09671APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
1
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION I PERMIT CATEGORY
BUILDING -F KIMCAI,MUMBINGMFCHANICAL
DECLARATION
I hereby affirmthat 1 am Bcer
tgwith Secb.r7000)of Division
omen is to hill _fgrc land effect.
I understand my plane shall be used as public commie.
,imnsed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt fromthe Contractors License Law for the
'.Bowfin¢... Gectlon 70315, Businessand Profesalona Code: Any city o,
1k a signed statement that he is IiemseA penmen to the provlsiomu of theMNEWRERDDMAL
:ormsnoesLicenseLaw(Chapler9(commencing with Section 7DW) of Divi -POOL
ELECTRICdon3oftheBusinessandp.f.bnaCode).,that
hebesempttherefromand
;he basis for the alleged exemption. Any violation of Setion 70315 by anyITCI-IES-FIX17URESapplicant
for a permit subjectsthe appllcanHo a civil penalty d nut more thanollas(5M.
DMAL ELECTR_SQFI.er
of the property, or my employees with wages as their sole
will do the work and the structure bout intended or offered for
sale (Sec. 7844, Business and Professlone Code: The Contractors License Law
don not apply w an owner of property who Wilds or improve thereon, and
who does suchwork himadforthrough hismen employee., provided that suchimprovements
are not intended or offered for sale. If, however, the Wilding orTOTAL::___..—r
...ua.,a.s,i.,.......nf—Inice.the.wner-WBderwill have.,.
-er re ,.. �,- ...-.,. ...- a:,,t s,#
t rde.dpewingthat hedid not WBdmimpieve ferpurpose-fele-.
I, as .weer of the property, am exclusively contracting with licensed
contractors to com mod the project(Sec 7094, Business and Prefeealme Code:
The Contractor's License Law doe not apply to an owner of property who
builds or improve thenen, and who contends for such p(ojects with a
cg3LL[+ctods) Bceor
nsed pursuant to the Contract's License Law.
LJ I am caempl under Sec B k P C for this reason
Owner Data
WORKMAN COMPENSATION DECLARATION
❑I hereby affirm that I have a certificate of consent in --if-insure, or is
certificate of Workns' Compereationinaumen out certified ropy thereof (Sec.
3800, LabC �-, �e
poi ty M L�
Com
[�C sal ed c y b hereby furnished.
❑Certified copy b toed with the city Wpectlon division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(rhl.section need not be completed lithe permit b fo,m a hundred doll..
($100) or len.)
I mrtifythat b the performance of the work forwhich this permit is baued,
I shall not employ any person in any manner n as to become subject to the
Worker' Compensation Laws of California. Date
the Workers' Compensation provisions
BACK FLOW PROTECT. DEVICE
DRAINS FLOOR ROOF, AREA COND.
FTK7URFS PER TRAP
HGREASE TRAP
$EWER-SANITARY-5'R7AM EA. ZIOFI.
CONSTRUCTION LENDING AGENCY
I hereby affirmtbat there b a conumudion lending agemy for the perform
ance of the work forwhich thio permit Is issued (Sec. 3097, Civ. C)
Lenders Name
Lender. Address
I certlfythat I have rendthls applicatienand stetetletthe aboveinformation
in mm&. I agree to comply with all city and county ordinances and stare laws
relating to building construction, and hereby avitiodie representative of this
city to enter upon the above-mentioned property for Wpection purposes.
(We) agree to save, indemedly an d keep harmiese the City of Cupertino
againatliabillttee,p greents,cmtsandexpenseswhich rnaylnanywayacerue
cgs' st id City idcoosemle� ithe gran of baapermit.
- HAZARDOUS MATERIALS DISCLOSURE
WIII the apphes torfuture building occupant store or handle herardoes
memorial as defined by the Cupertino Municipal Code, Chapter 9.1 2, and the
Health and Safety Code Se 32(.)7
❑ Yea No
W Ill the applicant or future building occupant use equipment .r devices
which et havardous air comaidranls as defined by the Bay
miArea Alr
Ouality Management District
yes o
have read the Fera sus materials requirements under Chapter 6.95 of
the Califomla Health A Safety Code, Sections 25505, 25533 and 25534. I
understand that if the building does net mrrently have a tenant, that it Is my
,responsibility to notify the occupant of the requirements which must be met
--to issuance of a Certificate of Occupancy.
NEW RESIDENTIAL PLMB. _SQ17-
TOTAL:
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT (TO 10,000 CFM)
AIR HANDLING UNIT (OVER 10,1X10 CFM)
EXHAUST HOOD(W/DUCT)
HEATLNG UNIT (TO 180,000 BTU)
HEATING UNIT (OVER 100,00) BTU)
VFNITLATION FAN (SINGLE RERD1
BOILER -COMP OHP OR 100,000 BTU)
BOILER -COMP (OVER 100,000 BTU)
OFFICE COPY
❑ ❑
Y
PLANCHECK FEE
PAID
Date Recei t# .
ENERGY FEE Y _ N
PAID
Date Receipt#
_ SUBTOTAL: 3
CONSTRUCTION TAX
CONSTRUCTION TAX PAID:
Date Receipt#
TOTAL: i
ISSUANCE DATE;
PAID /i
City of Cure
ISSUEDBX 10 V