24032APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
rotect Identification- /maw p ��
Building Address ildin P24032
PERMIT N
nevAPPLICATIONSUBMIrIAL
arae: - one: a
CITY OF CUPERTINO-BUILDINGDIVISION^
APPLICATION / PERM T'
BUILDING-ELECTRICAI.PLUMBING-MECHA AL
DATE
Contractor's Name: 4 .LIc. No:
CATEGORY '
X
Archited/Engineer. Lic. Na
QTY ELECTRIC PERFEE
M
BUILDING PERMIT INFO
C
Address. Ca.L%MA• L4Z
PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION q
LP
[hereby a(fbmthal l amlkensed under provisionsof Chapter9(cdruneno-
ingwith5eedon7000)of DtWeion3ofthe BuslnessandProfession.Cade,and my
Iicanee Is in ece and effect _
APPLIANCESRFSIDE L
JOB DESCRR'RON
PANELS
License Cls LIc.X�
DateContrector
```"ndeee��-�ta {{{�ersta 1���������`` ARCHITECT DE
I understand my platy e1uB W used as, public records.
1
AMPS
SQ. FT. FLOOR AREA
aa�
S/SQ. FT.
Licensed Professional
SI L TRICAL
1 a_ Cop
�C TTT
SPECIAL C
T/
OWNER -BUILDER DECLARATION
I herebyafRrtnthat I am exempt from the Contractors License Law for the
�r RPOLE [NST.
following reason. (Section 7031 .5, Business and Profess ons Code: Any city or
examlywhich requires apermitteconsa uct, alter, improve, deolish,orrepair
m
'
mystmdurepdor to Ra lasuance,atsorequirealhe applicant for such permittoPO
a signed statement that he is licensed pursuant to the provisions of the
CISfile
'
G POOL ELECTRIC
_
UTLE'ISSWITCHESFI%'TURFS ice
Contractor's Lim. Law (Chapter 9 (commencing with Section 70000 of Divi-
sion 3 ofthe Bushosamd Prates.sionsCode) orthat he b exempt therefrom and
the basis for the alleged exemption. Any violation of Section 70315 by any
applicmtfor. Penrod subjects the applicant to a civil penalty a not more than
' VALUATION
�:O O /��`
NX.� �.
five 1,--ownerundred of thepr.
❑ I, as owner of the property, army employees with wages an thelr.ole
NEW RESIDENTIAL ELECTR SQ9r.
STORIES
TYPE CONSTRUCTION
compensation, will do the work and the structure 6 not intended or offered for
'
sale (Sec. 7044, Business and Professions Liam
se The Contradoes Llcee Law
T
does not apply W an owner of property who Wilde or improves thereon, and
who doe. such work him selforthrough his own employees, provided that such
improvementsare not intended oroffered for sale. If, w
hoevepthebuildlegor
OCC. GROUT'
RES. UNITS
improvement bsold wllhinuneyearofcompletlogtheowner-bulWerwill have
tIry.den of proving that he did net Wild or Improve for purpose ofsals.).
u as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 70K Business and Professions Code:
QTY. PLUMBINGPERMIT FEE
FLOOD ZONE
APN
PpRNEpp NUANCE
The Contractor's License Law does not apply to an owner of property who
Wilda or Improves thereon, and who contracts for such plojecis with a
cgRtflcourW licensed pursuant to the Contractor's License Law.
LJ 7 am exempt under Sec. - B & P C for this reason
ALTER-DRAIN&VENT. WATER (EA)
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
OUTSIDEFEES
DRAINS FLOOR ROOF, AREA, CONTI.
SANITARY Y N_
REC= X
Owner Date
WORI(MAN COMPENSATION DECLARATION
❑I hereby affirm that I have a ttrtifivate of consent to self -insure, or a
M001 Laab Qte ofWorkeri Compensatloninsurance ore ttrtl(kd ropy thereo((Sec.
ll0, L
po
PityX
FIXTURES. PER TRA' ss�r
5CIdOOL TA% Y_ N_
RECEB f M
GAS EA. SYSIEM-1 INCA OUTLETS,
PARK FEE Y N '
RECEIPT #
�
GAEA. SYST-OVER4(EA)
S EM
���QQQrrn9yyXeeennny
BUILDING DIVISION FEES
d.
C allied copy 1. filed with the city inspection division.
�C9allied copy I.is herebyth the city
CREASE/INDUSTRL WASTE[ EPTOR
PLANCHECK FEE �,
CERTIFICATEOFE%EMPIION FROM WORBTERS'
COMPENSATION INSURANCE t 1=
(ThIsaction need not be completed lithe permit b for one hun will
($100)orless.)
I certify that In the performance of the work for which this pe 1. ed,
11
PAID ssssess
cel[
_ 200
- W
E G FEE Y_ U
9
E U
I shall not employ any person In any manner m as to become sur a
Workers'Compensation Laws of California. Date
-
W TING
PAID
Applicant
LPLMB. �.Ff.
Date 1 f#
NOTICE TO APPLICANT: If, after making this Certificate of Exemptla
should become subject tothe Workers' Compensation provisimu of the Labor
TO
BUILDING FE E ax
SEISMIC FEE
Code,you moat forthwith complywlth such provisions orthis permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lendingagenry for the perform-
an ce of the work forwhlch this permit ts issued (sec. 30W, Civ. C.)
Lender. Name
Lander'sAddee,
I certlfythidlhave read thbappucatianand statethattheabavelnformatlon
'ismrrect. l agree to complywlth all etyand county ordinances and state laws
70
ELE E y�
`.
PLU 'E
MEC ANICAL FIIE
QTY. MECHANICAL PERMIT FEE
PERMIT ISSUANCE
FEES PAID:
relating to building construction, and hereby authorize representatives of this
city toenter upon the above-mentioned property for Inspection purposes.
(We) agree to save, Indemnify an d keep harmless the City of Cupertino
against liabilities, Pdgments, mate and expenses which may In anyway accrue
Date ReceiF[q
- ^
ALTER OR ADD TO MUCH. 2(-
AIR HANDLING UNIT (TO 10,000 CFM) -
U13TOTAL:
against ea City In consequence of tic granting of this rtn�
-
AIR HANDLING UNIT (OVER 10,fXgCFM)
CONSTRUCT[ TAX
antradorata- e`--
EXHAUST HOOD(W/DUCn
CONSTRUCT[ TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous
Date Recei
HEATING UNIT (TO 100,000 BTU)
material as defined by the Cupertino Municipal Code, Chapter 9AZ and the
Health and Safety Code Section 25532(a)7
❑ Yes r] No
Wllltheapplicantorfuture building occupant use equipment or devices
HEATING UNIT (OVER 1Og000 BTU)
TOT
VENTILATION FAN (SINGLE MID)
-
ISSUA CE DATE
which emit hecardoua air contaMmnts as defined by the Bay Area Air
Q�aBty Management Distrld2 -
No
4 Yes.. Q us materials requirements under Chapter 6.95 of
have read the hazy
a., p p�
e+a % y
BOILER -COMP PHP OR 100,000 BTU)
BOILER -COMP (OVER IW,OW BTU)
the Califemia Health & Safety Code, Sections 75505, 25533 and 25534. I
understand that if the building does not currently have a tenant, that it is my
responsibility to notify the occupant of the requlreirmte which most be met
priortolsmanceofa CertificateofOcmpanry.
j)U/_�
7�
f EE�� d
NEW RESIDENTIAL MECH. SQ.FT.
ISSUEDBYN
Ownerorauthorized agent Data
TOT
OFFICE COPY . -