24191 (2)APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification / p . �,
Bulldin cid 22
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PERMIT NQ 4191
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wners aces: Fit one:
CITY OF CUPERTINO�BUILDING DIVISION
APPLICATION (PERMIT
BUILDING-ELECTRICAL-PLUMBINGMECHAMCAL
APP0CXTr5K7097rM-Ar5–ATr-
ctncio' Name: Lic.N°;
CATEGORY CONTROL#
BUILDING PERMIT INFO
Architect/Engineer. Lk. No:
QT' ELEC•TRICPERMIT FEE
(' ,�xx�
Addreae;3 �5 JS+Q �9/ Wv
❑ ❑ ❑
PFRMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION
I herebyaffirm that l am licensed under provisions of Chapter 9(rommene
Ingwtth5ecdon7000)of Dlvislon3 ofthe Buslnevsand Professlon.Code,and my
license lslns force anddfect.
Date Clam Cont
Date Contractor—
APPLIANCES -RESIDENTIAL
JOB DFSCRII-HON
,
n r --?I
t(�
-
PANELS
UP TO 200AMPS
ARCHITECTS DECLARATION
1 understand my plans shall be used ss public reconls
Licensed Professional
OWNER -BUILDER DECLARATION
I herebyafRrm that am exempt from the Contractors License law for the
following reason.(5mion 703 1.5, Business and Professions Code: Any city orTTNIpMETE[i
mntywhkhmqutresapermlttommu d,alter,Impmve,demlWh,orrepair
any assigned statemprior to ent
has a is licame d pursuant the a t the provisions
thea signed aatemcnt that he e, alan lremed pursuant pl the provi or ch permit of the
of e
Contractors License Law (Cha pter 9(commencing with Section 71100) of Divi-
sign 3 of the Business and Professions Code) or that he la exempt therefrom and
the bash for the alleged exemption. Any violation of Stolon 7071.5 by any
nt for a permit subjects the applicant to a civil penalty of not arc thin
appham
XIvc a odred dollars(f500).
as owner of the property, cur my employees with wages as their sok
satlon,wBldo the work, and theslrocture b not Intended or offered for
(Sec. 7094, Rua4,e... d Profeulotu Code: TM Contractors License Law
does not apply to an owner of property who build, or Improves thereon, and
who dare such work himself or through his own employees, provided that such
Improvements am not Intended oro((ered forsele, If, however,the buildlogre
Improverrentissuidwithln oneyearofcompletlon, theowner-builderevill have
tlSIjurden of proving that he did net build or Improve for purpose ofsale.).
u L as owner of the property, am exclusively contracting with licensed
corosetom to mrutruct the project (Sec. 7094, Business and Professions Code:
The Contractors License law does not apply to an owner of property who
Ifullds or improves thereon, and who contracts for such pkajece, with a
TTIficensed pumuant to the Contractor's License Law.
J 1 am exempt under Sec e B &TP C for this rn
201 -IOW AMPS
OVER 1000 AMPS
SQ. Fr. FLOOR AREA
_ �' D RL,
'V
D
S/SQ. FT.
SIGNS ELECTRICAL
SPECLILCIRCUIT/MISC
, ORPOLE (NST.
POWER DEVICES
SWIMMING POOL ELECTRIC
OUILETSSWITCIiESFlXTURES
' LUAT[ON
NEW RESIDENTIAL ELEM SQkT,
SIpRIFS
TYPE CONSTRUCTION
TOTAL:
QTY, PLUMBING PERMIT FEE
PERMRISSUANCE •�
ALTER -DRAIN &VENT -WATER (EA)
OCC.GROUP
RFS. UNITS
pLOOD7ONE
APN
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
DRAINS. FLOOR ROOF, AREA, COND.
MTURES PERTRAP �!e
SANITARY Y N
RECEIPT#
Owner Date
WORKMAN COMPLNSATION DECWRATION
❑1 hereby affirm that I have a certificate of convent to self.tmum, or a
certificate of Warken'Compewattoo losurana ma emitted copy themcf(Sec.
38N,Lab C.)
SCIi00L fAX Y N
RECEIPT #
GAS EA. INCA
PARKFER Y N_
#
Com an Y
GAS EA. SYSTFMAVER 6 (EA)
DING Of
BUILDING DI VISION FEES
d.
CertNed ropy is hereby tIt. city
❑Certified ropy is (fled with 1k city inspection division.
CERTIFICATE OFC FMPTION FROM WORKERS'
COMPENSATION INSURANCESEINER-SANITARY-STORM
Ifhlssection need nal be completed lithe permit la formahundred dollars
($100) that
I net employ any personhe in any co workfor
1 oris not employ any person in any manner at u to become subject to the
astowhich this permit is iso the
Workers' Compensation Iowa of California. Date
ApplicaNOTICE
N
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you
should become subjm to the Workers' Compensation provbloro of the Labor
Cade, you suet forthwith amply with,uch proviakru mthis permit shall be
dee
deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby a(firmthat there Is a construction lending agency forthe per(Drm
ance ofthe work for which this permit is Issued (Sec. 3097, Cly. C.)
Lender's Name
Lender's Address
I certilythatl haveread lhisapplicuttonand statethat theabeveleformatlon
Is correct. I agree to comply with all city and county ordinance and state laws
Making to building corotrunion, and hereby authorlse representatives of slats
city to enter upon theabovememkned property fee Impaction Purposes.
(We) agree to ave, Indemnify an d keep harmless the City of Cupertino
against llabiBtks' men/s, mesand expenses which may In an wayacrxue
ago Wl,ald Cl i ens of Ing ofthispe it.
' ,. y
re of Ap loot/ .on I'. to
HAlAR 1 fATERIALS DISCLOSU RE
Will the applicant or future Ildingoeupant stare or handle ha,suclous
romadal as defined by the Cupertino Municipal Cade, Chapter 9.12 and the
Ilealth and Safety Code Section 25532(a)7
❑ Yea No
Will the appliance tun building occupant use equipment or devices
which emit haeardous air cants minanty as defined by the Bay Area Air
Quality Management Dktdctl
Yes No
have read the haza oua materials requirement. under Chapter 6.95 of
the California Health & Safety Code, Sections 25505, 25533 and 25539. 1n
understand that lithe building donot currently have a tenant, that it b my
responsibility to notify the occupant of the requirements which most be met
prior to Issuance of a Certificate of Ocmpancy.
CREASE/INDUSML WASTE INTERCEPTOR
PLANCHECK FEE
PAID
D[Nate Recei
GREASETRAP
,I,A 20 rr.
WATER HEATER W/VENT/ELECTR
ENERGY FEE Y N—
PAID
Date Races tH
WATER SYSTEM/TREATING
NEW RESIDENTIAL PLMB, SQFL
TOTAL:
BUILDING FEE
T �^�'
SEISMIC FEE
ELECTRIC FEE
_
QTY. MECHANICAL PERMIT FEE
PERMIT ISSUANCE
PLUMBING FEE
MECHANICAL FEE
FEES PAID:
ALTERORADDTOMECH.
AIR HANDLING UNIT (M 10,000 CFM)
D ate Reeel of
SUBTOTAL:
AIR HANDLING UNIT (OVER I0,000CFM)
CONSTRUCTION TAX
EXI IAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HEATING UNIT (TO 100,000 BTU)
Date Recei f((
HEATING UNIT (OVER 100,(100 BTU)
TOTAL
VENTILATION FAN (SINGLE RESIO)
ISSUANCE DATE
f��k A N
U' A
SEP al0
_ as '0A10:)Owneror
ISSUEDBd�`�/'1�� 71
BOILER -COMP OHP OR 100,000 BTU)
BORER-COMP(OVEt 100,0lD BTU)
NEW RESIDENTIAL MECH. SQ.FT
authorized agent Data
'TOTAL:
OFFICE COPY