20106 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project IdentificationPERMIT NO.
Build A - • S�, c+ 20106
Trv—mt�\J`
er sName: ., hone: A=CATION SUBMITTALp
MI yvi L ICL CITY OF CUPERTINO-BUILDING DIVISION
Contr ctois me: Li,,No: APPLICATION /PERMIT
t1ur, Lkwn,,-� r C17 q C' BUILDING-ELECTRICALPLUMBING-MECHANICAL CATEGORY COIF
Architect/Engineer: Lic.No:
p O
az_1 Q C QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
AddressMcs. C j" i PERMITISSUANCE �
LICENSED CONTRACTOR'S DECLARATION LA
I hereby affirm that I am licensed under provisions of Chapter 9(commenc- APPLIANCES-RESIDENTIAL JOB D RIPTION
ing with Section 7000)of Division 3 of the Business and Professions Code,and my
license is in full fo and effect. PANELS
License lass Lic# C C CA
Date_ C Contractor SUP TO 2DO AMPS
ARCHITECTS DECLARATIO 201-1000 AMPS
(�a0 O I understand my plans shall be used as public records. OVER 1000 SQ.FT.FLOOR AREA $/SQ.FT.
Licensed Professional SIGNS ELECTIu
OWNER-BUILDER DECLARATION SPECIAL C
i I hereby affirm that I am exempt from the Contractor's License law for the
OF following reason.(Section 70315,Business and Professions Code:Any city or TEMP LE INST.
countywhich requires a permit to construct,alter,improve,demolish,or repair
a any structure prior to its issuance,also requires the applicant for such permit to POWER D
Ufile a signed statement that he is licensed pursuant to the provisions of the
O w Contractors License Law(Chapter 9(commencing with Section 7000)of Divi- N ELE C
O Q
sion3 ofthe Business and exemption. Any violation
he is exempt therefrom and VALUATION
•�] the basis for the alleged exemption. Any violation of Section 7031.5 by any E ' TCHEs4
applicant for a permit subjects the applicant to a civil penalty of not more than
Qo five hundred dollars($500). W EMTIAL E EC SQ.FT. STORIES TYPE CONSTRUCTION
Z¢
F-1 I,as owner of the property,or my employees with wages as their sole
compensation,will do the work,and the structure is not intended or offered for
q sale(Sec.7044,Business and Professions Code:The Contractor's License Law
r3$ 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 that such
improvements are not intended or offered for sale.If,however,the building or TOTAL: lCV
improvement is sold within one yearof completion,the owner-builderwill have
the�urden of proving that he did not bulla or improve for purpose of sale.). CryjJM$ING PERMIT SEE FLOOD ZONE APN
U L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE �j�
contractors to construct the project(Sec 7044,Business and Professions Code: 1 1..� 5
The Contractors License Law does not apply to an owner of property who
builds or improves thereon,and who contracts for such piyjects with a ALTER-DRAIN&VENT-WATER(EA)
contractors)licensed pursuant to the Contractor's License Law. n / j FEE SUMMARY
❑I am exempt under Sec B&P C for this reason BACK FLOW PROTECT.DEVICE hsr+C! OUTSIDE FEES
DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y_ N_
Owner Date RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
[:]I hereby affirm that I have a certificate of consent to self-insure,ora FIXTURES PER TRAP Ra�EIFT M
certificate of Workers Compensation Insurance or a certified copy thereof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y_ N_
3800,Lab CJ ,J RECEIPT#
Polity#any
m GAS EA.SYSTEM-OVER 4(EA) BUILDING DIVISION FEES
Co �! G�—�i 7��C rl
�Certifcopy 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 4-5'10 55(13
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200FT. Date Recei t#
(This section need not be completed if the permit is for one hundred dollars
($100)or less.) WATERI�AIERW/vENI/ELECIR 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 becom subject to the WATER SYSTEM/TREATING ��� PAID
Workers'Comps tion Lan�QQf Cal ornia.D e C-1
Z Applicant 1JU1 ru�Id� CZ36k NEW RESIDENTIAL PLMB. SQ Fl. Date Recei t#
7 O NOTICE TO APPLICANT:If,after rna#4ng this Certificate of Exemption,you
should become subject to the Workers ompensation provisions of the Labor TOTAL:
N Code,you must forthwith comply with such provisions or this rmit shall be
r j seemerevoked. P y P � BUILDING FEE
1J — CONSTRUCTION LENDING AGENCY SEISMIC FEE
L G I hereby affirm that there is a construction lending agency for the perform TOTAL: ELECTRIC FEE
D Z ance of the work for which this permit is issued(Sec.3097,Civ.C.)
O Lender's Name PLUMBING FEE
F- Lender's Address QTY, MECHANICAL PERMPT FEE
L U 1 certify that I have read this application and state that the above information
MECHANICAL FEE
W is correct.I agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE \ Z M FEES PAID:
y 0- relating to building construction,and hereby authorize representatives of this
city to enter upon the above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
Z (We)agree to save,indemnify an d keep harmless the City of Cupertino Date Receipt#
against liabilities,judgments,costs and expenses which may in any way accrue 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 Recel 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) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management District? BOILER-COMP(3HPOR 100,000 BTU) may,
Yes
ON.
4have read the hazardous materials requirements under Chapter 6.95 of BOILER-CAMP(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 notify the occupant of the requirements which must be met
prio to issuance of a Certificate of Occupancy.
i1111r) 416 NS,
Owner orlauthorized aent Date �ep I'D BY.. .TOTAL: �S.i+
OFFICE COPY