20183 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PER.NUT NO..
Building Address: 20183 log.*cl � AlIf�A)5'6A AVL- 73�-"Iq5 �
Owner's Name: hone: APPL11ATION sUBMITTAL DA
(c I- CITY OF CUPERTINO-BUILDINGDIVISION
Contractors Name: Lic.No: APPLICATION / PERMIT
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL CATEGORY CONTROL#
.rchitect/Engineer. Lic.No:
QBUILDING PERMIT INFO
TY ELECTRIC PERM
Address: PEP-NETISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(comment- APPLIANCES-RESIDENTIAL JOB DESCRIPTION
i ng with Section 7000)of Division 3 of the Business and ProfessionsCode,and my
license is in full force and effect. PSS /�,/�'"�
LicUP TO 200 ANTS
ense Class Lic.# 4: I'
Date Contractor
ARCHITECTS DECLARATION 201-1000 AMPS
Z I understand my plans shall be used as public records. OVER 1000 AMPS SQ.FT.FLOOR AREA 3/SQ.FT.
�.1 OF SIGNS ELECTRICAL
�v C1 V Licensed Professional
ca OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/
ZI hereby affirm that I am exempt from the Contractor's License Law for the
O ❑" following reason.(Section 7031.5,Business and Professions Code:Any city or TEMP.METER OR LEt�
Z r t county which requires a permit to construct,alter,improve,demolish,or repair
" "la any structure prior to its Issuance,also requires the applicant for such permit to POWER DEVICES
i
VU file a signed statement that he is licensed pursuant to the provisions of the
O c Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING FOOL ELECTRIC
3 O ,ion 3 of the Business and Professions Code)orthat he is exempt therefromand VALUATION
the basis for the alleged exemption. Any violation of Section 70315 by any OUTLETS-SWITCHESFIXTURES / /'� `_��
applicant for a permit subjects the applicant to a civil penalty of not more than 0v 0
o r five llyndred dollars($500). NEW RESIDENTIAL ELECTR SQXT. STORIES TYPE CONSTRUCTION
+ I,as owner of the property,or my employees with wages as their sole
Z¢ compensation,will do the work,and the structure is not intended or offered for
p sale(Sec 7044,Business and Professions Code:The Contractors License Law
does not apply to an owner of property who builds or improves thereon,and OCC.GROUP RES.UNITS
off. who does such work 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 one year of completion,the owner-builderwill have
the burden of proving that he did not build or improve for purpose of sale.). QW. PLUMBING PERMIT FEE FLOOD ZONE APN
❑L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec.7044,Business and Professions Code:
The Contractors License Law does not apply to an owner of property who ALTERIN-DRA &VENT-WATER(EA)
builds or improves thereon,and who contracts for such ptojects with a FEE SUMMARY
contractors)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
❑I am exempt under Sec B&P C for this reason SI
DE FEES
DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y_ N_
Owner A C'— Date RECEIPT#
WOR AN COMPENSATION DECLARATION r FIXTURES PER TRAP SCHOOL TAX Y_ N
❑I hereby affirm that I have a certificate of consent to self-insure,ora RF��#
certificate of Workers Compensation Insurance or a certified copy thereof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y_ N_
3800,Lab C.) RECEIPT#
Policy# GAS-EA.SYSTEM-OVER 4(EA)
Com any BUILDING DIVISION FEES
Certified 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-STDR.VIEA 200FT Date Recei t#
(This section need not be completed if the permit is for one hundred dollars
($100)or less.) WATER HEATER W/VFN'T/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 PAID
Workers'Compensation Laws of California.Date
O Z Applicant NEW RESIDENTIAL PLMB. SQ.FT. Date Recei t#
Z 0 NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
should become subject to the Workers'Compensation provisions of the Labor TOTAL:
N Code,you must forthwith comply with such provisions or this permit shall be BUILDING FEE '
deemed revoked.
LLI CONSTRUCTION LENDING AGENCY SEISMIC FEE Ing
Q. C 1 hereby affirm that there is a construction lending agency for the perform- TOTAL: ELECTRIC FEE
Z ance of the work for which this permit is issued(Sec 3097,Civ.C.) PLUMBING FEE
U. O Lender's Name MECHANICAL FEE
� Lenders Address QTY. MECHANICAL PERMIT FEE
U
I certify that I have read this application and state that the above information FEES PAID:
O W is correct.I agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE
} d relating to building construction,and hereby authorize representatives of this -.20-
�.. U) 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#
V against liabilities,judgments,costs and expenses which may in any way accrue AIR HANDLING UNIT(1O 10,000 CFM) SUBTOTAL: G
against said City inconsequence 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 ReceI t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the J
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(311I'OR 100,000 BTU)
rdo
Yes No
have read the hazaus materials requirements under Chapter 6.95 of BOILER MP PP(OVER 100,000 BTU)
the California Health&Safety Code,Sections 25505,25533 and 25534.I A ��glvj
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.Ff. f
responsibility to notify the occupant of the requirements which must be met
prior to issuance of a Certificate of Occupancy.
Cid �rnr+atif�n
Owner or authorized agent Date TOTAL: ISSUED BY:
OFFICE COPY