21784 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address: 21784
caner s hone: APPLICATION
�• q�— L,`j DCITY OF CUPERTINO-BUILDING DIVISION A A
Contractor'sName: Lic.No:
APPLICATION /PERMIT �a ��I
C BUILDING ELECTRICAIrPLUMBING-MECHANICAL CATEGORY CONTROL#
Architect/Engineer. Lic.No:
O Y ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: 1' 0h �� C1.S ` PERMIT ISSUANCE ElLICENSED CONTRACTOR'S DECLARATION El
I hereby affirm that I am licensed under provisions of Chapter 9(comment- APPLIANCES-RESIDENTIAL JOB DESCRIPTION
ingwith Section 7000)of Division 3 ofthe Business and ProfessionsCode,and my
license is in full force d effect. PANELS CJ
License Clams C– Lic# S
Date – Contractor , -1--r—
ARCHITECT'S DECLARATION 201-1000 AMPS N ��
O I understand my plans shall be used as public records. OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
SIGNS ELECTRICAL D
Z U Licensed Professional
Q w OWNER-BUILDER DECLARATION
�n SPECIAL CIRCUIT/MISC -�- E R
1., z I hereby affirm that I am exempt from the Contractor's License Law for the
lt- u
O following reason.(Section 7031.5,Business and Professions Code:Any city or
Z TEvIP.METER OR POLE INST.
county which requires a permit to construct,alter,improve,demolish,or repair l
any structure prior to its issuance,also requires the applicant for such permit to ppyygR DEVICES
O U file a signed statement that he is licensed pursuant to the provisions of the !!
u H Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi-
]3 O¢ sion3 of the Business and Professions Code)or that he is exempt therefrom and SWIMMING POOL ELECTRIC VALUATION
r the basis for the alleged exemption. Any violation of Section 70312 by any
3 Q O applicant for a permit subjects the applicant to a civil penalty of not more than OUTLETSSWITCHES-FIXTURES
M five hundred dollars($500). NEW RESIDENTIAL ELECTR SQS-T. STORIES TYPE CONSTRUCTION
Z
¢ ❑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
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 does such work himself or through his own employees,provided that such OCC.GROUP RES.UNITS
improvements are not intended oroffered for sale.If,however,the building or TOTAL:
improvement is sold within one yearof completion,the owner-builderwill have
the burden of proving that he did not build or improve for purpose of sale.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
ML as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE 11 FV
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-WATER(EA)
builds or improves thereon, and who contracts for such pgojects with a FEE SUMMARY
licensed pursuant to the Contractors License Law. BACK FLAW PROTECT.DEVICE
E]I am exempt under Sec B&P C for this reasnn 1
Owner Date DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y_ N_
RECEIPT#
WORKMAN COMPENSATION DECLARATIONS PER TRAP SCHOOLTAX Y N
hereby affirm that I have a certificate of consent to self-insure,ora FIXTURERECEIPT#
certificate of Workers Compensation Insurance or a certified copy thereof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y_ N_
3800,Lab C.)
Policy# USC�C> L'�� GAS Flt.SYSTEM-OVER 4(EA) RECEIPT#
Com any i 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-STORM FA.200FT. Date Recei t#
(This section need not becompleted if the permit is for one hundred dollars
($100)or less.) WATER HEATER W/VENT/ELF-CTR a ENERGY FEE Y N
I certify that in the performance of the work for which this pemilt is issued,
I shall not employ any person in any manner so as to become subject to the WATIR SYSTI2vf/TREATING
Workers'Compensation Laws of California.Date PAID
Z Applicant NEW RESIDENTIAL PLMB. SQYT. Date Rerni 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:
y Code,you must forthwith comply with such provisions or this permit shall be BUILDING FEE
L > deemed revoked.
1 0 CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z I hereby affirm that there is a construction lending agency for the perform- TOTAL: ff�� ELECTRIC FEE
an of the work for which this permit is issued(Sec.3097,Civ.CJ y,W
O L
e
nder's Name PLUMBING FEE Li
L H Lender's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
W
1 certiffthatl have read this application and statethatthe above information
is correct.I agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
> 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 Date Receipt#
_ (We)agree to save,indemnify an d keep harmless the City of Cupertino
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. CONSTRUCTION TAX
AIR HANDLING UNIT(OVER 10,000 CFM)
Signature of App Contractor A 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 Recej t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health and Safety Code ion 25532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL•
❑Yes 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 D s rtct? BOILER-COMP QHPOR 100,000 BTU) ��
'RYes E]No
ave read the hazardous materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) APR
�� y
the California Health&Safety Code,Sections 25505,25533 and 25534.I A r^ 2 # �"
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQXT. ti
responsibility to notify the occupant of the requirements which must be met
prior to issuance of a Certificate of Occupancy. 'IV
I) e � S-,Q1-'7/
Owner or authorized age Date ISS
TOTAL:
OFFICE COPY