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22702EN APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY Building Project Identification ,Building Address: /03&3 No6L_/WE cv10E121­7",o s6 PERMIT NO. 22 702 3WWR-ers ame: hone: APPLIQA A A ieE-J7– A _ 6--05 �5_ 0,J oo U3 •'b-1 � CITY OF CUPERTINO-BUILDING DIVISION APPLICATION / PERMIT Wct Contractor's Name: Lic. No: BUILDING -ELECTRICAL -PLUMBING -MECHANICAL CATEGORY CONTR L # Architect/Engineer. Lic. No: rY ELECTRIC PERMIT FEE BUILDING PERMIT INFO 11,11B MECH Address: ❑ OEN� 1:1LICENSED PERMITISSUANCE � CONTRACTOR'S DECLARATION I hereby affirm that I am licensed under provisions of Chapter 9 (commenc- ing ith Section 7000) of Division 3 ofthe Business and Professions Code, and my license is in full force and effect. APPLIANCES -RESIDENTIAL JOB DESCRIPITON ��+�a .0 ` PANELS License Claw Lic # Date Contractor `� S�� 201-1000 AMPS ARCHITECTS DECLARATION I understand my plans shall be used as public records. A� OVER 1000 AMPS SQ. FT. FLOOR AREA $/SQ. FT. SIGNS ELECTRICAL Licensed Professional p 1 N SPECIAL CIRCUIT/MISC Tp�Ip METER OR POLE INST. OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the following reason. (Section 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair E PZ/ POWER DEVICES RRee SWIMMING POOL ELECTRIC DO any structure prior to its issuance, also requires the applicant for such permit to 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- sion 3 of the Business and Professions Code) orthat he is exempt therefromand TION the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than OUTLETSSWITCHESFIXTURES f' hu dred dollars ($500). as owner of the property, or my employees with wages as their sole NEW RESIDENTIAL ELECTR SQ.FT. STORIES TYPE CONSTRUCTION ompe tion, will dothework, and the structure isnot intended orofferedfor sale (Sec Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself orthrough his own employees, provided that such improvements are not intended or offered for sale. If, however, the building orTOTAL: improvement is sold within oneyear of completion, the owner-builderwill have the burden of proving that he did not build or improve for purpose of sale.). I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, Business and Professions Code: V-1>0 SaNp FE a OCC. GROUP RES. UNITS QTY• PLUMBING PERMIT FEE FLOOD ZONE APN PERMIT ISSUANCE The Contractor's License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such pWjects with a contractors) Bcensed pursuant to the Contractor's License Law. ❑ I am exempt under Sec. B & P C for this reasonOUTSIDE ALTER -DRAIN &VENT -WATER (EA) FEE SUMMARY BACK FLOW PROTECT. DEVICE FEES DRAINS- FLOOR, ROOF, AREA, COND. SANITARY Y N_ RECEIPT # Owner Date WORKMAN COMPENSATION DECLARATION pI hereby affirm that I have a certificate of consent to self -insure, or a certificate of Workers' Compensation Insurance or a certified copy thereof (Sec. 3800, Lab C.) � 'S PER TRAP SCHOOL TAX Y _ N RECEIPT # ' GAS EA. SYSTEM -1 INCA OUTLETS PARK FEE Y_ N_ RECEIPT # Policy q Coffa.BUILDING Com an GAS EA. SYSTEM -OVER 4 (EA) DIVISION FEES Certified ified copy is hereby furnished. Certified copy is filed with the city inspection division. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE GREASE TRAP CERTIFICATE OF EXEMPTION FROM WORKERS' PAID SEWER -SANITARY -STORM EA 200FT COMPENSATION INSURANCE (This section need not be completed if the permit is for one hundred dollar ($100) or less.) I certify that in the performance of the work for which this permit is issued, Date Receipt WATER HEATER W/VENT/ELECTR ENERGY FEE Y _ N _ WATER SYSTEM/TREATING I shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws of California. Date PAID NEW RESIDENTIAL PLMB. SQ.FT. Applicant Date Recei t# NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Workers' Compensation provisions of the Labor TOTAL: BUILDING FEE Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY SEISMIC FEE I hereby affirm that there is a construction lending agency for the perform- ance of the work for which this permit is issued (Sec. 3097, Civ. C.) Lender's Name Lender's Address I certify that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws TOTAL: ELECTRIC FEE PLUMBING FEE QTY. MECHANICAL PERMIT FEE MECHANICAL FEE PERMIT ISSUANCE FEES PAID. relating to building construction, and hereby authorize representatives of this city to enter upon the above-mentioned property for inspection purposes. (We) agree to save, indemnify an d keep harmless the City of Cupertino gainst habiliti gments, costs d expenses which may in anyway accrue Date Receipt# ALTER OR ADD TO MECH. AIR HANDLING UNIT (TO 10,000 CFM) SUBTOTAL: a ai in co e o e gr tin permit. o _ � AIR HANDLING UNIT (OVER 10,000 CFM) CONSTRUCTION TAX EXHAUST HOOD (W/DUCT) CONSTRUCTION TAX PAID: Sig re pphcant/co a or Date HAZA OUS MA ERIALS DISCLOSURE Will the applicant or ture building occupant store or handle hazardous Date Recei t# HF-ATING UNIT (TO 100,000 BTU) material as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety Cade Section 25532(a)? Yes M No Will the applicant or future building occupant use equipment or devices HEATING UNIT (OVER 100,000 BTU) TOTAL: VENTILATION FAN (SINGLE RESID) IS DATE which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District? ❑ Yes d No I have read the hazar ous materials requirements under Chapter 6.95 of � ; BOILER -COMP (3HP OR 100,000 BTU) BOILER -COMP (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 responsibility to notify the occupant of the requirements which must be met �fins.ii NEW RESIDENTIAL MECH.-SQ.FT. prior to issuance of a Certificate of Occupancy. ISSUED BY: Owner or authorized agent Date TOTAL: OFFICE COPY