23136 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification IPERMIT NO.
Building Address: 23136
[ice � Auel- �, _- t
HersName: one: XP=TION SUBMITTALA
Ak CITY OF CUPERTINO-BUILDING DIVISION
Contractor's Name: Lic.No: APPLICATION /PERMIT
c' BUILDING-M ECTRUCALrPLUMBING-MECHANICAL CATEGORY CONTROL#
Archit /Engineer. &t.No:
ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address:9911c J✓ t E C,-t PERMITISSUANCE ❑ ❑ 1:1LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commenc APPLIANCES-RESIDENTIAL JOB DESCRIPTION
ingwith Section 7000)of Division 3 ofthe Business and ProfessionsCode,and my
license is in full force and effect. PANELS
License Class �- I-j Lic# y
Date-2-2 7-�}/ Contractor UP TO 2W AMPS
ARCHITECTS DECLARATION 201-1000 AMPS
a'Z I understand my plans shall be used as public records. OVER 1000 AMPS SQ.FI.FLOOR AREA $/SQ.Ff.
O
NO
SIGNS ELECTRICAL \"] ,A L E $../ I N
Licensed Professional
F w OWNER-BUILDER DECLARATION
] SPECIAL CIRCUIT/MISC
I hereby affirm that I am exempt from the Contractor's License Law for the
0.1- following reason.(Section 7031.5,Business and Professions Code:Any city or TEMp OR POLE INST.
Y(
W county which requires a permit to construct,alter,improve,demolish,or repair /
dany structure prior to its issuance,also requires the applicant for such permit to POWER DEVICES DAT
file a signed statement that he is licensed pursuant to the provisions of the
3 w Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC VALUATION
O a
sion 3 of the Business and Professions Code)or that he is exempt therefrom and
¢ ] the basis for the alleged exemption. Any violation of Section 70315 by any OUTLET-SWITCHES-FIXTURES
applicant for a permit subjects the applicant to a civil penalty of not more than
o O five hundred dollars($SM.
NEW RESIDENTIAL ELECTR SQ.FT. STORIES TYPE CONSTRUCTION
�j z� F-1 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
q sale(Sec 7044,Business and Professions Code:The Contractor's License Law
r3 does not apply to an owner of property who builds or improves thereon,and OCC.GROUP RFS.UNITS
who does such work himself orthrough his own employees,provided that such
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.). <yM PLUMBING PERMIT FEE FLOOD ZONE APN
LJ 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 Contractors License Law does not apply to an owner of property whoAL7 ALTER-DRAIN&VENT-WATER(EA)
builds or improves thereon,and who contracts for such plujects with a FEE SUMMARY
contractor(s)licensed pursuant to the Contractors License Law. BACK FLOW PROTECT.DEVICE
❑I am exempt under Sec. B&P C for this reason
OUTSIDE FEES
DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y N
Owner Date RECEIPT#
WORKMAN COMPENSATION DECLARATION FIXTURESPER TRAP SCHOOL TAX Y_ N
hereby affirm that I have a certificate of consent to self-insure,ora RECEIPT p
ceirtifleate of Workers Compensation Insurance or a certified copy thereof(Sec. GAS FA.SYSTEM-1 INCA OUTLETS PARK FEE Y_ N
3800,Lab C.)
Policy# �aS��C�3'`l� RECEIPT#
Com ny __ Y��
GAS EA.SYSTEM-OVER 4(EA) BUILDING DIVISION FEES
Certified copy is hereby fthmished. PLANCHECK FEE
❑Certified copy is filed with the city inspection division. GREASE/INDUSTRL WASTE INTERCEPTOR
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200FT. Date Recei t#
(Phis section need not be completed if the permit is for one hundred dollars
($100)or less.) WATERITEplER4V/VENT/11EclR 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 FI. 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:
N Code,you must forthwith comply with such provisions or this permit shall be BUILDING FEE
u > deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
L C I 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.)
.) 0 Lender's Name PLUMBING FEE
L H Lender's Address QTY MECHANICAL PERMIT FEE MECHANICAL FEE :).Q-014
uI 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 PERMIT ISSUANCE Bd FEES PAID:
:y N relating to building construction,and hereby authorize representatives of this
cityto enter upon the above-mentioned propertyfor inspection purposes. ALTER OR ADD TO MECH.
Z (We)agree to save,indemnify an d keep mless the ity of Cupertino Date Receipt#
against liabilities,judgments,costs and expenses which may in anyway accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
agar said City j consequen Ofthe
ging of this permit.
,�� u ��%1i/ j��7-y` AIR HANDLINGUNIT(OVER 10,000 cFM) CONSTRUCTION TAX
Sij atureofApplicant/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) d Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the _DD
Health and Safety Code Section 25532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑Yes No
Will the applicant 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 p A 1 D
Quality Management Dist'ct? BOILER-COMP QHP OR 100,000 BTU)
❑Yes No
I have read the hazy ous materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) J
the California Health&Safety Code,Sections 25505,25533 and 25534.I DEC 2 7 1991
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ J-7.
responsibility to notify the occupant of the requirements which must be met
prioZt �ance/, a�rtifica�yt `
I`) uanc Cl i Y Ur CUPLH I IN
Owner or authorized agent Date TOTAL: ISSUED B
OFFICE COPY