21790APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Buudm Pro ert ldentlflatian
Building Addrese:
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where ams:
PERWTNO.
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-
CITY OF CUPERTINO-BUILDING DIg�Ss]ON
APPLICATION / PERMI%._�"
A
°'"'" Lie. No:
rchitect/Engineer. Lic. No:
BUILDING-ELECTRICAI.PLUMBINC-MECIL CAL
CATEGORY
CONTROL#
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Address:
PERMITISSUANCE ()'p
LICENSED CONTRACTOR'S DECLARATION
thereby fit. that l am licensed under provisions of Chapter9(commmc-
Ingwlth Secdun700)of DiVWon3 ofthe Bukesssand Professions Code, and my
license lain (u8 rce and effect -,
Date Contractor ARCHITECT DECLARATION A,ps
(understand myplaroshallbe used as public records.
APPLIANCES -RESIDENTIAL
a
ANELS
OB DFS[ ON
V Vr l..
20 AMPS
OVER Hall AMPS
cam, pp, FLOOR AREA
$/SQ.pp.
SIGNS ELECTRICAL
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from thr�Conlractor's License law forthe
following reason. (Section 7015, Busbuseand Professions Code: Any city or
county which requires a permit to construct, alter, improve, demolish, or repair
any structure prior to its issuance, also requires the applicant for such permit to
file a de ed statement that he is licensed pursuant to the provisions of the
Contractors License Lave (Chapter9(commencing with Section 700) of Divi-
sion3ofthe Buelneasand Profeseloru Code)orthatheieexempttherefromand
the basis for the alleged exemption. Any violation of Section 7041S by any
applicant fora permit sub)ecte the applicant to a civil penalty of net more than
five hundred dollars ($500).
❑I, as owner of the property, or my employees with wages as their sok
compensation, will do the wank, and the structure isnot intended or offered for
ask (Sec. 7044, Business and Profeskro, Code: The Contractors Lt... Law
does not apply to an owner of property who Wilds or Improves thereon, and
who doeaeuch work himself or through his own employees, provided that such
are not intended oroffered forsak. If,howevegthebuildingor
improvement Issold withinoneyear.fcomple lamtheowner-WIlderwilt have
te rden of proving that he did not build or Improve for purpose ofaak.).'
L as owner of the property, am exclusively contracting with lice
Lj licensed
contractors to construct the period (Sec, 7044, Business and Prefeakers Code:
The Contractors Lkenee law does not apply to an owner of property who
Wilda or Improves thereon, and who contracts for such Ispiects with.a
actors) licensed pursuant to the Contractors License Law,
I am exempt under Sec. B & P C for this reasnn
SPECIAL CIRCUIT/MIST
TEMP. METER OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLE755W17'CHESEKTTJRES a
VALUA770N DD
l/
NEW RESIDENTIAL ELECTA SQ.FT•
W IS
t
TYPE CONSTRUCTION
OCC. GROUP
-
RFS. UNITS
TOTAL: . �Q
TY.
QTY. PLUM
PLUMBING PERMIT FEE
PLUMISSUANCE
a
ALTER DRAIN&VENT'- WATER (EA)
FLOOD wNe
- APN
BACK FLOW PROTECT. DEVICE
FEE SUMMARY
OUTSIDE F17FS
Owner Date
DRAINS- FLOOR, ROOF, AREA, COND.
TURES' PER TRAP(J d
SANITARY Y N—
RECEIPT#
WORKMANCOMPENSATIONDECLARATION
❑I hereby affirm that I have a certifiate of consent to self -Inure, or a
certifiate of Worken'CompenaallonImurance aacertifled copy thereof (Sec.
380,Iab C.)
Policy #
SC IDOL TAX Y _ N—
RECEPT #
GASFA.RYSTEM- INC.40UTLETS a
PARKFEE y N
RECOPY p
Com any
WA1Red ropy is herebyfurnished.the Od.
rti(led copy k filed with the Ety Impaction division.
GAS EA. SYSTEM-0VER4(El) s
CREASE/INDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
PLANCHECK FEE
�
GREASETRAP
CERTIFICATE OF E(EMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thlasectknneed -a becompleted lfthepermit Vforonehundeaddollars
($tII mftifees.)
]artif employ
Ishall not employ any person In any manner at as t° eu eR to the
person ian thework forwhkhthle permit is issued, the
Workere'Coqrp#�y (on Laws of Cs(y(ornk. Data ��
Appilrant m fI[(.1 —
NOTICE 70 APPLIGNT.lf, cr ma gthb Certitkate of Exemptbn, you
should become sob )ect to the Wmi ere'Compereation provisions of the Labor
Code, you most forth with comply with such provisions.,this permit shall be
deemed revoked.
PAID
Date Recei til
R-SANTTARY-STORM EA. 2`OWT.
WATER HEATER w/vENT/E.ECTR
ENERGY FEE Y N —
PAID
Date Recei t#
WATER SYSTEM/TREATING
NEW RESIDENTIAL PLMB. SQ.FI.
TOTAL:
BUILD( G
•QO
TOTAL: Q. C1�
CONSTRUCTION LENDING AGENCY
I hereby affirm that there Is a construction lending agency for the perform-
anceof the work for which this permit is Issued (Sec. 3097, Civ. C.)
lenders Nacre
I.enaara Address
Icertifythatl have readthieappliaaonand stmethatthe above information
complywith all city and county ordinances and state laws
relating to building conatmctl.n, and 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 Cuperflre
against liabilities, judgments, cons and expenses which may In any way accrue
seg Ctry In ce.f the granting e{,tthis permit.
SEISMIC FEE
ELECTRIC FEE
(iO
QTY. MECHANICAL PERMIT FEE
COlecorrect.Idgre,t°
PERMITISSUANCE •fry
ALTERORADDTOMECH.
AIR HANDLING UNIT (7010,00 CFM)
PLUMBING FEE
MECHANICAL FEE
FEES PAID.
Date Receipt#
SUBTOTAL:
]..,
AIR HANDLING UNIT (OVER 10,"CFM)
CONSTRUCTION TAX
)me
y
///a� zg q
Signature of Applicant/Cont, or Date
HAZARD[) MATERIALS DISCLOSURE
Will the applicant or future Wilding occupant store or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 0.12, and the
I•lealth and Salety Code Sect 32(a)7
RYea °
EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HEATING UNIT (TO 10,00 BTU)
Date Recei tN
HEATING UNIT (OVER 10,00 BTU)
TOTAL:
,.2
Iilthe epplicantorfuture building occupant use equipment or devices
which cost hazardous air contaminants as defined by the Bay Area Air
Ilia city Management Dlstr er?
Yes mfr°
4
^
VENTILATION PAN (SINGLE RESID) S(!
ISSUANCE DATE '
PAM
BOILER -COMP 0HPOR 10,00 BTU)
BOILER-COMP(OVIR 10,00 BTU))
have read the Faza ousmateriabrequimmntsunderChapter6.95of
the California Health & Safety Code, Sections 75505, 25533 and 25534. 1
understand that if the building does not currently have a tenant, that it E my
responsibility to notify the occupant of the requirements which must be met
prior to of a Certifkatc /o(�/�pancy.
,•
Odd .gent b /~Date
1 s7
wl AN 2 199a
ISSUED BY: Y I ~' I. o tdL-v
NEWRESIDENTIALMECH. SQ.FT.
]OTAL: � V V
OFFICE COPY