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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Pru'em Idenrifintlon
Building Address:
PERMITNO.
0,f % No ✓c -.M be r DR.
19952
one:
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CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BUILDINGFLECTRICALPLUMBINGMECHAMCAL
(�
Contractors Name: Lie. No:
F✓% Cb (2sa
CATEGORY
CONTROLS
A hitem/Engineee Lic. No:
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
`\
Add.
PERMITISSUAN&
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hthSMioflrmlhat r9(e,andm-
r/
APPIlANCFSRESIDENTIAl
]OB DESCRIPTION
PANF15
Ingwlih Section7000)of Dlvlelon3o(the Busineseand Profession#Code, and my
Divisien3oftheerpmvLSloneoffeWm
liwnscls lne(orae
{�{�
Date Contractor , p al/'n�rG (�'
ARCHITECTS DECLARATION
I understand my plass shall be used u public records
p • 000A.
ER1 AMPS 1
SQ. FF. FLOOR AREA
$/SQ. FI.
SIGIIISELECTRICAL Ij
Licensed Professional
SPECIAL CIItCNT/MESO
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
following reason.(Section 7031.5.Buslncuand Professions Code: Any city or
cou my which requires a permit W comtmm, alter, Improve, demolish, or repair
any structure prior to Its Issuance, also requires the applicant for such permit toppyyERVEVICES
file a signed statement that M as licensed pursuant to the provisions of the
Contractors License Law (Chapter 9(commencing with Section 7000) of Divi-
Bion 3 ofthe Business and Professions Code) or that he b therefrom and therefroand
'
. p,MEIT3t OR [bLE IKSi'.
- - j
SWIMMING POOL ELECTRIC ��
„
VALUATION
the basis for the alleged exemption. Any violation of Section 7031.5 by any
applicant fora permit subjectsthe applicant to a civil penalty of not rtnre than
five hundred dollars (5500).
[3l, as owner of the property, or my employen with wages as their sole
ETSSWITCHES IXTURES/j
^
NEW RESIDENTIAL ELECTRO_ SQFL
STORIES
TYPE CONSTRUCTION
compensation, wllldothe work and thesuucture Is not Intended or offered for
mle (Sec.7044, Business and Professions Code: The Contractors License Law
docs not apply to an owner of property who Wilds or Improves thereon, and
who does such work himself or through hieown employees, provided that such
OCC.GROIIP
RIS UNITS
Improvement are not intended oroffemd for sale. If, however thebuilding or
TOTAL:
Improvementbs Id MthinoneyearofcompletW tMe er-buRderwBllove
tt`9,�urden of proving that he did net build or improve for purpose ofsakJ.
u I, as owner of the property, am exclusively contracting with licensed
contractors to cometrom the project (Sec. 7014 Business and Professions Code:
QTY, PLU BIND PERMIT FEE
FLOOD ZONE
APN
PERMITISSUANCE
TM Contractor's License Law does not apply to an owner of property who
Wilds or Improves thereon, and who contracts for such pteects with a
<}fB(acmr(s) licensed pursuant to the Contractor's License Law.
LJ 1 am exempt under Sec. B 6 P C for this reason
ALTER -DRAIN &VENT- WATER (EA)
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
OUTSIDE FEES
DRAINS FLOOR ROOF, AREA, GOND.
FIX.IURFS PER )RAP
SANITARY YY_ NRECEIPT »
OwnerDate
WORKMANCOMPENSATIONDECLA RATION
MIhere affirm that I have a certificate of consent to self -insure, ora
certificate ofWorkeri Compensation Insurance or a certified copy thereof (Sec.
Is
G/}
SCHOOL TAX Y_ N_
RF-CEBT N
GAS EA. SYSTEM -1 INCA OUTLET'S
PARK FEE Y3C8o0m0,
NCC N
Policy
/Y
n�v
.
BUILDING DI VISION FEES
LCertOled colly is hereby furnished.
�y Certified copy is filed With the city inspection division.
GREASE/INDUSTRL WASTE INTERCEPTOR
PLANCFIECK FEC
GREASE TRd'
i CERTIFICATE OF IXFTLTION FROM WORKERS'
PAID
SEWER-SANTTARY-STORM EA 200FI.
COMPENSATION INSURANCE
(Thissemion need not W completed If the permit is forces hundred dollars
($IW)orless.)
1 nertify that In the perf...ca.f the work for which Nle permit i.laaaed,
Date Recei l#
WATER IiEATF34 w/vPxr/EI.FGTR
ENERGY FEE Y_ N_
WATER SYSTEM/TREATIN'G
I shall not employ any person In any runner w as to become subject to the
Workeri Compensation laws of California. Date
PAID
NEW RESIDENTIAL PLMB. SQ.FT.
Appllesnt
NOTICE TO APPLICANT. If, after making this Certificate of Exemption, you
should become subject to the Workers' Compensation provisions of the Labor
Date Recei t#
TOTAL:
BUILDING FEE
Code, you must forthwith comply with such provisions or this psrrNt shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
SEISMIC FEE
I herebyaffirmthatthem baronstrvmlon lendingagency fortha perform,
ance of the work for which this permit Is Lamed (See. 3097, Civ. C.)
Lender. Name
Lenders Address
I certifythail have read thisapplicattonand gate that theabove Information
Is correct. i agmeto comply with all city and county ordinances and gate laws
TOTAL:
ELECTRIC FEE
PLUMBING FEE
QTY. MECHANICAL PERMIT FEE
MECHANICAL FEE
^
PERMITISSUANCE a
FEES PAID:
relaing to building construction, and hereby amhorl a representatives of this
city to enter upon the above-mentioned property for inspection purposes.
(W e) o save, Indemnity and keep harmless the City of Cupertino
ag thablRues,' dgment, cogs .pensee whichmayinanywayaccrue
a Int said Cityi consequen granting dthis rtnit.
ALTER OR ADD TO MECH.
Date Receipt#
AIR HANDLING UNIT CFO 10,00 CFM) Qp
SUBTOTAL:
AIR HANDLING UNIT (OVER 10,000CFM)
CONSTRUCTION TAX
eft�wtu plicaot/ mracm Dan
D(HAUSTHOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAZARD ATERIALS DISCLOSURE
Will the applicant orfufum building occupant store or handle havzrdous
HEATING UNIT 00 100,000 BTU) 94J -
Date Recel t#
material as defined by the Cupertino Municipal Cade, Chapter 933 and the
IieaRhandSafety Code Section 25532(a)?
Yes No
Will the applicant futurebuilding occupant use equipment or
HEATING UNIT(OVER 100,000 BTU)
TOTAL:
s
VENTILATION FAN RFSID)
ISSUANCE DATE
which emit havzrdous air contaminant as defined by the Bay Arca Air
Quality Management District?
4 Ye IGl No
have read ihehaz us materials requirements under Chapter 6.95 of
BOILER -COMP OHPOR 100,000 B'FU)
BOILER-COMP(OVER100,000 BTU)
the Glifrnla I l alth & Safety Code, Sections 25505, 70533 and 255M. 1
understand if the building does not currently have a tenant, that it Is my
NEW RESIDENTIAL MECH. SQFr.
res ileywn ofytheocoupantofthemquim.ntswhichmustbewlt
p or toissuanmo aCertificate of0 hey.
7 Ge,
Vp
ISSUED BY: -\L
ncr or od>ed ager Date
OFFICE COPY C�lYnr yvU
n..
Ore.