23952APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
Bulldin Pm est Identification
Building AddI.s: s -L QIctS �,
PERADT NO.
2 3952
wore ante: one:
1l a -o
CITY OF CUPERTINO�BUILDING DIVISION
APPLICATION / PERMIT
BUILDINGdECTRICAL-PLUMBINGM CAL
Contractor's Nanta: sea
9 73
CATEGORY
CONTROL
ArcItect gineer: laic. No:
QTY ELECTRICPERM FEE
BUILDING PERMIT INFO
Add... IJ
K PERh17TISSUANCE �.�
S
LICENSED CONTRACTOR'S DECLARATION
Thereby affirm that l am Beamed under provisions of Chapter 9(commenc
Ing wah5ect1on7000)of Dl effect o(the Buslneaeand Pm(eaeloneCode,and my
licenseisln fu_ and .fret. 3R 3
Lianse Cla LIc.M
APPLIANCMRFSI L A
JOB DESCRB'TION
yrs.
IiJL
P
Date 7CordratoF��J,_IF
201- AMPS
ARCHITECTS DECLARATION
I understand my plam.hall be used as public records.
OV 1000
Ff. LO R ARE& /SQ. FI.
SIGNSELEC AL
Licensed Professional
�SQ.
'
E
OWNER -BUILDER DECLARATION
Ihercbya(flrm that I exempt ER DE Contractor. License law for the
11��/af/—/,�7`
m �' E R�
SI'ECIALCERCUIT/MISC
following reme.(Seciion7031S, Buainessand Professkrm Code: Any city or
muntywhichrequimaper ttodomtmc4alter,impmve,demolhh,orrepair
TEMP.ME[ER OR POLE IN ST.
U
B V 9 UU
Asa,
anystm=mpdortoits ance,alsorequlmtheappllnntforsuchper tto
file a signed statement that he h licensed pursuant to the prevhlem of the
Contractor's License Law (Chapter 9 (commencing with Section 7000) of Divi.
sion3 ofthe Business and Pmfessiam Code) arthat he Is exempt therefmmand
the basis for the alleged exemption. Any violation of Section 70315 by any
t ban
applicant fora permit subjects the applicant to a civil penalty offset more ban
]OWER DEVICES
TE `%9J
SWIMMING I00L ELECTRIC
OUTLETSSWI[ESFl%•TURpS
T.CF
VALUATiQy�r
V D�
NEW RESIDENTIAL ELFOIR SQI,7'
five hundred dollars ($500).
E]L as owner of the property, or my employees with wages as their sok
STORIES
TYPECONSTRUCTION
compensation, will do the work, and the structure h not [mended or offered for
as le (Sec 70K Rest. and Professbm Code: The Contractor. License law
does not apply to an owner of property who Wilds or improves thereon, and
whodoessuchwmkhlmseBorthrough hi.mveemployees, provided that such
OCC.GROUP
RES. UNITS
improvements are not Intended oroffered forszle. If, however, the bulldingorT
ImprovementholdwithinoneyearofcompIMWmtheownerb ilderwillhave
t rdenofpmving that he did not Wild or impmee for purpose ofWn).
construct, L as owner of the property, am exclusively contracting with licensed
contractors to consthe project (S 7044 Business and Professlom Chole-
QTY. PLUMBING PERMIT FEE
1 PERMIT ISSUANCE ��
nooD ZONEL_j
APN
The Contractor. License Lw dm nae apply to an owner of property who
Wild. or Improves thereen, and who mntncis for such pRejects with a
contmtor(s) Bcumed punuant to the Contractors License Law.
LJI am exempt under See B & P C for this owaonnITToincePec
ALTER -DRAIN &VENT •WATER [EA)
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
DRAINS ITOOR ROOF, AREA, CONTI.
