21978T
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
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L �H• GDEc)y 2APPLICAI
s"7-7139
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BUILDING-ELECTMCAL-PLUMBING.MECID NICAL
ION SUHM[I I AL DA LE
c°"t� • EC70 �P �"IlJfs
}ILII
CATEGORY
CONTROL M
Architect/Gglneer. No:
QTY ELECTRICPERMIT FEE
BUILDING PERMIT INFO
Address
1:1 1:1❑
P13WTISSUANCE
LICENSED CONTRACTOR'S DECLARATION
Ihe.byafflrmthatlam Ucrosedunderpro Wonso(Chapter9(mmmm
Ingwith Section 7000)of DiNsion3o(theBuetnessandPmfeWonsCode, and my
license Is In full force and Effect.
Li... Class -1.1c.11
Data Contractor
ARCHITECT'S DECLARATION
I understand my phos shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby af0renthat I am exempt from the Contractor's License Law for the
following reasan.(Sectbn7031.5, Butlnessand PmI.mrsCode:Anydtyor
mantywhich requires a permit tocomtmct, alteq Improve, de=[Lsh,ormpalr
any stmHum prior to its issuance, also requires the applicant for such permit to
file a signed statement that M is licensed pursuant to the provisions of the
Contractor's License Law (Chapter 9(commencing with Section 7000) of Divi-
.Iona of the Bueinessand Pmfembm Code) mthat heb exempt therefromand
the basis for the alleged exemption. Any violation of Stolon 7031.5 by any
applicant for a permit subjects the applicant to a civil penalty of net room than
five hundred dollars ($500.
Fj I, as owner of the property, or my employees with wages as their sale
compensation, will do the work, and the structure b net Intended or offered for
sale (Sec. 7044, goal.. and Prof.mi.. Code: 71. Cmarectoe. License law
does not apply to an owner of property who builds or improves therein,and
who doessuch work himsel(orthrwgh hla awn employees, provided that such
improvements arc not intended oroflered forsale. If, humvep thebuliding or
Improvement Isaold within omyearofcomplmiom the owner-buUderwlll have
rd an of proving that he did not build or improve for purpose of sale.).
as ..or of the property, am exclusively contracting with licensed
tact--to..Imd Me pmjm (See.7044, Buslne. and Profe.lona Code:
e Contractors License Law does not apply to an owner of property who
Wilds or Improves thereon, and who contracts for such pto)ects with a
g5actor(s) licensed pursuant to the Contractor's License Law.
c LJ I am exempt under 4c. B & P C for that reasonOUTSIDE
APPLIANCES -RESIDENTIAL
JOB DESCRIPTION
PANELS
UP TO 200AM5
201-1000 AMPS
OVER 1000 AMPS
SQ, FT. FLOOR AREA
$/SQ. FF.
SIGNS ELECTRICAL
SI'ECIALCI(CUfT/MLSC
TEMP. METER OR POLE INST.
POWER DEVICES
SWIMMING IDOL ELECTRIC
OUTLEISSWITCHCSFl)(TURFS
-
VALUATION
NEW RESIDENTIAL ELECIR °'Q'17'
TYPE CONSTRUCTION
TOTAL -
QTY. PLUMBING PERMIT FEE
OCC.CROUP
RES. UNITS
PERMTTLSSUANCE rY
ALTER -DRAIN & VENT - WATER (EA)
FLOOD TONE
APN
FEE SUMMARY
LACK FLOW PROTECT. DEVICE
DRAINS -FLOOR ROOF, AREA, COND,
►y F.IX.MiES. PER •Y•
�1 V
SANITARY Y_ N_
RECEIPT a
Owner Date
WORKMAN COMPENSATION DECLARATION
❑I hereby affirm that I have a amifiate of consent to eel( -Insure, or a
certificate ofWorkers'CompemOra certified copy thermf(Set.
3500, Lab C.)
Pollry M
$p{DOL 7A% Y N
RECEIVE Matlonleaurance
GAS G.SYSTEM-1 INCA OUTLETS
PARK FEE Y N
a
S F.A.ECEIPT
CASYSTEM-OVER
Com an Y
BUILDING DIVISION FF.CS
Certified copy le herebytehed.
Certified copy V filed withh the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thissectlon need not be completed lithe permit be for one hundred dollars
($100 aIcssJ
IaoutE ployan person
cwork(ors to besurrermltbho the
I shall not employ .y Lawn In any manner sa u to become subject to the
Works.' Compensation Lewe of California. Date
OTICE
NOTICE
NOiICETO APPLICANT: If, after making this
sation ate o(ExemptiOn, you
Code,shoulbecome subjectlr the Workers Compensation prmatlon or thiomomits Labor
Code, you must forthwith comply with such proWebna or this permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that them is, aconstruction lending agency for the pedorn,
arm of the work for which this permit is issued (Sec, 30W, Civ, C.)
lender'. Name
L.endEe.Addre.a
I mdBythatI have readthisapplicatlonand &ate thattheabove Information
lecormd. l agmatocomplywith all cttyand counlymelicanmand state laws
relating to building construction, and hereby authorize representatives of this
cityloenterupontheabove,mentioned property for inspection purposes.
(We) agree to save, indemnify an d keep harmless the City of Cupertino
against liabilities, jud l.,"aaod neeswhlch maylnanywayaceme
aga Wt said CltyI ensu of ting of this permit.
3 1
GREASE/INDUSTRL WASH, INTERCEPTOR
PLANCHECK FEE
PAID
Date Recel t#
CREASE TRAP
SEWER -SANITARY -STORM FA200FT
WATER HEATER W/VENT/ELECTR ZXO
ENERGY FEE Y N
PAID
Date Remi t#
WATER SYSTEM/TREATING
NEW RESIDENTIAL PLMB. JQ.FT.
TOTAL:
FEE
SEISMIC FEE
TOTAL:
ELECTRICFEE
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID:
-
ALTERORADDTOMECH.
Date ReCCi f#
AIR HANDLING UNIT (TO 10,000 CFM)
SUBTOTAL:
'
AIR HA NOTING UNIT (OVER IQ000CpM)
CONSTRUCTIONTAX
ret6glloo Ap to r ate
HAZARDOUS MATERIALS DISCLOSURE
Will the appllant orfuture building occupant store or handle haaardous
material as deli ned by the Copan] no Mu ricipal Code, Chapter 9.1 2, and the
Fleaith and Safety Code Section 25532(x)?
Yes No
Will the applicant or lure's ildingoccupantmeequlpmentordevias
which emit h.vardous atr cortamlmnl. as de0ned by the Bay Area Air
Quality Management District?
4 Yes N No
have read the hares out materials requirements under Chapter 6.95 of
the G)ifoml. Health & Safety Code, Sediona 25505, 25533 and 25534. I
understand that lithe bulldtngdms nes currently have a tenant, that It B my
responsibility to notify the occupant of the requirements which moat be met
prior to Issuance oda Certificate of Ocmpancy.
EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HEATING UNIT (TO 100,000 BTU)
Date RecCi t#
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
VENIILATIONFAN(SINGLERESID)
ANCE DATE
r'41 pv
1'/T'fu d ggg7
e7
as�
ISSUED BY;
BOILER -COMP OHP OR 100,IXp BTU)
ROLLER.COMP(OVER 10D,000 BN)
NEW RESIDENTIAL MECH. SQ.Fr.
Owner or authorized agent Date
TOTAL:
OFFICE COPY