22168APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro ed Identification
Building Address:
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PERMITNO.
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nen erne:
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CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
A A
{,
Cietranee. Name: Lie. No:
BUILDINGELECTRICALPLUMBINGMFCHANICAL
CATEGORY CONTROL #
Archlte t/Engineer. Lk. No:
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Address
PFRh9TI55UANCE
-Y] ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby afllrm that]cant licensed under provWone of Chapter9 (commenc-
Ingwith Se HonAX)(Dof Division3ofthe Busiaessand ProfesdonsCode,and my
It... Is in fun, fora and effect
LianseClan Lk. N
Date Contramor
ARCH ITECPS DECLARATION
I understand my plans shall be used as public record..
APPLIANCES -RESIDENTIAL
JOB DP$$$CCC
L�.-1 1-L'TS / ftD' 1 QyP
L `t] t s / !qy� ,�41 —
H \ \V�
PANELS
201-1000 AMPS
OVERIOOOAMPS
SQ. Fr. FLOOR AREA
$/9Q -FT.
SIGNS ELECTRICAL
Licensed Professional
SPECIALCIRCUIT/MISC
OWNER -BUILDER DECLARATION
I hembyafOrmthat I am exempt from the Contractor's License Law for the
'
TEMP MEFERORPOLEINST.
following reason.(Section 7m15, Business and Professions Code: Any city or
county which reclaims a permit to construct, alter, Improve, demolish, or repair
anystrucwrc prdorto its Issuance, also requiresthe applicant lorsuch permit to
file a signed statement that he Is licensed pursuant to the provisions of the
POWER DEVICES
SW0.A0NG POOL ELECTRIC `VALUATION
to our -LETS -SWITCHES FTXIVRES J U' Q
Contractor's License Law (Chapter9 (commencing with Section 7000) of Divl-
don3 of the Businessand Professions Code) orthat he Is exempt themfromand
the bash for the alleged exemption. Any violation of Section 70115 by any
OO
appllcant fora permit subjects the applicant to a civil penalty a not more than
t
` S -od-
five hundred dollies, (S500).
1, as r of the property, or my employees with wages as their sok
NEW RESIDENTIAL ELECTRFC.
STORIES
TYPE CONSTRICTION
compareati.,wBldothe work andthe swcture 6.& Intended or offered for
sola (Sec. 704A B..bmss and Profesamru Code: The Contractor. License Iso
1
TOTAL: `
does not apply to an owner of property who Wilds or improves thereon, and
whod.e.ch work himselforthrough hisown employees, provided thatsuch
improvements am nm intended oroffered for sale. If, however, thebuilding or
OCC.GROUP
RFS. UNITS
Improvement b wld within omyearofcomptetion, the owner-budderwill love
t rden of proving that he dldnot build or improve for purpose ofeale.).
owner of the property, am exclusively contracting with licensed
.trade. to.aslruct the project (Sec. 7046, Buslncas and Professions Code:
QTY. PLUMBING PERMIT FEE
FLOOD ZDNE
APN
PERMIT ISSUANCE
Contractors License Law does not apply to an owner of property who
builds or Imprwn thereon, and who contracts for such ptojeda with a
qq¢¢llr7 nods) Ilmnsed pursuant to the Contrador's License Law.
B & P C far this rean
cLJ I am exempt under Sec w
ALTER -DRAIN & VEM-WATER (EA)
FEE SUMMARY
BAIX FLOW PROTECT. DEVICE
OUTSIDE FEES
DRAINS FLOOR ROOF, AREA, COND.
SANITARY RECEIPT Y
OwnerDate
WORKMAN COMPENSATION DECLARATION
❑1 hereby afllrm that I have a certificate of consent to self -insure, a a
certificate of Workers' Comperadim Insurance ora certified copy thereof(Sa.
3800,1.1,C.)
policy Y
FIXTURES PER TRAP
SCHOOLTAX Y_ N_
RECFTI'T M
GAS. EA.SYSTEM-1 INC OUTLETS
PARK FEE Y N
f M
GAS FA. SYSTEM -OVER 6 (FA)
Com ny
BUILDINGDING DDI VISION FEES
Certilled copy Ishercby famished.
❑ Certified copy Is filed with the city Inspection division.
CREASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE
CREASETRM
CERTIFICATE OF E)(EMPTION FROM WORKERS'
PAID
SEWFR-SANITARY-STORM EA 200FT
COMPENSATION INSURANCE
(This section need net W completed if the permit is fororm hundred dollars
(S100)or1en3
1 certify that In the performance of the work for which this permit is bored,
Date Remi t#
WATER HEATER W/VENT/ELECTR
ENERGYFEE Y_ N_
WA.IER SYSTEM/TREATING
I shall not employ any person In any manner w ss to become subject to the
Workm.'Compensatlon Iswe o(GII(ornla. Date
PAID
NEW RESIDENTIAL PLMB. SQbT.
Applicant
Date ReCel t#
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you
should become subject to the WorkersCompersat ion provisions of the Labor
TOTAL:
BUILDING FEE
k
Code, you most forthwith comply with such proettIons or this permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
SEISMIC FEE
i U
I herebyaf0rmthat there is a construction lendingagency forthe perform
once of the work for which this permit Is lssued (Sec. 3097, Civ. C.)
Lender. Name
l.enaer.Adder
1 cedlfythatl have read thetapplicationan urate that theabove information
to comply with allcityand muntyordleancesand statelas
beorren. lags w
relating to building uudlon,andhercby authorize representatives of thio
enytoenterupont ve.mentloned property for inspection purposes.
(We) agr to ere Indemnify an d keep harmless the City of Cupertino
against abllit es,' d nl.tortsandexpenseswhich.yin.nywayaaroe
TOTAL
ELECTRIC FEE
n
PLUMBING FEE
QTY. MECHANICAL PERMIT FEE
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID:
ALTERORADOTOMECH.
Date Receipt#
AIR HANDLING UNIT (7010,000 CFM)
SUBTOTAL:
against sea Ity n .seri e.a of the granting of this permit.
'r:;s,
AIR HANDLING UNIT(OVER 10,000CFM)
CONSTRUCTION TAX
gesture of Applicant/Contractor Date
EXIiAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building o pant store or handle hazardous
HEATING UNIT (TO 100,ODO BTI)
Date Recef t#
material as defined by the Cupertino Municipal Code, Chapter 9.1Z and the
I ealth and Safety Code Section 2S532(a)7
❑ Yes r i No
Willthe applicant or future building occupant use equipment ordevices
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
VENTILATION FAN (SINGLE RESID)
ISSUANCE DATE
which emit hazardous air contaminants as dented by the Bay Area Air
Quality Management D'utrid7
Yes FI No
Ihave rcadthe h.7loos materials requirements under Chapter 6.95 of
Pa11RW1
aadYY//
BOILER -COMP 018' OR 108000 BTU)
BOILER-COMP(OVER100,000 BM
the California l Iealth & Safety Code, Seniors 2550.5, 25533 and 25536. 1
understand that if the building does not currently have a tenant, that it is my
l.n" 7 p ln[]
P1
NEW RESIDENTIAL MECI-L SQ.FT.
responsibility to notify the occupant of the requirements which must be met
MAY Q Y
prior to Issuance of a Certificate of Omcpa ney.
-,
ck*TOTAL:
T�]1�.
ISSUED.y en,� '_' v'
Owner or authorized agent Date
OFFICE COPY