27747- USE BALL POINT PEN ONLY
CITY OF CUPERTINO..'.....
APPLICATION/PERMIT PI-uMBINr.-MF:cxnrvlcAl. 27747
7 /17
BUILDING DIVISION IDBNNFICA'I4 1'ION ( 1
r
LICENSED CONTRACT'OR'S DECLARATION j
I hereby affirm Ihol I am licensed under provisinmofChaper9 (commencing with
Section 9100) of Division 3 of the Business and Pmfesslons Code, and my license is In
fall force and effect. _ ?go
License Class Lic p
btu C.O.
ARCHITECT'S DECLARATION
I undemmnd my plans shell be used as public roctimb.
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that I can exernpt from the Contractors Licrnse Law for the
following reason. (Section 9031.5, Business and Professions Code: Any city or county
which requires a Permit to conavuct, alter, improve, demolish, or repair any srrunure
prior to its issuance, also requires the applicant fm such permit to file a signed summers
that he is licensed pursuant to the provisions of the Contrecmrs License law (Chapter
9 (commencing w'nh Section 70(0) of Division 3 of the Business and Professions Code)
or shut he Ix exempt therefrom and the balls for the alleged esempdnn. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant br a civil penalty of
not roam than five hundred dollars ($500).
❑ I.u'owmer ofthe por,my,ar my employees with wages uthcir sole ..,.ad.,
will do the work, and the suacure is not intended or offered for Ode (Sec. 7040 Business
and Professions Code: The Contractors License Law does not apply to an owner of
property who builds or Impwves thereon, end who does such work himaelfor through his
wn crap l oyees, prov ided that such i mprovetrtents arc not imendedor offered tar sale. If,
however, the buildingar improvement is sold within one yearafcomplction. the owner -
thimble, will have the burden of proving that he did not build or improve for paBwse of
sale.).
❑ Loa the Prdthe Sec.7y,am Business and Prmatiawithde:)edconwemrsm
construct the project (Sec. 7044, Business and wfuslou Code:) the Contrncmrs
License 1a w Aces not apply to an owner of pmpery who builds ns improve, the Corton, and
who contracts for such projects with convazmr(s) licensed pursumt m dw Conrazmrs
License law.
❑ 1 wit exempt under gee. , B & P C for this reason
WORKMAN COMPENSATION DECLARATION
❑ Thereby affirm Chm lhuve acenificam of mnaenno sdf-inc 3ROO. Lab C.) which
Worker 1 Cnmp employee's
der this
m u certified copy thereof (See. Jg00, Lab C.) which
rs all employee's under this permit.
Policy N
Company
❑ Ccnified copy is d ewfamished.
❑ Cmificd copy is filed
lflet with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This season need not be cumpded if the pmanut is feature hundred dollar ($100)
or less.)
I cenify then in the performance of the work for which this permit is issued. I sholl
not employ any person in any manner so as to become subject to the Workers
z Compensmionlawsof Califomm Darn
Applicant
NOTICE TO APPLICANT: If, after making this Cenificate of Exemption, you should
q became subject m the Worker's Compensation provisions ofthe labor Code, you must
forthwith comply with such Provisions or this .it shall be deemed revoked.
F CONSTRUCTION LENDING AGENCY
Z I hereby affirm that hem is a construction lending agency for the performance of
U O the work for which this permit is issued(See. 3097, Civ. C.)
t�---•Lenders Name
U" F' Lender's Address
0 U I certify that I have read this application and sore that the above information is
%' 0. correct. l agree to comply with all city and county ordinances and sate laws relating to
res building construction, unit hereby authorize representatives of this city to enter upon the
U Z above.mcneonestpmrsi fur inspection Finite s.
(We) agree to save, indemnify and kap harmless the City of Cupertino against
liabilities,judgmenu, cuts and expenses which may in any way accrue agaiuuaid City
in ex!JJ&,iduence of the grunting of this permit. _ I — I_
I IAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupum.aore or handle hazardous material
as Jdincd M1y the Cupcnino Municipal Code. Chapter 9.12, avd Che Ilcahh end Sulcry
Crile, Section 25532bd?
