20122 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
_
Building Project Identification PERMIT NO.
Building Address: 20122 3 hauc Q��t`�o.
wners ame: tAJ hone: APPLICA17ON SUBMITTALA
O
�:. • S "� CITY OF CUPERTINO-BUILDING DIVISION
Contractor's Name: Lic.No: APPLICATION /PERMIT
BUILDING-ELECTRICAL PLUMBING-MECHANICAL CATEGORY CONTROL#
Architect/Engineer. Lic.No:
t2T1f ELECTRIC PERMIT BUILDING PERMIT INFO
Address:
I'ERMITISSUANCE LF1 El
CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commenc- APPLLANCESRESIDENTIAL JOB DESCRIPTION
ingwith Section 7000)of Division 3 of the Business and Professions Code,and my
I icense is in full force and effect. PANELS
License Clams Lic# n cp ,
Date Contractor "lt
ARCHITECTS DECLARATION 201-1000 AMPS
O 1 understand my plans shall be used as public records. OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
Z0 Licensed Professional SIGNS ELECTRICAL
[—Q OWNER-BUILDER DECLARATION
SPECIAL CIRCUIT/MISC
t z I hereby affirm that I am exempt from the Contractors License Law for the
p following reason.(Section 7031.5,Business and Professions Code:Any city or
Z HTEMP.METER OR POLE INST.
� county which requires a permit to construct,alter,improve,demolish,or repair
Oaany structure prior to its issuance,also requires the applicant for such permit to POWER DEVICES
c,U file a signed statement that he is licensed pursuant to the provisions of the
3 u Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC
O sion 3 of the Business and Professions Code)orthat he is exempt therefromand VALUATION
Gthe basis for the alleged exemption. Any violation of Section 70315 by any ^ OUTLETS SWITCII ESFIXTURES S no
applicant for a permit subjects the applicant to a civil penalty of not more than V
o five hundred dollars($500). NEW RESIDENTIAL ELECTR SQ.FT.
50I,as owner of the property,or my employees with wages as their sole STORIES TYPE CONSTRUCTION
compensation,will do the work,and the structure is not intended or offered for
p 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
who doessuch work himself orthrough his own employees,provided thatsuch OCC.GROUP RES.UNITS
improvements are not intended proffered for sale.If,however,the building or TOTAL: ,OL
improvement is sold within oneyearof completion,the owner-build erwill have
thrden of proving that he did not build or improve for purpose of sale.). 42TY 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 DRAIN&VENT-W IFR(EA)
builds or improves thereon,and who contracts for such p{ojects with a FEE SUMMARY
contractor(s)licensed pursuant to the Contractor's License Law. BACK FLAW PRO CE
I am exempt under Sec B&P C for this reason
OUTSIDE FEES
D FLOG 001 COND. SANITARY Y N
ern ate ZRECEIPT#
W COM ENSAT N D CLARA 10 SCHOOL TAX Y N
❑I hereby affv that I have a certificate of consent to self-insure,or REE=#
certificate of Workers Compensation Insurance or a certified copy thereof(SeAGREASE)�b&SIRLWA
O ET PARK FEE Y_ N_
3800,Lab CJ RECEIPT#
Policy#
Com any O 4 ) BUILDING DIVISION FEES
Certified copy is hereby furnished. C TOR PLANCHECK FEE
❑Certified copy is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SA NITARY-STORM 200FT Date Recei t#
(This section need not be completed if the permit is for one hundred oars
($100)or lest.) WATER HEATER W/VENT/ELECTR 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
Workers'Compensation Laws of California. Date PAID
Z Applicant NEW RESIDENTIAL PLMB. SQ.Fr. Date Recei t#
O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
should become subject to the Workers'Compensation provisions of the Labor TOTAL:
U) Code,you must forthwith comply with such provisions or this permit shall be BUILDING FEE
u > deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
L 0
I hereby affirm that there is a construction lending agency for the perform ELECTRIC FEE
0 Z ance of the work for which this permit is issued(Sec.3097,Civ.C.) TOTAL: PLUMBING FEE
Lender's Name
F Lender's Address (Y". MECHANICAL PERMIT FEE
L C) I certifythatI have read this application and statethatthe above information MECHANICAL FEE
W is correct.I agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
I. N 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 f
Health and Safety Code Section 25532(a)? HEATING UNIT(OVER 100,000 BTU) `_k cex
❑Yes M No
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DA�1,,J
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management District? BOILER-COMP(3HP OR 100,000 BTU) APR
❑Yes M No
I have read the hazardous materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) }�
the California Health&Safety Code,Sections 25505,25533 and 25534.I �7 of CU PS
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
prior to issuance of a Certificate of Occupancy.
� %rl
rorauthgent Date TOTAL: ISSUED BY: t
OFFICE COPY
ADDITIONAL PE=T FEES
j
BUILDING PROJECT I DENTI F;uATiON VALUATION
BUILDING j
ADDRESS - -- _ -
I
OWNER'S
I NAME FEE SUMMARY
Pr ONE�
CONTRACTORS 1 ,
NAME BUILDING
LIC NO PLAN CHECK
CONTRACTOR'S F E E
ADDRESS
F PHONE SEISMIC FEE I
I
QTY. ELECTRIC PERMIT FEE
UTLETS-SWITCHES-RECEP ELECTRIC
LIGHTING FIXTURES PLUMBING
APPLIANCES-RESIDENTIAL I
I
PANELS MECHANICAL
SIGNS
I SIGNS TRANS. TOTAL '' ^l'
r 1
,+ SPECIAL CIRCUIT i,<U j
PERMIT VALIDATION
-
EMP.METER OR POLE INS.
MOTORS SEE FEE SCH.
O SERVICE CHANGE
F . Z
o
Z A
TOTAL r 5,::X 4 - :.nc+:�rw A
ISSUANCE DATE .
Lu > QTY. PLUMBING PERMIT FEE BLDG. ELECT. PLG. MECH.
Z ALTER-DRAIN&VENT-WATER(EA.)
U O BACK FLOW PROTECT.DEVICE
LL U DRAINS-FLOOR,ROOF,AREA,COND.
O w
} N FIXTURES-PER TRAP
Z GAS-EA.SYSTEM-1 INC.40UTLETS
(� GAS-EA.SYSTEM-OVER 4(EA.)
INDUSTRIAL WASTE INTER.
LAWN SPRINKLERS-1 INC 5 V.B.
LAWN SPRINKLERS-OVER 5(EA.)
SEWER-SANITARY-STORM EA.200ft/
WATER HEATER W/VENT `
WATER SYSTEM
WATER TREATING EQUIP. PAM
TOTAL G 2 2 lQu
QTY. MECHANICAL PERMIT FEE
ALTER OR ADD TO MECH. t
APPLIANCE
AIR HANDLING UNIT(TO 10=C.F.M:)
AIR HANDLING UNIT(OVER 10=C.F.M.)
EXHAUST HOOD(WITH DUCT)
HEATING UNIT(TO 100,000 B.T.U.)
HEATING UNIT(OVER 100,000 B.T.U.)
VENTILATION FAN(SINGLE)
BOILER-COMP13 H.P,or 100,000 B.T.U.)
BOILER-COMP(0�,100,000 BTU)SEE FEE SCH.
1 TOTAL