20970 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES --d USI= BALL, P;11 "
Building Project Identification _ PERMIT NO.
Building Address: 20970
n r sName: Phone: APPLICATION BMl AL MAT-
CA
Ae G 2y3 - 640(, CITY OF CUPERTINO-BUILDING DIVISION
Contractor's Name: r Lic.No: APPLICATION / PERMIT
/: d,/ BUILDING-ELECTRICALrPLUMBING-MECHANICAL CATEGORY CONTROL#
Architect/Engineer. Lic.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address:
PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(comment- APPLIANCFS-RESIDENTIAL JOB DESCRIPTION
ing with Section 7000)of Division 3 of the Business and ProfessionsCode,and my
license is info e�rntd effect. PANELS
License C1a&r Jeic.# f
Date f e"(�K�' Contractor ' VUPT0200AMPS '
ARCHITECT DECLARATION 201-1000 AMPS
Z I understand my plans shall be used as public records. OVER 1000 AMPSOMNSQ.FT.FLOOR AREA $/SQ.FT.
Lia IN
Z U Licensed Professional SIGNS ELECTRICAL
cW
OWNER-BUILDER DECLARATION
affirm E
cn�cn
[-. Z I hereby arm that I am exempt from the Contractor's License Law for the SPECIAL CIRCUIT/MISC
7O_— following reason.(Section 7031.5,Business and Professions Code:Any city or
.METER OR POLE INST. PUT R
r� a county which requires a permit to construct,alter,improve,demolish,or repair
any structure prior to its issuance,also requires the applicant for such permit to POWER DEVICES IIATE
O U file a signed statement that he is licensed pursuant to the provisions of the
Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi-
SWIMMING POOL ELECTRIC UA1164
°Q sion 3 of the Business and Professions Code)orthat he is exempt therefromand
dthe basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWITCHESFIXTURES
applicant for a permit subjects the applicant to a civil penalty of not more than i
p Q° five hundred dollars($500).
NEW RESIDENTIAL ELECTR SQ.FT.q
j z¢
F]1,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
n 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 —
who does suchwork himself or through his own employees,provided that such q OCC.GROUP RES.UNITS
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.). Q'I•Y, PLUMBING PERMIT FEE FLOOD ZONE APN
❑L as owner of the property,am exclusively contracting with licensed
contractors to construct the project(Sec.7044,Business and Professions Code: PERMIT ISSUANCE
The Contractors License Law does not apply to an owner of property who
builds or improves thereon, and who contracts for such projects with a ALTER-DRAIN&VENT-WATER(FA) _.•
contractor(s)licensed pursuant to the Contractor's License Law. FEE SUMMARY
❑I am exempt under Sec. B&P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE
DRAINS-FLOOR,ROOF,AREA,COND. SANITARY Y N
Owner Date RECEIPT#
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOL TAX Y N
[:]I hereby affirm that I have a certificate of consent to self-insure,ora RECEIPT#
3800,Lab C)certificateWorkers Compensation Insurance or a certified copy thereof(Sec. GAS-EA.SYSTEM-1 INCA OUTLETS PARK FEE Y_ N
Policy# t r ' GAS-EA.SYSTEM-OVER 4(EA) RECEIPT#
Com any f�t -/�� r- BUILDING DIVISION FEES
Certified copy isw furnished. GREASE/INDUSTRL WASTE INTERCEPTOR ! PLANCHECK FEE
(�Certified copy is filedled with the city inspection division. i
f CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP 9 PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200FT. Date Receipt#
(This section need not be completed if the permit is for one hundred dollars
($100)or J WATER HEATER W/VENT/ELECTR 1 ENERGY FEE Y N
I certifythat
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 j
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:
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 TOTAL: ELEC'T'RIC FEE
0 Z ante of the work for which this permit is issued(Sec.3097,Civ.CJ
V O Lender's Name PLUMBING FEE
t- Lender's Address QTY. MECHANICAL PERMIT FEE
O W IcertifythatIhavereadthisapplicationandstatethattheaboveinformation MECHANICAL FEE
d is correct.I agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE ' f FEES PAID:
relating to building construction,and hereby authorize representatives of this
U)
F. 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 anyway accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL
against said City in consequence of the granting of this permit.
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
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 I HEATING UNIT(TO 100,000 BTU) Date 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 100,000 BTU) TOTA
❑Yes M No
Will the applicant or ture building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) IS�I�CE DATE
which emit hazardous air contaminants as defined by the Bay Area Air }�
Quality Management District? BOILER-COMP(3HPOR 100,000 BTU)
❑Yes K]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 25534.1 `l;
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT.
respo ty to notify the occupant of the requirements which must be met a
prior to iss ante of a Certifica Occupancy. l/t?
1
��_-,_-ut onzed gent Dat ISSUED BY:
TOTAL: 7
OFFICE COPY