21448APPLICANT TO FILL IN INFORMATION WITHIN REDLINES — USE BALL POINT PEN ONLY
Building Pro ee Identlflotlon�
Roil l Address: P
IlAuzo
PERMIT N21448
one:
• /�T N17EM
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION/ PERMIT
BUILDINGELMTRICAL-PLUMBING.MECHANICAL
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Cast. LkNq�
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CATEGORY
CONTROL
Architect/ r
c Llc. No:
QrY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Address: }, •
LOU hl,�l PLUMB MhLH
❑ ❑
PERMETISSUANCE
LICENSED CONTRACTOR'S DECLARATION
I herebyafflrm that l Am licensed under providonsof Chapter 9(commenc
ingwithse on7OM)of Dlvidon3ofthe Bualnnaand PmfeslansCode,and my
license is in full fora and affect.
anes Class •
Date Contractor'UP
DCont
ARCHITECTS DECLARATION
I understand my plana shag be used As public records.
Licensed Prof.Wnsl -
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt fromthe Contractors License Law for the
following reason. (Section 7MI5, Business and Professions Code: Any city or
countywhW requiresapermbtowmtmgalter,Improve,demolish,orrepar
anystm=mpriortolt,L ance,ab mmquWtheappffantfursuchpermitto
file a signed statement that he b licensed pursuant to the probilums of the
Contractor's License Law (Cha pter 9 (commencing with Section 7000)of Divi-
Alon3 of the So dress and Profeslord Cola)ar that he b exempt themfmm and
the basisfor the alleged exemption. Any violation of Section 70HS by any'
applicant fora permit schools the applicant to a civil penalty of no rnorethan
five hundred dollars ($500):
❑ T, as owner of the property, or my employees with wages as their sole
compensation, will do the work, and the structure is not Intended or offered for
sale (See. 7040 Bushms and Professions Code: The Contractors License law
don not apply to an owner of property who bulldsar improves thereon, and
who does such work himself orthraugh hlsownemplayen, provided thatsuch
improvements are not Intended oroffered forsale. If, however, thebullding or
Improvementeaold within oneyearofcompl&Wrytheowner-bugderwillhave
thLIforden of proving that he did cwt build or Improve for purpose ofsale.).
L j L as owner of the property, am exclusively contracting with licensed
contractor' to construct the project (Sm 70K Rude. and Professions Code:
The Contractor's License Law don not Apply to an owner of property who
builds or Imes provthereon, and who contract. fa such ptojects with a
on ador(s) licensed pursuant to the Contractor'. License Law.
I am exempt under Sec B & P C far this reason
APPLIANCES RESIDENIAL
JOB DESCRI'DON
PANELS
TO 2DO ANTS
201-I0OOAMPS
OVERIODOAMPS
SQ. FT. FLOOR AREA
$/SQ. FT.
SIGNSELECTRICAL
SPECIALCI(CUIT/MISC
TEMP. M= ORPOLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
`
y OUTLETS—SWITCHES-FIXTURES' t J�
VALUATION
(nodi cz
NEW RESIDENTIAL ELECTR SQ.FT.
STORIES
TYPE CONSTRUCTION
TOTAL: aVs �`•'
QTY. PLUMBING PERMIT FEE
OCC.GROIIP
RES. UNITS
FLOOD ZONE
APN
PERMIT ISSUANCE
ALTER -DRAIN & VENT -WATER (EA)
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
OUTS] DE FEES
DRAINS FLOOR ROOF, AREA, CONTI.
SANITARY Y_ N_
RFGFR'i's
Owner Date
WORKMAN COMPENSATION DECLARATION
❑I hareby affirm that I have a axmigate of consent to ee161ns
mnlflans
te ofWorkeW Compensation lurmas or a certified mpy thereof(Sac.
3800,L.b C.)
Pollry M
FUTURE& PER TRAP
SCHOOL TAX RECEIPT M
CAS F.A. SYSTEM -1 INCA OUTLETS
PARK PEE Y N
RECEIa
GAS EA. SYSTEM OVER 4 CEA)
Co
DING DI
BUILDING DIVISION ISION FT:ES
Cerliied copy b hereby dwith necity
rl CedNed spy b filed with the city inspection division.
CERTIFICATE OF IXEMPTION FROM WORKERS'
COMPENSATION INSURANCE r
(Thlssectlonneednorbecompletedffthepert tbforonshundreiddal
(SID(fiales.) L
ladifythat Wthepedocross.ofthewakforwhichthispermlti.W.0 ;.
I shall not employ any person in any manner An as to became subject to t e
Workers' Compensation Laws of California Date
Applicant
NOIICETO APPLICANT. It, after maklogthb Certlflrateof Exempt) n, you
should becomesub)ect to the Workers' Compensation provisions of1h Labor
Code, you moat forthwith comply with each provisions mthb permit
revoked,
CONSTRUCTION LENDING AGENCY
I herebyafBrmthat there is a construction lendingagency forthe pedorrn-
anceofthe work forwhichthis permit Is Issu
Lenders Name
Lenders Addre.. -
I certifytha )have read thbappliationand statethattheabovelnforrouton
b arced.I agree to comply with all city and munty, ordinances and date laws
relating to build Ing construction, ami hereby authorize representatives of this
city to enter upon the above-mentioned property for Inspection purposes.
(We) agree to save, Indemnify an d keep harmless the City of Cu Fenian
against liabilities, Judgments, coal. and expenses which may in any way accrue
against said City In conuquena of the granting of this permit.
GREASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE
PAID
Date 1 ted
�7 sy��
"L�
ii
GREASE TRAIs P. ^. l
SANITARY-STORMFA
/ WATERHRATRRW/VENT' 4 '�
ENERGYFEE N
P
a RLroei tp
,HBW RE9D
1a.
�_
TOTAL:
B
LWdeemed
SEI E
TOTAL:
-
ELECT FEEed(Sec.30Y7,Civ.C3
Z. S�
PLUMBING FEE
QTY. MECHANICAL PERMIT FEE
MECHANICAL
PFRMITISSUANCE
FEES PAID:
ALTER OR ADD TO MECH.
Date R 1 ted
AIR HANDLING UNIT (TO 10,000 CFM)
$UBT IAL:
AIR HANDU NG UNIT (OVER 10,000 CFM)
CONSTRUCTION TA
gnatu re of Applicant/Contactor Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.1$ and the
Health and Safety Code Section 25532(a)2
qYes No
ill the appllcam Mrs, building occupant me equipment or devices
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management Disldd2
�i J Yes
Than No ve read haur�ous materials requirement, under Chapter 05 of
the CA fifomla Health & Safety Code, Sections 25505,25533 and 25534. 1
understand that ifthe building dace not currently have a tenant, that It my
resp I='.Y,- nalfy the occupant he requirements which mu be
prior Issuance aCedlflateof aFancy-bl.
A, cx'gcj
Ow r r e77
ill- IF 9
DCHAUSTHOOD(W/DUCT)
CONSTRUCTION TAX AID:
HEATING UNIT (TO 100,000 BTT))
Date Recei
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
V
VENTILATION FAN( SINGLE RESIDI
CE DA'Z'E
17
TMo (
/A.� �j
(hT',fC{Sy Cx(
^^.�
ISSUED BY�aL/I17•J•-a"e"G
BOILER -COMP DIE' OR 100,0(0 BTU)
BOILER -COMP (OVE(100,000 BTU)
NEW RESIDENTIAL MECH. SQ.FT.
TOTAL:
OFFICE COPY