23152APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification
go Ing Aad
PERMIT NO.
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CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION/ PERMIT '
BU[LDINGELECTRICALPLUMBING-MECHAMCAL
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C ole Name: !� Llc o:
rchllect/ls1441 ik
grocer. Lie. No:
GATE -CORY CO LRllf
QTY ELECTRICPERMIT FEE
'BUILDING PERMIT INFO
Adde.s
"I 1 6 1'
u L❑
PERMIT ISSUANCE AP
LICENSE TRACTOR'SU C RATION
Iherebya(firrnthatl licensed under president, alChapter9(coruvmc-
Section 7000).!Db,bI n3oftheBuslncsaand Professlons Code, and my
littn.e le In fullfes d affect
Limn Lic. M(Q_Q�
APPLIANCESRESIDENTIAL
JOB DESCRIPTIONIngwith
_.�
1
PANELS
-I
Date Contract r
IM TO 200ANTS
201-IMOAMPS
ARCHITECTS DECLARATION
I understand my pl...hall be used as public record,
OVER1000AMP5 a,SQ.
FT. FLOOR AREA
$/SQ. Fr.
SIGNS E TRICAL
Licensed Professional
"') / '�
7
OWNER -BUILDER DECLARATION
1 hereby .fibro that Ism exempt from the Contractor'.Li... Law for the
SPE4JALC CUI /M
o'� b
TEMP. R LE INST.
following mason. (Section 703 S, Bu.iness and Profesalons Code: My a ty.r
countywhich requires a permit toconstrvct, alteq Improve, demolish,orrepair
any.tructure prlorto Its is.uance,also require.theappllraut forsuch perMtto
file a signed statement that he Iv licensed porment to the provisions of the
Contracture License Law (Chapter 9(commencing with Section 7000) of Divi-
Men 3 fthe Business and Prefemlons Code) or that he b exempt therefrom and
the bassis for the alleged exemption. Any violation of Section 7011.5 by any
applicant for a permit subjects the applicant to a civil penalty a not more than
five hundred dollars ($500).
n1, as owner of the property, or my employees with wages cue (Felt sole
POWER DEVICES
SWIMMING POO CTRIC
OUTLETSSWITCHES It
VALUATION
(�
NTiW RE9DENTIAL SQ.FT.
STORIES
TYPECONSTRUCTION
compensation, will do the work and the structure Isnot Intended or offered for
sale (Sec 7044, Business and Professions Code: The Contractors License Law
does not apply to an owner of property who Wilds or Improves thereon, and
who doessuch work himself orthrough his own employees, provided that such
OCC. GROUT'
RES UNITS -
improvements are not Intended oroffered for sale. If, however, thebullding or
Improvement beold within oneyear o(complello, the owner -W Ilderwlll have
T
t ano( proving that he did not build or Improve for purpose of sale.).
as owner of the property, am exclusively contracting with licensed
ractone to construct the project (Sec. 7044, Business and Professions Code:
QTY, PLUMBING PERMIT FEE
PERMIT ISSUANCE
FLOODZONE
APN
e Contractors Lianse Law don net apply to an owner of property who
Wilds or Improves thereon, and who contracts for such p(ojects with a
eqn(actor(.) licensed pursuant to the Contractor's License Law.gpC((p(OW
u I am exempt under Sec B A P C for this mason
FEE SUMMARY
PROTECT. DEVICE
DRAINS. FLOOR ROOF, AREA, COND.
Fp(TURES PER TRAP
SANITARY 'Y N
RECEIPT p
Owner Date
�.�1 WORKMAN COMPENSATION DECLARATION
certificate"hereby affiork chat I have o certificate of consent t. opl-themod ora
0,LbC.) rkern Compensalonlnsurame ora certified copy thenaof(Sec.
3800, leis C.)
SCI FOOL TAX Y_ N_
RECEIPT M
CAS F.A. SYSTPM-1 iNC.4 OUTLETS
PARKFEE y N
Policy N_
RECEIPT M
Com any
Cul
opybhereby umbred'
m CertIB copy b filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(I'hlssectlon need not be completed lithe permit b(orona hundred dollars
(81I urdlem.)
eenNt lc booed,
Ill not that lethe person
I .hall not employ any person In any manner ro a to become subject t. the
In an theworkmanner to as to become
Workers'Compencatlon Laws o(GIIlornb. Date
Applicant
NOTICETO APPLICANT: If, after making this Certlfiate of Exemption, you
should become subject to the Workers' Compensation provisions ofthe Labor
Code, you must forthwith comply with such provisions orthls permit shallW
dnmed m..nkad.
CA -0 Eftd(EA)
CR E R
BUILDING DIVISION FEES
PLANCI-]ECK FEE
PAID
Date RC tq
310 a
CR r
SEWER-SA[a,1.I•ARY S70
WATER ]iEAi771 '�
ENERGY
Y
PAI
aD �a
WATER SYSTEM]/TREATING J
NEWRESIDENTIALPLMB. SQFT.
Date R 1 tIF
14
/NS T ev$f�r
TOAL:
B I D
%
TOT
B$ S IC E
EL RI FEE
a
CONSTRUCTION LENDING AGENCY
]hereby affirm that there is a construction lending agency for the perforce,
.nae of the work for which this permit b Issued c. 3097, Civ. C.)
Le.daraName
Lenders Address
I cedilythel have read this applicatlonand state that theabove information
PL B TE
QTY. MECHANICAL PERMIT FEE
M CHANICAL FEE
FEES PAID:
iscoreact. l agree to comply with all city and county ordinances and mate law.
PERMIT ISSUANCE
relalleg to building constNOidg7lind herebyauthorize representatives olthb
city to enter upon th vv - boned property for inspection purposes.
I(Wo) agree t ve, Ind 1( the City of Cupertino
ALTERORADDTOMECH.
Date eceipt#
ag.bodl ,pdS stsandexpense mayln anywayaccrue
against sa by inc s e (the - ego(thle permsit.
AIR HANDLING UNIT CFO 10,OW CFM)
SU OTAL•
AIR HANDLING UNIT(OVER 10,000 CFM)
CONSTRUCTION X
vmre ppBant/Contractor Dale
EXHAUST HOOD(W/DUCT)
CONSTRUCTION X PAID:
HAZARDOUS MATERIALS DISCLOSURE
HEATING UMT(TO 100,(00 BTU)
WE cappBcanl or future building occupant store or handle hazardous
material a. defined by the Cupertino Municipal Cod, Chapter 9.1 7, and the
Date CCI
HEATING UNIT (OVER 100,000 BTU)
T
Health and Safety Code Section 25532(a)?
17 Yes No
VENTILATION PAN (SINGLE RESID)
ISSUANCE DATE
(� p D
P A
Wllltheapplium orfutureWildingoecopantuseequiprmnt ordevices
which emit himefous air contaminants as defined by the Bay Area Air
Qa hty M.nagcnmm District?
4 Yea No
havereadthebav usmaterlabrequimmenbunder Chapter6.95.!
the California Health k SafetyCode, Sections 25505,25533 and 25534. 1
BOILER -COMP OHPOR 100,000 BTU)
BOILER-COMP(OVER 100,000 BTU)
NEW RESIDENTIAL MECH. SQ.FT.
understand that if the building does not currently have a tenant, that It is my
responsibility
esp to issuance of notify the occupant
pipoto issuance faCertificate of of panty. requirements which must be met
ant of the reqs
fir
MAR se 3�
ISSUEDB .(,,' (�JVCri I114U
Owner.rauthmized agent Date
OFFICE COPY