21909APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification Sos�ti�til�o {gyp
Building Address:
M � i iJ�J, c.00-0 `tI5 14 1-2770
PERMIT NO,
f"I a� ^ O
G I t�Jj ly7
caneTr^, came:Phone-
1dct�1 - N O S 22J 82.
CITY OFCUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
APPLICATIONS
`� 7 /
f
Contraors Name: Lie. No:
BUILDING-ELECTRICALPLUMBING-M HANICAL
CATEGORY
COITaTI I /
Arch's en/Engineer. Llc. No:
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Addrns:1
PERMITISSUANCE IIA Cit,
�I
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that lam licensed under poundersof Chapter 9(comment.
[nano, is in full formanDiNect. (the8u,insaandl'rofesslonsCAde, and my
license b in fun farce and effect.
APPLIANCESRESIDENTAL
JOB DESCIZ' ON
PANELS
License Clae9 LIc.R
jPOO
Data Contractor
IM TO 200 Al,25
201-1000 AMPS
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
OVERIODOAMPS
SQ. FT. FLOOR AREA
S/SQ. FT.
SIGNS ELECTRICAL
Licensed Professional
OWNER -BUILDER DECLARATION
Ihereby wingrason.(that
ction7 xemptfrom
followingreason.ossa Contractor's License Law fort he
reclu (Section it tocxusines"t Profession Code: Any mpality r
any stricturetatemepirborto lts that he Issuance, also requlresthe ttothet or rewlalhe,ofpermit e
anycoustruclum requbsa permit tomntnuiresthe a prove, demsuch,ar to
010 a signed statement that he t licensed pursuant to the provisions of the
with xectknherefom andl.
Contractor's License Law usiness and V exempt therefrom and
the basis the xemptionC Any
the basis for the alleged exemption. Any violation of section 70315 by any
Applicantdforapears(subjectathc applicant toacivil penalty do«more than
fWe hundred dollars he pr).
the property, or my employes with wages r thele sole
I, as owner will
compensation, workand the mrocture Is not Intended oroffendfor
as
H
�\ n n
C) b V e TER
'
SPECALCIRCUIT/M15C I �7 CDJ
TEdp METERORPOLEINST.
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS -SWITCHES -FIXTURES
V qTI
n
�4/ a
NEW RESIDENTIAL ELECTR � �
STOIRIES
TYPE CONSTRUCTION
70K Business
sale (sec. 7070, Business and Professions Code: The Contractors License Law
does not apply to an owner of property who W lids or improves thereon and
who doessuch work himselforthrough his own employees, provided that such
OCCGROUP
IUNIIS
❑nprovementsamnotlntendedorofferedformle. l(howevegthebulldingor
improvement ksoldwithinomyearofcomplelontheowner-bunderwill have
TOTAL:
th_tkunlca of proving that he did nmbuildorimproveforpurpouufaak.).
I, as owner of the property, am exclusively Contnatng with —1—
contractors ec
to construct the project(S. 9074, Busir and Professloru Code:
The Contractor's License Law don not apply to An owner of property who
or Improves thereon, and who contracts for such ptujects with a
<gtil[actoKs)11sensed pursuant to the Contractor's License Law.
I_J I am exempt under Sec B & P C for this mason
QTY. PLUMBING PERMIT FEE
PERMIT ISSUANCE I ^s , x�
-
EATER -DRAIN &VENT WWATERbuilds (EA)
FLOODZANE
APN
BACK FLOW PROTECT. DEVICE
FEE SUMMARY
Owner Date
WORKMAN COMPENSATIONRECEIPT
WORKMAN DECLARATION
QI hereby .(firm that I have a ttniB«te of consent d self -insure, or a
«rti(Icate of Workers Compansatlon] ran certi(kd Ihemof (Sec.
3ROq Tab C.) , L� ra0 �`
Poiicyp `� U
( DRAINS FLOOR ROOF, AREA, COND. 'Z.Oa
SANITARY Y N_
M
FD(TURF5- PER TRAP
SCHOOL TAX Y_ N_
RFCEIeTM
GAS EA. SYSTEM -1 WCA OUTLETS
I "],s (J�
PARK FEE Y_ N
RECFR'Tx
Com any �—
Certified copy B hereby formal ed.
