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BUILDIN DIVISION APPLICATION/PERMIT r L
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CONTACT: PHONE:QTY. ELPI'RI�Ci PERMIT FEE
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BUILDING PERMIT INFO
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PERMIT ISSUANCE
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LICENSED CONTRACTOR'S DECLARATION APPLIANCES- RESIDENTIAL
JOB DESCRIPTION
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I hereby affirm then l am llcenseduader provisionsofChAper9mm
(coencingwith
Section 7") of Division 3 of the Business and Professions Code, and my ]am= is in PANELS
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full Imre and -!faro.
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Licenu Clads Lic.p UP T0200AMPS
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Dam Co... -1000 AMPS
-201
SQ. FT. FLOOR AREA
S/SQ.FT.
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ARCHITECTS DECLARATION OVER 1000 AMPS
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I understood my plans shell be used as public records.
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SIGNS ELECTRICAL
Licensed Professional
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OWNER -BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
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1 hereby affirm that I am esempt from the Contractors License Law for the
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following reason. (Seddon ]031.5, Business and Professions Code: Any city m country, TEMP. METER OR MILE MST.
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which requires a Permit to construct, ager, improve, demolish, or repair any s rectum
prior to its issuance, also requires the applicant for such pemduo file a signed statement POWER DEVICES
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that he is licensed pursuant to the provisions of the Commences License law (Chapter
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91commencng with Section 10001 of Division 3 of the Business and Professions Code) SWIMMING POOL ELEIIRIC
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in fla, Any v
the bmori
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Sectioheisexempttherefromand
L56ye bjeallegdexeicim,. parmnof OUTLETS -SWITCHES -FIXTURES
fore permit subjesathe epplicam mecivil Pendry of
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er
nenion'loh
not more than five hundnA dollms(4500).
hundred
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STORIES
TYPE CONSTRUCTION
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NEW RESIDENTIALELECTR _SQ. FT.
❑ Lssowrk,anbeproPmy,, thwedfor
is ma intended or age (Sec. 1014. Business
7W,Busness
will dotheCode:eswnarciactotiaLmnsarafwdam
of apSec.
and Professions Cole: Tic Contractor Littnu law does not apply in an owner of
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properry who builds or improves thereon, unit who does such wo& himrelfor through his
OCC. OROU �
RES. UNITS
cmployecs,provided lhatsuch improvementsene not imm�dedoroffereA farwle. IL
however, he building or improvement is sold within one
yearofcampletion,became,
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builder will have the burden of proving that he did not build or improve for purpose id
s wnaoHhe n am exdusivel conbaaip QTY. �,' _ PLUMBINGPERMIT
Pm. R Y B Committees ¢, .,
Codr:)
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APN
Th
Business and oro Crimp The Coma. ees
cored t the project (Sec. s
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oano ,who thereon,and PERMIT ISSUANCE
and
apply ma monitcomProperty whosed
whonxlawdoesnm
pursuant in dr,
whocse ALTER Projects wiNaconummr(e)lic<nxd pursuantmthe Conmectols ALTER-DRAIN&VENT -WATER
ESUM
ARY
LIWox law. SEA)
Law.
❑ 1 em exempt under Sec. , B & P C for this reason BACK FLOW PROTECT. DEVICE
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SANITARY Y N
Owner De¢
WORKMAN COMPENSATION DECLARATION DRAINS- FLOOR, ROOF, AREA, COND.
RECEIPTp
SCHOOLTAX Y_N
❑ Thereby affirm th¢tlheveettrtificato of coram bulf-insure,.. a cenifiene of FIXTURES - PER TRAP
RECEIPT#
PARK FEE Y N
RECEIPT it
WmkcW Compensation Insurance or acenifird copy thmrogSec. 3801, Lab CJ which
coven all employes', under this p ort. GAS -EA. SYSTEM-] INC. 4 OUTLETS
Policy#
BUILDING DIVISION FEES
Company GAS - EA. SYSTEM -OVER 4 (EA)
PLANCHECK ME
❑ Cmifed copy m herby furnished.
GRADING FEE
❑ CertifW copy is fled with the city inspection division. GREASIONDUSTRL WASTE INTERCEPTOR
CERTIFICATE ON EXEMPTION FROM WORKERS' GREASETRAP
SOILS FEE
COMPENSATION INSURANCE
ENERGY FEE
(This section red oat b, completed if Ne parrot is for one hundred dollas(SI00) SEWER - SANITARY - STORM EA, 200FT.
or leas.)
I cerify then in the performance of the work for which this Permit a issued. )shall WATERHEATERW/VENT/ELECI'R
not employ any Person in any nmenum an as in become subject m the Workers'
PAID
Compensationlawsof California. Date WATER SYSTEM/TRE.ATING
Date Receipt#
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Applicant
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NOTICE TO APPLICANT, If, ofto making this Centficam of Exemption, you should NEW RESIDENTIAL PLMIL SQ. FT.
TOTAL:
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become subject to the Wo&ees Compersalicn provisions ofthe Labor Code, you must
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forthwith comply with such provisions or this permit shall be clamed revoked.
BUILDING FEB
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CONSTRUCTION LENDING AGENCY
SEISMIC PEE
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I hereby affirm that them is a construction lending agency for the performance of
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Ne work far which this Permit is issued (Sec. 309.7, Civ. C.) TOTAL:
Lender'. Name yjg"
ELECTRIC FEE
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Lenders Address QTY,i Aye. ;MECHANICAL PERMIT 17.E
PLUMBING FEE
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I certify then 1 have reed this application and state that Ne above infamtotion is
laws
MECHANICAL WE
correct. I agree to comply with all city and county ordinances and atom raking to PERMIT ISSUANCE
CONSTRUCTION TAX
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building ... ction,and hercbyamhonse reprncoative,ouf lhnitity tp enter upon the
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above-mentioned property far inspection porticoes. ALTER OR ADD TO MECH.
(We) agree to save, indemnify and Imp harmless the City of Cupertino against
liabilities,judgments.ecams andexpemes which may many wayaccomagaimtsmd CityAIR HANDLING UNIT (TO 10.0010 CFM)
consey nee of the g m, of Nis permit.
G Z AIR HANDLING UNIT (OVER 10,(100 CFM)
Signet r of APPlica mahmarmr Data EXHAUST HOOD(WIDUCD
PAID
HAZARDOUS MATERIALS DISCLOSURE. HEATING UNIT (TO 100,000 BTU)
Dente Rttei
Will the applicant or furore building occupant re mom handle haaurdo., material
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as defined by the Cupertino IIQ000 Municipal Code, Chapter 9.12, and the Health and Safety HEATING UNIT (OVER IBTU)
Code. Section 25532(x)7 VENTILATION FAN (SINGLE MID)
❑ Yes ❑ No
ISSE
i
Will theepplicmmrfuwre M1uildingmcupenmxcquipmemoNeviceswhich emit BOILER-COMP(JIIP OR I00,000 BTU)
uardom air contaminants res defined by the Bay Area Air Quality Management BOILER - COMP(OVER Ui BTU)
°imrim?
241993
❑11JUN
Yes No NEW RESIDENTIAL MECH. SQ. ff.
1 have read the humrdous mmerids reyuircmenrs under Chapter 6.95 of the
CITY tont l:uren I uvv "
California Health & Safety Code, Sections 25505, 25533 and 25534. 1 understand that
if the building does no, mommuly have a tenant, that it is my responsibility to notify the
meupant of the requirements which must be met prim to issuance of a Cerdfeate of
Occupancy.
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ISSUED B
Owner or mahonzd agent Dam TOTAL: