19900 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
BuildingIT
Project Identification • PERMNO.
Building Addm
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CITY OF CUPERTINO-BUILDING DIVISION ZO a
C. "°r'•N•°• Lie.No: APPLICATION /PERMIT
BURAINC ELECTRICAlePLUMBINC-MECHAMCAL CATEGORY CONTROL Y
A ltect/ grocer. Lk.Ns
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Add.
PERMITISSDANCE 1:1 11 ❑
LICENSED CONTRACTOR'S DECLARATION
Ihereby Sectio arm )ofDiv Bcm3afthe usimm drsrof sion.9(mmmrn A['PLCANCESRE9DENTIAL OB DESCRNITON
7
II...1Sect1on7000)o(DIvINon3ofthe BuslmasandprofeaslansC°de,andm - /
licensehpP
1.
Llcen C Lin#
Date• Contractor
TO2 UP 201.1"AMPS
DO AMPS
ARCHITECTS DECLARATION
pQ+0ZC0C. (understand my plow shag be used as public records. OVER 1000 AMPS SQ,FT.FLOOR AREA S/SQ-FC.
E U Licensed Professional SIGNS ELECTRICAL '
Lis OWNER-BUILDER DECLARATION $PFLULCCRC MIST
ZF a Ihercbyaflrenthat l amexempt fmmthe Contractor's License Law forthe
following reason.(Section 7MIS,Business and Professions Code:Any city or
O I:.
F�
county which requires apertNt to construct alter,lmprove,demolish,or repair TIME.METER O L INST,
q'y�s any structure prior to its issuance,aato requires the applicant for such permit to POWERDEVICES
LS pe file a signed statement shat he at licensed pursuant to the Innovations of the
3w� Contractor'•License Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING VALUATION
O
too of the Business and Professors Code)orthat he atxa
em therefrom and
t+ Q S the basis for the alleged exemption. Any violation of Section 7031.5 by any
°tm
}}CPPk?11ccc applicant for a permit subjects the applicant to a civil penalty of nom than
live hundred dollars CfSOO). RLSID LFL Ff. STORIES
❑1,as owner of the property,or my employees with wages as their sole TYPE CONSTRUCTION
compensaflon,wUldothewwk,andthestmc matnm Ntendedor offered for
$ O sale(Sec.7044,Business and Professions Cade:The Contractors License law
pj$$ does not apply to an owner M property who builds or Improves thereon,and OCC.CROUP RES.UNITS
CC;; whodacssuch work himsUwthr°ugh Msownemployees,provided that such
Improvements are not Intended oroffered far sale.If,however,thebuilding or TOTAL:
Improvement iswld within omyearofcomplelio",the owner-bullderwill have
t1ti.4unden of proving that he did notbulldorlmproveforpurpose.fule.). QTY, UMBI E IT FEE
L as owner of the pmNay,am exclusively contracting wish licensed FLOOD ZONE APN
PERMIT ISSUANCE
contractors to construct94,ct the project(Sec.70Business a rad Professions Code:
The Contractors License Law does not apply to an owner of property who
builds or Improves thermn,and who contras foe such pWjem with a VTI
NT VT-WATER(EA)
cgVctm(a)licensed pursomm to the Contractor's License Law. FEE SUMMARY
L-J'am exempt under Sec B&P C for this reason BACK FLOW PROTECT.DEVICE
DRAINS FLOOR ROOF,AREA,CONT. SANITARY Y N
• Owner Date RECENT Y
WORKMAN COMPENSATION DECLARATION MTURM�T.RAP SCHOOLTAX Y N
❑I hereby affirm that I have a certiBate of consent to self-Insure,w a RECEIPT If
certificate of Workers'Compensation Laurance or a certifkxl copy thereof(Sec. GAS EA.SYSTEM-1 ING4 OUTLETS PARKFEE Y N
3800,lab C. ,p /� RFLEE'C Y
Policy It �ili'�'�17���( GAS EA.SYSTEM-OVER4(EA)
Com ray BUILDING DIVISION FEES
C.
ad copy I hereby furdshed. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
❑CerlBled ropy at Ned with the city Inspection division.
CERTIFICATE OF EXETIPFION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCESEWER-SANITARY-SCORN EA pBF f• Date Rccei t#
('hbaection need not be completed lithe permit bfor one hundred dollars
(5100)°rlese') WATER HEATER W/VENT/ELEC7R ENERGYFEE Y_ N—
I malty that In the performance of thework forwhlch this permit Is Issued,
I shall not employ any person In any manner w as to become subject to the WATER SYSTEM/TREATING
Workers Compensation Lawa of California.Data
PAID
ZZ Applicant NEW RFSTDLNTAL PLMB. SQ.FI'. Date .Reeel t#
O NOTICE TO APPLICANT:B,after ,.king this Certlfiamrf Exemption,you
Mould became subject to the Workers Compensation provisions of the Labor TOTAL:
N Code,you must forthwith comply with such provisions orthls permit shall be I57
`>j doomed rooked. BULDING FEE
W — CONSTRUCTION LENDING AGENCY SEISMIC FEE 0
[L I hembyafflrmthat there ataconstmctlon lendiagagency forthe perform, TOTAL: ELECTRIC FEE
n Z anceofthe work forwhich that permit is Issued(Se
l. edc.3097,CIv.C.)
V O Lenders Name - PLUMBING FEE
LL F Lender.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Icertlfythat l have read thatappItalionand statsthattheabove Information
IS correct.CLIdgme to complywilhW D .
cityand county ordinances and state laws PERMIT ISSUANCE FEES PAI
>. W relating tobutiding construction,and hereby authorize representative.ofthis
cit t entero upon above-mentlomd for inspection ses. ALTERORADDTOMECH.
1' 2 Y ° w propertyP(Cu Date Receipt#
_ (We)agree to ave,IndemNty and keep harmless the City.(Cupertino
against W cs,judgments,mite and expenses which may In anywayacrne AIR HANDLING UNIT(TO 10,000 CPM) SUBTOTAL
agar' oldty in co .eqeginbub Permit.g
3/��Y�' AIRHANDLINGUNIT(OVERIO,000CFM) CONSTRUCTION TAX
Sig m of Apphemt/Contra or � SUMUST HOOD(w/DICT CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
O
rBlthe appItant or future building wmpant store or handle hazardous HEATING UMT(TO 100,01)0 BTU) - Date Recci I#
matemlasde0nedbythe CupeA] Municipal Code,Chapter9.IZandthe -
IlealthandSafetyCodeSe 91G)7 HEATING UNIT(OVER 100,=BTU) •+ TOTAL: �
❑ Yes °
Will the applicant or future building occupant us.equipment or devices VENTILATION FAN(SINGLE RESID) - -^^ "^"k�`a�-PACns•1 'NCE GATE
which emit hazardous air contaminants as defined by the Bay Area Air ■■.�,��''�JJ'-�L'��jjJ„
. Quality Management T99
Di Md? BOILER-COMP PIN OR 100,000 BTM -,�✓
Yes r R
4havercadthehat. Ed?
BOILER-COMP(OVER 100,000 BTU) K el 0
the California Health&Safety Code,Sections 25505,25533 and 25534. 1 ^
understand that lithe building dm not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT.
res Illty to notify the occupant of the requirements which must be met „� CfYy Vl' I? jn0
orlo uanceofa Ce cafe OaupaRcyRIv +n A AQ
2 v
ncroraulhors eat TOTAL: ISSUED BY:
OFFICE COPY