FI%'TURES PER TRAP
SANITARY Y_ N
RECEIPT 1'
Owner Date
WORKMAN COMPENSATION DECLARATION
E31 hereby affirm that I have a certlfleate of consent to self -Insure, ora
SCIdOOL FAX Y N
3800,Lab C)
RECEIPT N
S INCAcedifioteofWorkers'CompewtlonimunnworamAifledmpylhennf(Sot. GAEA. SYSTCM•1INCAOUTLETS
PARR FEE Y N
Po11ry 8
RECE
GAS LA. SYSTEM -OVER 41 MA)
CT) Y
rtNed espy a
Certified espy hllled wllh the dty Impectlon dlvielon.
BUILDING DIVISION FEES
GREASE/INDUSTRL WASTE INTERCEPTOR
PLANCI'IECK FEE
GREASE'IRAP
CERTUICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need rat becempltM If the permit h (mom hundred dollars
(S100)rtifyt) he anyperson1performance n shework one,. as to b ca permitI.blued,
] artily that employ
I .hall not employ any person In any runner n m to became subject to the
Workcrs'Cempenutlon Lova o(Ca Bfomh. Date
PAJD
Date RCCeI tit
SEWER -SANITARY -STORM EA 7001-7.
WATER HEATER W/VENT/ELECTR
GNGIiCY PGE Y N
PAID
WATER SYSTEM/TREATING
ApplicaNOTICE
OTICE Exemption, you
shoulNOTICEca esubjeAM:e after nukinglhhsation provicate ofsions
Code, you
Code, you mewed forthwith comply with such provhiom or this permit shall be
forth ithto co Workers' Comp rovionprovhlonaofdhe Laborbe
deemed revoked.
Date Recei til
NEW RESIDENTIAL PLMB._SQ3-7.
TOTAL,
BUILDING FEE
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that there h a conatrectlon lending agency forthe perform-
ance of the work for which this permit I. hwed(Sec. 3097, C1v. C.)
fin
ELEC'T'RIC FEE
Q'TY, MECHANICAL PERMIT FEE
PLUMBING FEE
larder's Name
larder's Addhsm
I artffydhat] have read this application and statethattheabove Information
Is comt.I agree tocomplywith all city and county ordinances and state laws
relating to Wilding coretmction, and hereby authorize representativesof thl.
elf PERMIT ISSUANCE '
MECHANJCAL FEE
FEES PAID:
city to enter upon the above,menlloned property for inspection purposes.
(Wa) agree to save, Indemnify an d keep ham -Jew the City of Cupertino
ag tliabNiks, pdgmemAs, expeI aw'ch may In anyweyaccme
ag City In ron.c{ue ceoll 'rat of thh pernlL
ALTERORADDTOMECH.
Dare Recei tM
AIR HANDLING UMT(T010,000 CFM)
SUBTOTAL'
AIR HANDLING UNIT (OVER 10,000CFM)
CONSTRUCTION TAX
'Igature of Applicant/Contractor Data
IMIAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS TRIALS DISCLOSURE
HEATING UNIT (TO 100,000 BTU)
- _
Will the apptimnt orfuture building oavpaet.toreor handle hazardous
material as defined by the Cupertlno Municipal Code, Chapter 9.1 Z.mi the
Date Recei till
HEATING UNIT (OVER 100,000 BTU)
TO
Health and Safety Cade Section 25532(a)7
Yea No
VENTILATION FAN (SINGLE RESIU) O
ISSUANCE DATE
Will the applicant... tyre Wilding occupant use equipment or devices
which emit hazardous air contaminants as defined by the Bay Area Air
BORER -COMP (3E1'OR 100,007 BTQ
lity M.mgement DhWtT
Yea No
W.
BOILER-COMP(OVER 100,000 BTU)
read the hazy vusmaledals requirements under Chapter 6.95 of
the California I Icalth& Safety Code, Sedio , 25505, 75533 and 75534, 1
NEW RESIDENTIAL MECH. SQkT.
and ends rad that if the building does not currently have a tenant, that it is my
responsibility to notify the occupa rat of the rcqulrcmenta which must be met
prior to Issuance of a Certificate of Occupancy.
(��� �-s,
ISSUED IIY_UD.
Owner or authorized agent Data
—
T
OFFICE COPY