19827APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification
PERMITNO.
BuOing Address:
�o32Sr�on�
19827
Owner's a Phone:
A A .
Xm� (`o
CITY OF CUPER7-INO-BUILDING DIVISION
APPLICATION / PERMIT
.. / go
b
Cont a car's Namv:: LIc. N.
BUILDINGELECTRICA4PLUMBINGMECILANICAL
CATEGORY
CONTROL N
Architm/En n e`r Lk, Nm:
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Address:
PERMBTISSUANCE
1:1 1:1 1:1LICENSED
CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter9(oxnmem
APPLIANCESRF.SIDENTIAL
JOB DESCR11r11ON
PANELS
ingwlth Se on7000)of Division3ofthe BuMh and Pmfessions Code, and my
limn. b In full force and
w'�
LI[.N
c. #
125 �
L v
DeeLaom.Claco_
Daze Contractor—
UP TO 200 AMPS
A.MI'S
ARCHITECTS DECLARATION
Am shall
I understand my plan shall M used a public records.
OVER00
OVER 1000 AMPS
SQ. FT. FLOOR AREA
SIGNS ELECTRICAL
Licensed Professlorul
.
SPECIALCIRCUIT/MLSC
OWNER -BUILDER DECLARATION
I hereby affirmthat I am exempt fromthe Contractor'sLIUnse Law for the
TEMP. METER OR POLE INF.
following reason(Sectlw 7031.5, Business and Professions Code: Anycityor
county which requires a permit to construct, alter, improve, demolish, or repair
anystrocture pdorto its lamaance, alsorequlreatheapplicant farsuch permitw
file a signed statement that he is licensed pursuant to the provisions of the
POWER DEVICES
SWIMMING POOL ELn RIC
Contractors License Law (Chapter9(cemmendng with Section 7000) of Divi-
cion 3 of the Business and Profenions Cade) orthat he Is exempt therefromand
VALUATION
the basis for the alleged exemption. Any violation of Section 7031.5 by any
applicant for a permit subjects the applicant to a civil il penalty of net than
OUTLETSSWIiCHFS-
Off%
/ ( (� v {/
live hundred dollars($500).
n1, as owner of the property, or my employees with wages as their sok
NEW DENTIALEL IV
STORIES
TYPECONSTRUCTION
omp,raaMon, will do the work and the stroctom Is not Intended or offered for
sale (Sec. 700A Bualness and Protestore Cede: The Contractors License Law
does not apply to an owner of property who builds or Improve, IbermR and
who does such work himself orthro sigh hisown employee, provided that such
OCC.GROUP
RES. UNITS
Improvements are not intended oroffered for sale. If however, the building or
TAL:
improvementtasoldwithinoneyearofeomplet mtheowner-Wilderwillhave
ben ofpmving that he did not build or improve for purpose ofsale.).
owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 70" Business and Profession Code:
QTY. gdumBiNI6hRrAIT FEE
FIADDZONE
APN
PERM SSUANCE
The Contractor's License Law don not apply to an owner of property who
Wilds or Improve thereon, and who contracts for such pilojects with aTql"
o,,➢LVITador(s)Licensed pumuant to the Contractor's Limn. Law.
c LII am exempt under Sec. B & P C for this reason
ALTER -DRAIN & VFM- WA
FEE SUMMARY
BACK FLOW PR[CT. UE'A I
OUTSIDE FEES
DRAINS FLqO R
ND.
SANITARY RECEIPT N
Owner Date
WORKMAN COMPENSATION DECLARATION
❑1 hereby affirm that I have a certificate of consent to self -Insure, ora
UniOcate ofWorkera Compensation lnsurarimma Unified copy thereof(ec.
3800, Lab C.)
FIX.Il1RESP•
SCHOOLTAX Y_ N_
RECEB'T N
GAS EA. SY' 1 VJCA OUTLETS
PARKFEE Y N
RECEIPT N
Poacy p
Com any
GAS EA, SYSITM VER6(EA)
BUILDING DIVISION FEES
�Cenlfed copybhereby fumished.
couEed copy E filed with the dty inspersion dlvialon.
GREASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE
CERTIFTCATEOFEXEMPTION FROM WORKERS'
GRFASETRAP
PAID
SEWER-SAM.I.ARY-SNRM EA EpF1.
COMPENSATION INSURANCE
(This section need not be completed tithe permit b forom hundred dollars
(S100)orle..)
1 Unify that in the perfomamw of the work for which this permit Is Issued,
Date Recti I#
WATER HEATER W/VFM/ELECTR
ENERGY FEE Y_ N_
WATER SYSTEM/TREATING
I shall not employ any person in any manner ro as to become subject to the
Workeri CompensationUwsof California. Date
PAID
NEW RESIDENTIAL PLMB. SQXT.
Applicant
Date Revel t#
NOTICE TO APPLICANT: U, after making this Certificate of Exemption, you
should become subject to the Workers' Compensation provisions of the Labor
TOTAL:
BD
Code, you must forthwith comply with such provision. or this permit shall be
dUmod revoked.
CONSTRUCTION LENDING AGENCY
SEISMIC FEE
I herebyafOrmthat there is a mnstrorsion lendingagency forthe perform-
ance of the work for which this permit is Issued (Sec. 3097, Civ. Q
Lenders Name
Lender's Address
TOTAL:
ELECTRIC FEE
PLUMBING FEE
QTY. MECHANICAL PERMIT FEE
MECHANICAL FEE
I certifythat I have read this application and statethatthe above information
b oarred.I g.t.c..plywith all dtyand countyomtinancn and state laws
PERMIT ISSUANCE
FEES I'nl
ize presentative of this
relating to building construction, and Mreby authorre
city to enter upon the above-mentioned property for WpMion purpose.
(We) agree to save, indemnify an d keep harmless the City of Cupertino
against gabilftles, pdgments, costa and expenses which may in any way accrue
ALTER OR ADD TO MECH.
e `
Date Receipt#
AIR HANDLING UNIT (TO 10,000 CFM)
SUBTOTAL:
ga id qty in consequence of the granting of this penin .
a �((�
a � 6
AIR HANDLING UNIT (OVER 10,000 CFM)
CONSTRUCTION TAX
•
Sigrom re of AApplica^t/Contractor Date
EXHAUST HOOD(W/DICT)
CONSTRUCTION TAX PAID:
HA2 RDOUS MATERIALS DI SCLOSURE
HEATING UNIT (TO 100,00) BTW
-
Date Receipt#
Will the a pplies rat or future building occupant store or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.1 2, and the
Hes lth arad SafMC on 75532(a)7
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
--.
❑ Yes NTo
Will the applicant or future building occupant use equipment or devices
which coot havrdous air rontaMns^ts as defined by the Bay Area At,
Goality Managementt 7
Yes N
nus materials requirements under Cha pier 6.95 of
4Mve read the hazy o
VENTILATION FAN (SINGLE RESID)
ISSUANCE DATE
� tj�� V
BOILER -COMP OHP OR 100,0(0 BTU)
BOILER-COMP(OVER 1000 BTL)
00
the GOfmia Health & SafetyCoda Senlons 8505, 2SS33 and 8539. I
understand that if the building does not currently have a tenant, that it 6 m
NEW RE51DFNUAL MECH. SQ.FT
responsibility to notify the occupant of the requirements which most be met
prior to issuance of a Certificate of Occupancy.
_
I rU BY: -
Owner or authorial agent Date
TOTAL:
OFFICE COPY