100 BTU
( )
s diZ,tIANCE DATE
/p��,,s Ii( of
r///
Will lair co icantorfmmre derio d by the Bay equipmentordevices MwM1lchemit
air conaminwts as defined by me Bay Area Air Quality Management
Chat
Disriq?
BOILER -COMP (OVER 100,000 BTU)
❑ Yes ❑ No
�eII
/s A� s( -Q
NEW RESIDENTIAL MECH. SQ ET.
of me
haveal he hazardous mcomme,s rcquim55J3 under Chapter understand
Californiah "d ty Cede, Sections 25505.255]3 d S:W. IundersmnJ shat
n curently have tenant, thmi nsibil' to notify the
ace.car which must be met Certificate ofdmA
9g3
r
Qty,
`G
BY:
gem Dare
TOTAL: ISSUED
OFFICE