CenUed copy is filed with the city inspection division.
GAS EA. SYSTEM -OVER 4(EA)
GREASE/WDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
PLANCHECKFEE
GRFASETRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thl,ac ftmotaed net be completed tithe permit hhundred dollars
PAID
Date ReC i t#
193''3
SEWER-SANITARY-STORM
STORM EA. 20OFT.
($]Inoify th in )WATERHEATERW/VENT/ELECTR
1«not thatoy any amoninaoftmanner so sa tobehbpennitbuo the
I shah not employ any person in any manner ro n to become subject to the
Compensation Laws of California.A.�
Workers ry fornfa. Date
Applicant
NOTICE TO APPLICANT; if, after making this Certificate of Exemption, you
should become subject to the Workers Compensation provision of the Labor
Code, you meat forthwith comply with such provisions or this permit shall W
deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby a((trm that there b a construction lend Ing agency for the perform-
antt of the work for which this permit V Issued (&c. 3097, Civ. CJ
Tender's Name
Lender: ndare,a
I «rtlfythat I havereadthbapplkatlonand state that theabove information
Is rornxt. Iagrcetocomply with allcity and rountyordlnancs and state laws
relating to bulWing construction, and hereby authorlu representation o(th6
city to enter upon the above -mentions property for Wpecron purposes.
(We) agree to save, Indemnify a d keep harm] m the City of Cupertino
against liabilitls,judgments, costs and expenses p'hich may In any wayaccrue
again said Gtyin conte`' n«o(the granting o(this permit.
ENERGYFEE Y N
PAID
Date Recei t#
SYSTEM /TREA7IDIG
NEW RESIDENTIAL PLMB.__SQ.FT.
TOTAL:
B IL TNG
�t
TOTAL: ' �Q
SEISMIC FEE
ELECTRIC FEE
l
'Z s Ro
QTY. MECHANICAL PERMIT FEE
s�
� PERMIT ISSUANCE tl+i�
ALTERORADDTOMFCH.
AIR HA NDLING UNIT (TO 10," CFM)
PLUMBING PEE
L t
MECHANICAL FEE
7
FEES PAID:
Date Receipt#
SUBTOTAL:
AIR HANDLING [A'IT (OVER l0,000CFM)
CONSTRUCTION TAX
(.0 ,l,('" L 4 7�1'il L,3n �I
s n eof Applicant/Contrecior Dates
HAZARDOUS MATERIALS DISCLOSURE
Wlllthe applicant or town, bulldingoccupant store or handle haaardous
material., defined bythe Cupertino Municipal Code, Chapter 9.1 3, and the
Health and Safety Cede sa �Section 25532(a)7
F1 Yet, u No
Willthe applicant or future buildingoceupant use equipment ordevio:s
which emha
it sardous all Cont -malaris m deo and by the Bay Arca Air
Quality Management Dist rict7
11 ❑ Yn the h Q No
! Thawnia Heath&Ssous Code, Se rcons Z5nt,undeandCha pter 25534.1 of
/the Californiaatifth &Shiny Code, Sell tons tlyhve a tenant that 7
understand thatn rify the occupant of the requirements which most be met
of me currently seats tenancy that it met
rnpr to Issuance,
to of a Certificate
prior to Issuance N a Certl(kate of Occupancy.
EXFAUBTHOOD(W/DUCA
CONSTRUCTION TAX PAID:
CDC
HEATING UNIT (TO IMODO BN)
Date Reaei t#
_
HEATING UNIT (OVER 100.000 BTU)
TOTAL:
VENTILATION FAN (SINGLE RESID)
ISSUANCE DATE
P I�12
/App 3 U
APR J TMa
���trn0
ISSUED BY:
BOMER.COMP (3H P OR 100," BTU)
80ILFR-COMP(OVER IW,OW 87U)
NEW RESIDENTIAL MEIN. SQ.FT
41 Po-ky_5'
Owner or authorlud agent Date
TOTAL: Sa
OFFICE COPY