23446 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address:
10 L+'2--Z- V06,L- 23446
Owner'sName: F one:
E.y �b CITY OF CUPERTINO-BUILDING DIVISION ^ t A A
con r'sNa Lic.No: APPLICATION /PERMIT .$ "�'�` �1 Z.-
Architect/En
BUILDING-ELECTRICALrPLUMBING-MECHANICAL CATEGORY CONTROL#
eer. Lic.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMIT ISSUANCE E] ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commenc- APPLIANCES-RESIDENTIAL j JOB DESCRIPTION
ingwithSection7000)ofDivision3oftheBusiness and ProfesaionsCode,and my s- , '
I icense is in full force and effect. PANELS
License Class Lic#
Date Contractor UP TO 200 AMPS
ARCHITECT'S DECLARATION 201-1000 AMPS
CW4 O I understand my plans shall be used as public records. OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
O U Licensed Professional SIGNS ELECTRICAL LED
PW OWNER-BUILDER DECLARATION C
Cn� SPECIAL CIRCUIT/MISC R
H Z I hereby affirm that I am exempt from the Contractor's License law for the
0_ following reason.(Section 7031.5,Business and Professions Code:Any city or
Z t, TEMP.METER OR POLE INST.
county which requires a permit to construct,alter,improve,demolish,or repair
F /
«1 any structure prior to its issuance,also requires the applicant for such permit to 1
1 Q V file a signed statement that he is licensed pursuant to the provisions of the POWER DEVICES (/
3 w Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC
O sion 3 of the Business and Professions Code)orthat he is exempt therefromand VALUATION
j 0 O the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWITCIiESFIXTURES
applicant for a permit subjects the applicant to a civil penalty of not more than
five hundred dollars r. NEW RESIDENTIAL ELECTR SQ.FI'. STORIES TYPE CONSTRUCTION
Z¢O ❑I,as owner of thehe property,or my employees with wages as thew sole
compensation,will do the work,and the structure is not intended or offered for
O sale(Sec.7044,Business and Professions Code:The Contractots License Law
3r does not apply to an owner of property who builds or improves thereon,and OCC.GROUP RFS.UNITS
who doessuch work himself or through hisown employees,provided that such
improvements are not intended or offered for sale.If,however,the building or TOTAL:
improvement issold within oneyearofcompletion,the owner-builderwill have
the burden of proving that he did not build or improve for purpose of sale.). (3TY PLUMBING PERMIT FEE FLOOD ZONE APN
❑I,as owner of the property,am exclusively contracting with licensedI PERMIT ISSUANCE
contractors to ronstruct 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 p�Djects with a FEE SUMMARY
contractor(s)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
El am exempt under Sec B&P C for this reason
OUTSIDE FEES
OwnerDate DRAINS FLOOR,ROOF,AREA,GOND. SANITARY Y_ N_
RECEIPT#
WORKMAN COMPENSATION DECLARATION PER TRAP SCHOOLTAX Y
❑I hereby affirm that I have a certificate of consent to self-insure,ora ECN
FnrI.
certificate of Workers'Compensation Insurance or a certified copy thereof(Sec. R 3800,Lab C.) GAS EA.SYSTEM-1 INCA OUTLITS PARK FEE Y_ N_
Policy# GAS EA.SYSTEM-OVER 4(EA) RECEIPT PT
or ray BUILDING DIVISION FEES
ertified copy is hereby furnished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
ertified copy is filed with the dty inspection division.
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.) WATER HEATER W/VENT/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 W SYSTI1vi/ EATING
Workers'Compensation Laws of California.Date PAID
Applicant NEW Date Recei t#
7 0 NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you RESIDENTIAL PLMB SQ.FT
should become subject to the Workers'Compensation provisions of the Labor TOTAL:
0 Code,you must forthwith comply with such provisions or this permit shall be BUILDING FEE
L j deemed revoked.
L 0 CONSTRUCTION LENDiNG AGENCY SEISMIC FEE
I hereby affirm that there is a construction lending agency for the perform ELECTRIC FEE
3 Zance of the work for which this permit is issued(Sec.3097,Civ.C.) T L.
0 Lender's Name PLUMBING FEE
L H Lender's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
' iU Icertify that Ihave read this apph tion and state that the above information
is correct.I agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
relating to building construction,and hereby authorize representatives of this
Z city to enter upon the above-mentioned property for inspection purposes. ALTER OR ADD TO MECH. Date Recej t#
Z (We)agree to save,indemnify an d keep harmless the City of Cupertino P
against liabilities,judgments,costs and expenses which may in anyway accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
against said C' nsNuence of the I ting of this permit. CONSTRUCTION TAX
t AIR HANDLING UNIT(OVER 10,000 CFM)
ignatu 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
Health and Safety Code Section 25532(a)? BEATING UNIT(OVER 100,000 BTU) TOTAL.
❑Yes M 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(3HPOR 100,000 BTU) P A f D
Yzs No
have read the hazardous materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU)
��
y
the California Health&Safety code,Sections 25505,25533 and 25534.1 �^�
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT.
responsibility to notify the occupant of the requirements which must be met
prior to issuance of a Certificate of Occupancy. CI j Y Ur CUf'Cn I ITV
Owner or authorized agent Date ISSUED BY:
TOTAL:
OFFICE COPY