19847 APPLICANTTO FILL IN INFORMATION WIIHIN KL.i.r LIN L,)
Building Project Identification PERMIT NO.
Building Address:
61 17'-y 1NA—F1tAcv �,5o A1 AO)e� . 19847
Owner'sName: Phone: APPLICATION SUBMIT`TALDATE
[-,k 4� __ ,Ej-> 7#6._0 CITY OF CUPERTINO-BUILDING DIVISION _
Contractor's Name: Lic.No: APPLICATION / PERMIT
& 6 L('t flit tyc,: 134 i-tt BUILDING-ELECTRICAIrPLUMBING-MECHANICAL CATEGORY CONTROL#
Arch ect/Engineer: Lic.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE f ❑ ❑ [ILICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commenc- APPLIANCES-RESIDENTIAL 1 JOB DESCRIPTION
ing with Section 7000)of Division 3 of the Business and Professions Code,and my
license is in full force d effect. - e PANELS
License Classc_3r Lic.A C L �y
Date—a -- C� Contractor `• I'r.
ARCHITECTS DEC RATION 201-1000 AMPS n
�4 O I understand my plans shall be used as public records. OVER 1000 AMPS j SQ.FT.FLOOR $/SQ.FT.
Zr, SIGNSELECTRICAL
U Licensed Professional
E~Q OWNER-BUILDER DECLARATION
w mSPECIAL CIRCTJIT/M 1
F, I hereby affirm that I am exempt from the Contractor's License Law for the
ZOO_p following reason.(Section 7031.5,Business and Professions Code:Any city or TEMP.METER OR POLE T.
W county which requires a permit to construct,alter,improve,demolish,or repair
r_4¢ any structure prior to its issuance,also requires the applicant for such permit to ppyygR DEVICES f
file a signed statement that he is licensed pursuant to the provisions of the
3 w Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELECT VALUATION
F O sion 3 of the Business and Professions Code)or that he is exempt therefrom and
the basis for the alleged exemption. Any violation of Section 7031.5 by any
OUTLETS-SWITCHES-FIXTURES
applicant for a permit subjects the applicant to a civil penalty of not more than
qo O five hundred dollars($500). SQ.FT. STORIES TYPE CONSTRUCTION
r NEW RESIDENTIAL ELECTR
..� �I,as owner of the property,or my employees with wages as their sole
�ZQ compensation,will do the work and the structure is not intended or offered for
q sale(Sec.7044,Business and Professions Code:The Contractor's License law
does not apply to an owner of property who builds or improves thereon,and OCC.GROUP RES.UNITS
who does such work himself or through his own employees,provided thatsuch
improvements are not intended or offered for sale.If,however,the building or TOTAL:
improvement is sold within one yearof completion,the owner-builder will 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: Z eV
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
builds or improves thereon, and who contracts for such pipiects with a FEE SUMMARY
contractor(s)licensed pursuant to the Contractor's License Law.
E] gp pIAW PROTECT.DEVICE
I am exempt under Sec. B&P C for this reasonOUTSIDE
DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y N
Owner Date RECEIPT It
WORKMAN COMPENSATION DECLARATION 7+ FIXTURES PER TRAP Z SCHOOL TAX Y N
�I hereby affirm that I have a certificate of consent to self-insure,ora / / RECEIPT p
certificate of Workers'Compensation Insurance or a certified copy thereof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y_ N_
Policy#lab CJ RECEIPT#
PolicGAS EA.SYSTEM-OVER 4(FA) BUILDING DIVISION FEES
Com an
Cey rtified copy is hereby furnished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM Date Recei t#
(This section need not be completed if the permit is for one hundred dollars
($100)or less.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y_ N
m _
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
Workers'Compensation Laws of California.Date PAID
OZ Applicant NEW RESIDENTIAL PLMB. SQ FI. 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:
fn Code,you must forthwith comply with such provisions or this permit shall be BUILDING FEE
deemed revoked.
W > CONSTRUCTION LENDING AGENCY SEISMIC FEE
d I hereby affirm that there is a construction lending agency for the perform- ELECTRIC FEE
Z Len the work for which this permit is issued(Sec.3097,Civ.C.) TOTAL:
0 Lender's Name PLUMBING FEE
LL F
Lender's L6 QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
1 certify that I have read this application and state that the above information
O 111d is correct.I agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
>_ IL relating to building construction,and hereby authorize representatives of this
cit to enter upon the above-mentioned roe for inspection purposes. ALTER OR ADD TO MECH.
~ z y(We)agree to save,indemnify an d keep h rmless he City f pertino Date Receipt#
V against liabilities,judgments,costs and expenses which may in anyway accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL: _
a ainst said Ci c s uence of the granting of this permit.
g w `�` g P
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
CONSTRUCTION TAX PAID:
Signature of Applicant/Contractor Date E xHAUST HOOD(W/DUCT)
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Da Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health and Safety Code Section 25532(a)? HEATING UNIT(OVER 10Q000 BTU) TOTAL:
❑Yes 9 No
Will the applicant o future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management District? BOILER-COMP QHPOR 100,000 BTU) ?t
Yes ®No -
I have read the hazlydous materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BN)
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 MI CH. SQ.FT..
responsibility to notify the occupant of the requirements which must be met r�, _ d
prior to issuance Qf ica Occupancy. --Z -qU D
Owner or authorized agent Date ISSUED BY:
TOTAL:
OFFICE COPY