20234APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification
Building Address:
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CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
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Itect Fa neer. Lk. No:
BUU.DINGELECTRICALPLUMBING-MFLHAMCAL
CATEGORY
CONTROL M
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BCECTRIC PERMIT*,-'-i'FEE'
• . BUILDINGYERMIT INFOi,t
Address
PERMITISSUANCE 12�iS
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L�j Jd.J
LICENSED CONTRACTOR'S DECLARATION
I herebyefonthat l arohmosed under provblonsof Chapter9(mmmse
Ing with Section 7000)of Division 3 ofthe Business and Pro(essuksC e, and my
Iianse le In fell Clam and effect. -
Lkense Ch® LILY Z S7'
Date Contractor
APPL7ANCFSRESIDENTIAL
JOB DFSCRIPDDN
PANELS
_
201-1000 AMPS
ARCHITECrS DECLARATION
I understand my plans shall he used as public records
OVERI000AMPS
SQ. FT.FLOOR AREA
$/SQ. Fr.
SIGNS ETEC AL
Licensed Professional
SPECIALCIR M
RMETERO EI
OWNER -BUILDER DECLARATION
I hereby afBrenthat I am exempt form the Contractor's License law for the
Code:Any city it
Collowingreason.(Sectioni1.5, o strut and improve,
cmntycter, which permitro construct Implica
-
dorso Its
forsuch,ormitto
any structurepdormit the Of to
01e a signed statement thrt M b licensed pursuant to the provisions o! the
licensedpursuant t the provisions
Contractor's License law (Chapter 9 (commencing whit Section Mail of Divi.
slon3ofthe Buslneea and Profteadmu Code)orthat hats exempttherefromand
the basis for the alleged exemption. Any violation of Section 70115 by any
appllantfora permit subJecbthe appOcanitoativll penalty o(nat rtnrethan
DEW
S NG ETEC
O t
VALUATION
NEW RAL TR SQ11T'
five hundred dollars ($500).
F1 1, as owner of the pmperty, or my employees with wages as their sole
STORIES
TYPECONSTRUCTION
compensation, will do the wank andthe structure b not Intended or offered for
sale (Sec, 7044, Business and Professions Code: The Contractor's Llceee Law
x
_
does not apply to xove n owner of property who builds or imprtherme, and
whodonuchwoikhlnuelf urthwgh hlsownemployee, providedthatuch
OCC.GROUP
RES. UMTS
Improvements are notintended oroffered forsale. II, however,thebuilding or
ImprovemenHsa Mwlthinoneyearofcompletb tMwner-bullderwlll have
the*rden of provingthat he did nabulld or improve forpurpose ofule.).
u L as owner of the property, am exclusively contracting with Ilcemed
contractors W construct the project (Sec. 7044, Stains and professors, Code:
The Contractors License Law don not apply to an owner of property who
Wild. or Improves thereon, and who contracts for such pPjecte with a
onctor(s) licensed pursuant to the ContraoYs License Law.
I_I I ct
am exempt under Sec. B 4 P C for this reason
TOTAL:
Q7y- PLUMBING PERMIT FEE
PERMIT ISSl1ANCE •
ALTER -DRAIN & VENT WATER (EA)
FfADD ZONE
-
APN
BACK PLOW PROTECT. DEVICE
FEE SUMMARY
UTROP FEES
DRAINS- FLOOR ROOF, AREA, COND.
SANITARY Y_ N_
4 Owner Date
WORKMAN COMPENSATION DECLARATION
�I here a!llrm that I have a coni0ate of consent to self -inure, or
FIXTURES PER TRAP l.Jta
SCI'Il70L TAX YRECEIPNR
conl0al: Workem'Co., ties Insurance or a on ruffed ropy Iharen HSec.
3800, Lab G)
RF-CEBxT M
GAS EA. SYSTEM -1 NCA OUTLETS
PARK FEE Y N_
Policy 4
If
RECGAS
Com an 25/9 1�aHG
Certified copy b filedhx tumbhed.
Certified copy b rues'wttn the city Inspection division.
EA. SYSTEM -OVER 4 (EA)
BUILDINGDIVISIONV ISION FEES
CREASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE
GREASE TRAP
CERTIFICATE OF UEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Ohbcection need not be completed the permit la for one hundred tlollars
PAID '
Date Remi t#
SEWER -SANITARY -STORM EA 2001?
($103)mless.)
I comtltythat In the perfomuna of the work forwhich this permit is bued,
I shall not employ any person In any manner so as to become subject to the
Workers' Compeneation laws of California. Date
WATER HEATER W/VENC/ELECTR
ENERGY FEE Y N —
PAID
WATER SYSTEM/TREATING
ApplicaNOTICE after making thio Certificate of Exemption, you
NOTICETON'PLIC to
should become subject to the Workers' Compensation provblow of the Labor
Code, you most forthwith comply with such provisions or thio permit shall be
deemed revoked.
Date Recei t#
NEW RESIDENTIAL PLMB. SQ.FT.
TOTAL:
BUI NGa
TOTAL:
l a
SEISMIC FEESo
ELECTRIC FEE
L
CONSTRUCTION LENDING AGENCY
I herebyafRme that there is a construction lending agency for the perform
ante of the work for which this permit is ng ued f5ec. 3097, Civ. C.)
Lander'. Name
Lmd.r'.Addreu
I mrti/ythe l have mad this appliationend matethattheabove Information
b correct.I agree to comply with all city and munty ordinances and nate laws
.. : i;
QTY: "'MECHANICAL PERMIT," FEE'
PLUMBING FEE
�.
;`
,�,,\,
PERMIT ISSUANCE a)
MECHANICAL FEE
FEES PAID:
relating to building mnctruction, and hereby authorise repressntetives of thi.
city to enter upon the.bovcmeationed property for inspection purposes.
(We) agree to save, Indemnify an d keep harmless the City of Cu pertlno
against lbblloles, judgments, mets and expenses which may In any way accrue
against said City in consequence, of the gra king of this permit.
_T
ALTER OR ADD TO MECH. ♦w
AIR HANDLING UNIT (TO IQOOO CFM)
r
Date ReCel t#
SUBTOTAL:
NR HANDLING UNIT(OVER 10D0 CFM)
CONSTRUCTION TAX
Signature of Applicant/Contractor Date
EXHAUSTHOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HALO RDOUS MATERIALS DISCLOSURE
HEATING UNIT (TO 100,000 BTU)
Will the a ppllcantorfuture In diegomvpant smre or handle haaaelous
material as defined by the Cupenln unlcipal Co de, Chajaer 9.12, and the
Heallh eel Seety Cede Section 25532
Rill the applicant Cratere iat meant use the Bay Area devices
which emit haeardous air conlamirunb ae defined by the Bay Arca Ab
ralBy MavgemenR7
Date Reeel I#
-
HEATING UNIT (OVER 100,= BTU)
TOTAL:
VENTILATION PAN (SINGLE REBID)
ISSUANCE DATE
BOILER -COMP OtB'OR 100,0(10 BTU)
4 Yea No
BOILER -COMP (OVER 100,000 BTU)
i have read "ax, s materials requirements under Chapter 6.95 of
the California Health k Safety Code, Sections 25505, 25533 and 25534. I
NEWRESIDENIIALMECH. SQ.F7.
understand that if the building doe. nm corrently have. tenant that it is my
responsibility to notify the occupant of the requirements which most be met
prior to Issuance ofa Ce le of Occupancy.
nem or au horl dagentnt Date
;�
ISSUEUBYiJ :J✓
TOTAL:
'— OFFICE COPY