20996APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
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CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BUILDING-aMTRICAL-PLUMBINC-MECHANICAL
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.764102
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CONTROL#
rc tect/Englneert LIc. No:
QTvELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Address:
❑ ❑ El
PERMITISSUANCE
CONTRACTOR'S DECLARATION
I hereby affUmthat tai licensed 3oftheunder
usiroandrs Chapter 9de,and c
Ing with Sect1on7000)0l DlWmon3oflhe Bumnessand Pro(esaloneCade,and m
Iicenseisin jR daffect.
License Cie LIc# ^µye
Data A CHEEECPS DECLARATION S� /
I understand my platy shall be used as public records.
Licensed I'mfesslomi
OWNER -BUILDER DECLARATION
I hembyaffirm that I amexempt from the Contractor'. License Law for the
following reason.(Searm 7MIS,Businessand Professlana Code: Any city or
aaantywhich requlresa patriot to commect, alter, improve, demolbh,or repair
anysmocture prior to its lssuance,also requlmthe appBmnt(orsuch permit to
file a signm
ed statement that he Is licensed pursuant to the provisions of the
Contractor's License Law (Chapter 9 (commencing with Section 7000) of Divi.
slon3ofthe Besineasand Profrcal.v Code) or that he b eempt therefrom and
the basis for the alleged exemption. Any violation of Section 71131.51 any
applicant far. permit subjectsthe applicant to a civil penalty of not mom[M1an
five hundred dollars ($500).
F] 1, as owner of the property, or my employees with wages a. Ihefr.ole
compensation, will do the week and the structure Isnot Intended or offered for
sale (Sec. 7044, B.Li ese and Pmfemloru Cale: The Contractors License Law
does not apply to an owner of property who builds or improves thereon, and
donsuch work himself or through hlsown employees, provided that such
Improvements are not Intended crof(eredforsale. If, however, thebullding or
Improvement Issold Mthinoneyearofcomple]oNtheowner-bullderwlll have
ttli,purden of proving that he did not build or improve for purpose of sale.).
U L as owner of the property, am exclusively contracting with Ikenxd
Contractors to cormtruct the project (Sec 7044, Business and Professions Code:
The Contractor's License law does not apply to an owner of propery, who
Wild. or Improves therecontnci
on, and who s for such ptojects with a
cgpjpcmr(e)licensed pursuant to the Contractor's License Law.
I_l I am em.pt under Seo B & P C for this rcawn
APPLIANCESRESIDENTIAL
JOB DESCRIPTION
PANELS
201-IODDAMI'S
OVER 1000 AMPS
SQ. FT. FLOOR AREA
$/SQ. FT.
'
SIGNS ELECTRICALyes,
SPECIALCIRCUIT/Misr
Tp2,4pM OR
LOWER CES
SWENhINO
OUTLETS$ IiESFI ES
VALUATION
/ n Q �s-a
/va d
NEW REST AL ELECTR FL.
STORIES
TYPE CONSTRUCTION
- TOTAL:
QTY. PLUMBING PERMIT FEE
OCC.GROIIIs
RFS. UNITS
pp�RISSUANCE
- •
ALTER -DRAIN VENTWATER LEA)
FLOODZONE
APN
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
DRAINS. FLOOR ROOF, AREA, COND.
FIXTURES. PER TRAP
SANITARY Y N'
RECEIPT #
Owner Date
WORKMAN COMPENSATION DECLARATION
hereby affirm That 1 have's certificate of consent to wit -insure, or a
ce 1(Inle of Worken'Compensatlon huurana ora certlfhd copy tM1ereof(Sec.
3800, Lab C. pp
Policy
Ca�ar)
art ed opt, V M1ereby fvmiehed.
crteied ropy V f0ed wltM1 the cit, Iwpectlon divlmon.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(fhistwetlonneednbecomplecd lithe permit isforosohundred dollar
($I(X)) or less.)
Iartifythat In the performance of the wank forwhich thio permltlnbsued,
I shall not employ any person In any manner no as to became subject to the
Woekcri Compensatlan Iaws of Cahimnia. Date
ApplicaNOTICnt
NOTIGETO esubjeAM:e, after making this ationIpro of Faemptbn,you
should become subteen. the Workers Cuch proaiio p orthiomofthe Lab or
Code, you must forthwith campy with such provieloro or this permit shall be
deemed invoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there V a construction lending agency forthe perform
once of the work for whkh lhb permit b I..ued (Sec. 3D97, Clv. C.)
Larder'. Name
Lender'.Address
I emilythatl have read this application and statethat theaWee Information
I.c meci.l<greetorrmplywlthalamtyandcountyordlnanceeandetatelaws
reaming to building construction, and hereby authorize repmenlative, of this
city to enter upon the above-mentioned property for Inspection purposes.
(We) agree to save, indemnify an d kap harmless the City of Cupertino
ag tits fliticajIudgrinno,corsand meawhichmaylnanywaycove
a I told vyleconfthe a [tngenthi.pamit.
.
/O
9CIIOOLTAX Y_ N_
RFCFL'f #
GAS EA. SYSfEM4 INCA OUTLETS
PARK FEE Y N
N
GAS EA. SYSfG1.OVER d (EA)
DING Of
BUILDING DI VISION FE ES
GREASE/WDUSIRL WASTE INTERCEPTOR
PLANCHECK FEE
PAID
Date Remi t#
GREASE TRAP
gpWEg-SAMTARXot STORM 11A. 20OFT.
WATER HEATER W/VENT/ELECTR
ENERGY FEE Y N
PAID
Date ReCel t#
WATER SYSTEM/TREATING
NEW RESIDENTIAL PLMB. SQFT.
TOTAL:
1 IT -E
aa�/a
LW
SEISMIC FEE
TOTAL:
ELECTRIC FEE
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
MECHANICAL FEE
PERMIT ISSUANCE
PEE$PAID:
Date Reeei t#
ALTER OR ADD TO MRCH.
AIR HANDLING UNIT(TO 10,0(0 CFM)
SUBTOTAL:
AIR HANDLING UNIT (OVER IO,DJOCIM)
CONSTRUCTION TAX
Signature of Applicant/Conlramor Dateq/
HAZARDOUS MATERIALS DISCLOSURE.
Will the a pplleant orfutu m building occupant store or handle hazardous
materialae defined by the Cupertino Municipal Code, Chapter 9.1 2, and the,
HraIalt Yacnd Safety Cod�D(yl Nrloon 25532(0)7
Will theeppllont c tMir re Wildangoccupant use equipment or devices
which emit hazardous air contaminants as defined by the Bay Area Air
Qu Ilty M.aagemant rict7
4 Yn No
have read lM1e hzz ausmmertaisrequimr nmunderChapter6.95of
the Cxll(ornla liealth Safety Code, Sections 25505, 25533 and 25534. L
understand that if the building don not currently have a tenant, that it is my
m ibilit rccaality the. pant emqulrementswhich must be met
F, r iss once of I to o(O ncy.
EXHAUST FLOOD (W/DUCT)
CONSTRUCTION TAX PAID:
HEATING UNIT (TO 100,000 BTU)
-
Date RCCCI t#
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
VENTILATION FAN (SINGLE RFSID)
ISSUANCE DATE
s_
#-
w
all
JE
���y�tp>J
ISS(IED BY:y ��/ u�r�'-"_
BORER -COMP OFIP OR 100,000 BTU))
BORER -COMP 100,000 BTU)H(til
NEW RFSIDFIMAL MI:CH. SQ.F4.
Owner authorizN agent Date
TOTAL:
OFFICE COPY