❑ Yes ❑ No
Will the applicant or l more building uecupanl use equipment or dev ices which emit
hazardous air asntamimins us defined by the Bay Arca Air Quality Management
District!
❑ Year ❑ No
I have mad the hazardous materials requirement, under Chapter 6.95 of the
CaliIbmis Health & Safety Cade, Sections 25505, 25533 and 25534. 1 understand that
if the building does not curently have a tenam, that it is my responsibility to ratify the
oocupom of the requirements which must be mit prior to issuance of a Certificate of
Occupancy.
Owaa ar authmi'r.cd agent Orale
_o t 6ox 3y N 1 s 6-.64
77 sl ELECTRIC PERMIT :
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL
PANELS
UP TO 200 AMPS
POLE INST.
POWER
OUTLETS'-'SWITCHPS-PoXTURES
NEW RESIDENTIAL ELELTR _SQ. ET.
Sl S6
❑
APN
PERMIT ISSUANCE'
[ZEE
-,BUILDING
QTY. "- MECHANICAL PERMIT FEE
BL
ELE T
FEE SUMMARY
ALTER OR ADD TO MSCI I.
'^�A
JO�BB OF
BACK FLOW PROTECT. DEVICE
n ea
MECH
El
QTY. - PLUMBINGPERMIT FEF,
FLOOD ZONE
APN
PERMIT ISSUANCE'
TOTAL:
ELECTRIC FEE
QTY. "- MECHANICAL PERMIT FEE
AL'JER - DRAIN & VENT - WATER (EA)
PERMIT ISSUANCE
FEE SUMMARY
ALTER OR ADD TO MSCI I.
CONSTRUCTION TAX
-79
OUTSIDE FEL
BACK FLOW PROTECT. DEVICE
SANITARY
Y N
EXHAUST HOOD(W/DUCD
PAID
Date Receipt
RECEIPT N
DRAINS- FLOOR. ROOF, AREA. CONI).
SCHOOLTAX
Y N
BOILER - COMP (3HP OR 100.000 BTU)
- BOILER. COMP (OVER 10X1,000 BTU)
ISSLFANCEIVATE
DEC 12'994
C11Y Ut- L;;u(rtkllNO
ISSUED 155::t rt a e�
RECEIPTN
FIXTURES - PER TRAP
PARK FEE
Y N
TOTAL:
RI?CE;]"N
GAS - EA. SYSIT1,14 INCA OUTLETS
BUILDING DIVISION FEES
GAS - EA. SYSTEM -OVER 4 EEA)
PLANCIECK FEE
GREASEdNDUSTRL WASI 17 INTERCEPTOR
GRADING FEE
GREASETRAP
SOILS FEE
SEWER - SANITARY - STORM EA. 200FT.
ENERGY FEE
WATER HEATER WNENDMLECTR
PAID
WATER SYSTEMIMEATING
Date
Receipt Ji
NEW RESIDENTIAL PLMB. SQ. FT.
TOTAL:
BUILDING FEE �•
SEISMIC FEE
TOTAL:
ELECTRIC FEE
QTY. "- MECHANICAL PERMIT FEE
PLUMBING FEE
PERMIT ISSUANCE
MECHANICAL FEE
ALTER OR ADD TO MSCI I.
CONSTRUCTION TAX
AIR HANDLING UNIT (TO 10,000 CFM)
'
AIR HANDLING UNIT (OVER 10,000 CFM)
EXHAUST HOOD(W/DUCD
PAID
Date Receipt
HEATING UNIT (TO 100.0(1(1 BTU)
I MATING UNIT (OVER I(QOBO BTU)
TQ
A
VENTILATION PAN (SINGLE BESID)
BOILER - COMP (3HP OR 100.000 BTU)
- BOILER. COMP (OVER 10X1,000 BTU)
ISSLFANCEIVATE
DEC 12'994
C11Y Ut- L;;u(rtkllNO
ISSUED 155::t rt a e�
NEW RESIDENTIAL MF.CIL SQ. FT.
TOTAL: