19811 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES
Building Pr-!•ect Identification PERMIT NO.
Building Addres 19811
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wn AMI
Phone: A B A A
CITY OF CUPERTINO-BUILDING DIVISION
Cont nt 'a Name: APPLICATION / PERMIT
BUILDING-ELECTRICA1,PLUMBING-MECHANICAL CATEGORY CONTROL#
Architect/Engineer: Lic.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address-1692, � ' I 1:1 1:1 1:1PERMIT ISSUANCE
LICENSED CONTRACTOR' DECLA TON
I hereby affirm that I am licensed under provisions of hapter 9(comment- APPLIANCES-RESIDENTIAL k JOB DESCRIPTION
ingwith Section 7000)ooffP ision3oftheBustn_es�and� fessionsCode,andmy
license is i fu fect. `j� 0 PANELS
Li, app L c.# ✓
Date 1 Contractor FfX. J y
ARCHITECTS DECLARATION 201-100 PS
Z I understand my plans shall be used as public records. OVER 1 SQ.FT.FLOOR AREA
O
U Licensed Professional SI NSEL CA
OWNER-BUILDER DECLARATION S ISC
I hereby affirm that I am exempt from the Contractor's License Law for the
O 2'a following reason.(Section 7031.5,Business and Professions Code:Any city or TER W4E INST.
county which requires a permit to construct,alter,improve,demolish,or repair
4�J any structure prior to its issuance,also requires the applicant for such permit to DEVICN
C file a signed statement that he is licensed pursuant to the provisions of the
O w Contractor s License Law(Chapter 9(commencing with Section 7000)of Divi- L ELE C
O sion 3 of the Business and Professions Code)orthat he is exem therefrom and LL VALUATION
the basis for the alleged exemption. Any violation of Section 7031.5 by any OI)LETS TCHES- ES r�� !�
applicant for a permit subjects the applicant to a civil penalty of not more than (�/ f
a o O five hundred dollars($500).
r,2 NEW WIDENTIA NLEC SQ.FT.' STORIES TYPE CONSTRUCTION
❑1,as owner of the property,or my employees with wages as their sole
�Z¢ compensation,will do the work,andthe structure is not intended or offered for 1
q sale(Sec.7044,Business and Professions Code:The Contractors License Law
3r does not apply to an owner of property who builds or improves thereon,and t OCC.GROUP RFS.UNITS
who does suchwork himself orthrough his own employees,provided that such
improvements are not intended or offered for sale.If,however,the building or TOTAL:;
improvement is'sold within oneyearof completion,the owner-builderwill have
the burden of proving that he did not build or improve for purpose of sale.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
❑I,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec.7044,Business and Professions Code:
The Contractor's License Law does not apply to an owner of property who ALTER-DRAtN&VENT-WATER(EA)
builds or improves thereon, and who contracts for such projects with a FEE SUMMARY
contractor(s)licensed pursuant to the Contractors License Law. BACK FLOW PROTECT.DEVICE
F-1I am exempt under Sec. B&P C for this reasonOUTSIDE
DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y N
ner Date RECEIPT#
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SC1400L TAX Y N
I hereby affirm that I have a certificate of consent to self-insure,or a
RECEIPT M
certificate of Worker Compensation Insurance or a certified copy thereof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
3500,Lab )� P 1 y RECEIPT#
Policy# 1. GAS EA.SYSTEM-OVER 4(EA) BUILDING DIVISION FEES
Cknryifi
ed copy' ere rnish d. GREASE/INDUSTRL WASTE INTERCEPTORPLANCHECK FEE
ified copy' filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.20oFT. Date Recei t#
(This section need not be completed if the permit is for one hundred dollars
($100)or less.) WATER HEATER W/VENT/11 ECTR ENERGY FEE Y N
I certify that in the performance of the work for which this permit is issued,
I shall not employ any person in any manner so as to become subject to the WATER SYSTEM/TREATING
Worker Compensation Laws of California.Date PAID
ZZ npplicant NEW RESIDENTIAL PLMB. SQ.FT. Date Recei t#
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
should become subject to the Workers'Compensation provisions of the Labor TOTAL:
Code,you must forthwith comply with such provisions or this permit shall be BUILDING FEE �Tq,CZ
deemed revoked.
W CONSTRUCTION LENDING AGENCY SEISMIC FEE 1 �j
a I hereby affirm that there is a construction lending agency for the perform- ELECTRIC FEE
� Z ante of the work for which this permit is issued(Sec.3097,Civ.CJ TOTAL:
(L PLUMBING FEE O Lender's Name LendeisAddress QTY, MECHANICAL PERMIT FEE
H
MECHANICAL FEE
O W
IcertifythatI have read this application and state that the above information
is correct.I agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
d
>- (L
Lrelating to building construction,and hereby authorize representatives of this
cit to enter upon the above-mentioned propertyfor inspection purposes. ALTER OR ADD TO MECH.
~ Z y(We)agree to save,indemnify an d eep harmless the City of Cupertino Date ReCelPt#
V against liabilities,judgments,costs and expenses which may In anywayaccrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
against said City in consequence of the granting of this permit. CONSTRUCTION TAX
AIR HANDLING UNIT(OVER 10,000 CFM)
Signature of Applicant/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date Recej t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the (�
Health and Safety Code Section 25532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑Yes N No
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUASCZJA L E
05 which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management District? BOILER-COMP QHP OR 100,000 BTU)
Yes No
have read the bazar oils materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU)
the California Health&Safety Code,Sections 25505,25533 and 25534.I
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH._ SQ.FT.'
responsibility to no
the occupant of the requirements which ust
to issuance a rtifi of Occu
ner rauthorize ent V Dirle ISSUEDBY:r4() P013W&ULC;
TOTAL:
OFFICE COPY