23591 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -- USL 6-A',.: t .:
Building Project Identification �p PERMIT NO.
Building Address: f23591
Esc *i �Y
wners Phone: APPLICATION BMI ADATE
40c) CITY OF CUPERTINO-BUILDING DIVISION
Contract rsptra _ ¢ n Lic.No: APPLICATION /PERMIT
BUILDING-ELECTRICAGPLUMBING-MECHANICAL CATEGORY CONTROL p
Architect/Engineer. Lic.No:
QTY ELECTRICPERMIT BUILDING PERMIT INFO
Address: PERMITISSUANCE ❑ TA ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commenc- APPLIANCES-RESIDENTIAL JOB DESCRIPTION
in withSection7000)ofDivision3oftheBusinessandPrcfessionsCode,andm
license is in full f rcQand effect. y PANELS
License lass
Date Contractor
ARCHITECT'S DECLARATION 201-1000 AMPS
0O Z I understand my plans shall be used as public records. OVER 1(X10 AMPS SQ.Fr.FLOOR AREA $/SQ• •
W P SIGNSELECTRICAL
V U Licensed Professional
Q N OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/M
F 2 I hereby affirm that I am exempt from the Contractor's License Law for the ff
OQ following reason.(Section 7031.5,Business and Professions Code:Any city or TEMP.METER OR E INST.
ut county which requires a permit to construct,alter,improve,demolish,or repair
P ¢ any structure prior to its issuance,also requires the applicant for such permit to pOWERDEVI
DEO VI
file a signed statement that he is licensed pursuant to the provisions of the
3 Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING L ELECTRIC 1VAFAR011
O 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 7031.5 by any OUT LEWI.I.CHES-FIXTURES l
applicant for a permit subjects the applicant to a civil penalty of not more than
a qo five hundred dollars($500). NEW IDENTIAL ELECTR SQ.FT. STORIES TYPE CONSTRUCTION
I,as owner of the property,or my employees with wages as their sole
Z¢ compensation,will do the work,and the structure is not intended or offered for
q sale(Sec.7044,Business and Professions Code:The Contractors License Law
r� does not apply to an owner of property who builds or improves thereon,and OCC.GROUP RES.UNITS
who does such work himself or through hisown employees,provided thatsuch
improvements are not intended or offered for sale.If,however,the building or TOTAL:I
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
❑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 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{ojects with a FEE SUMMARY
contractor(s)licensed pursuant to the Contractors License Law. BACK FLOW PROTECT.DEVICE
F-1I am exempt under Sec. B&P C for this reasonOUTSIDE
DRAINS-FLOOR ROOF,AREA,COND. SANITARY Y N_
Owner Date RECEIPT#
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOL TAX Y_ N
1-1I hereby affirm that I have a certificate of consent to self-insure,or a RECEIPT#
certificate of Workers Compensation Insurance or a certified copy thereof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N_
3800,Lab C J •) RECEIPT#
# o js
Policy ^
jco <d26 jGAS EA.SYSTEM-OVER 4(EA) BUILDING DIVISION FEES
m any l;
ertified copy is ereby furnis ed. GREASE/INDUSTRL WASTE INTERCEPTOR c PLANCHECK FEE
Certified copy is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200FT. Date Recei t#
(This 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 WATER SYSTEM/TREATING
Workers'Compensation Laws of California.Date PAID
O Z Applicant NEW RESIDENTIAL PLMB. SQ.FT. Date Recei t#
Z NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
should become subject to the Workers'Compensation provisions of the Labor TOTAL:
P N Code,you must forthwith comply with such provisions or this permit shall be BUILDING FEE
deemed revoked.
W CONSTRUCTION LENDIN.,AGENCY SEISMIC FEE
(L 1 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,Clv.C.) PLUMBING FEE
00 Tender's Name "
LL H Lender's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW 1 certify that I have read this application and state that the above information
CL is correct.I agree to comply with all city and county ordinances and state laws E PERMIT ISSUANCE FEES PAID:
>. relating to building construction,and hereby authorize representatives of this
W city to enter u above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
_ Z Date Receipt#
(We)a ee t ve,indemnify an eep harmless the City of Cupertino
u against liabil't' ,judgme ts,co s n e penses which may in anyway accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
against said ty inion ue e o t e 'anting of this permit. CONSTRUCTION TAX
' AIR HANDLING UNIT(OVER 10,000 CFM)
Signature o 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 Recel 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
F]Yes N 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
Qualitv Management District? BOILER-COMP QHPOR 100,000 BTU) Lam.
is
No f
ve read the Nazar ous materials requirements under Chapter 6.95 of 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 NEW RESIDENTIAL MECH._ SQ.FT.
responsibility to notify the occupant of the requirements which must be met 4• i'. i� t
prior to issuance of a Certificate of Occupancy.
1.
Owner or authorized agent Date �•• ISSUED BY;
TO
OFFICE COPY