23932 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE bALI. j�_;.;':
Building Project Identification PERMIT NO.
Building Address: / /^ 7'A'_
1 /f I
wnersName: Phone: APPLICATION BM AL DATE
CITY OF CUPERTINO-BUILDING DIVISION
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Co=}Y/udor's Name: y Lic.No: APPLICATION / P E R M I T
V L i C BUILDING-ELECTRICALPLUMBING-MECHANICAL CATEGORY CONTROL#
Architect/Engineer: Lic.No:
QTY ELECTRIC PERMIT FEg BUILDING PERMIT INFO
Address: PERMIT ISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION ON
I hereby affirm that I am licensed under provisions of Chapter 9(comment- APPLIANCES-RESIDENTIAL JOB DESC
ing with Section 7000)of Division 3 of the Business and Professions Code,and my
license is in full force and effect. n � PANELS
License Cl ss // �C Lic.# -n =_5 )
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Date ' L ., Contractor r j�D�l UP TO 200 AMPS
'
ARCHITECTS DECLARATIO 201-1000 AMPS
r4Z I understand my plans shall be used as public records. OVER 1000 AMPS SQ.FT.FLOOR AREA 7FT.
O
U Licensed Professional SIGNS ELECTRICAL + v ^ t
F Q cW OWNER-BUILDER DECLARATION d V
u n SPECIAL CIRCUIT/MISC
Z I hereby affirm that I am exempt from the Contractors License Law for the
ZO O H W following reason.(Section 7031.5,Business and Professions Code:Any city or TEMP.METER OR POLE INST.
ui county which requires a permit to construct,alter,improve,demolish,or repair
any structure prior to its issuance,also requires the applicant for such permit to POWER DEVICES _
U 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- SWIMMING POOL ELECTRIC VALUATION.
O¢ sion 3 of the Business and Professions Code)or that he is exempttherefrom and
H r 7 the basis for the alleged exemption. Any violation of Sectio7031.5 by any r,
Q O OUTLETS-SWITCHES-FIXTURES 1 �5, �
applicant for a permit subjects the applicant to a civil penalty of not more than --,k �a�} (- L/
five hundred dollars($500). NEW RESIDENTIAL ELECTR SQ.FT. STORIES TYPE CONSTRUCTION
El1,as owner of the'property,or my employees with wages as their sole
Z Q 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
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 year of completion,the owner-builder will have
the burden of proving that he did not build or improve for purpose of sale.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
❑L 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 projects with a FEE SUMMARY
contractors)licensed pursuant to the Contractor's License Law. gp FLOW PROTECT.DEVICE
El 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
F-11 hereby affirm that I have a certificate of consent to self-insure,ora RECEII'T#
certificate of Workers'Compensation Insurance or a certified copy thereof(Sec.
3800,Lab C.) GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N_
/
Policy,# `f � - "� RECEIPT#
Com any c 6:i !�� -�s�% �' fly% GAS EA.SYSTEM-OVER 4(EA) BUILDING DIVISION FEES
Certified copy is hereby furnished, PLANCHECK FEE
rD ertified 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#
(This section need not becompleted 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
0Z Applicant NEW RESIDENTIAL PLMB. SQFI'. ! Date Recei t#
ZO NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
should become subject to the Workers'Compensation provisions of the Labor TOTAL:
= ; Code,you must forthwith comply with such provisions or this permit shall be BUILDING FEE _w
deemed revoked.
W — CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL I hereby affirm that there is a construction lending agency for the perform- TOTAL: ELECTRIC FEE
Z ante of the work for which this permit is issued(Sec.3097,Civ.C.)
02 Lender's Name PLUMBING FEE
LL !- Lender's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW I certifythat I have read this application and state that the above information
11 is correct.I agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
fn 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 (We)agree to save,indemnify an d keep harmless the City of Cupertino Date Receipt#
V against liabilities,judgments,costs and expenses which may in any way accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
agaisaid CJty,in con ue ce of the gr,nting of t4is permit. CONSTRUCTION TAX
77 AIR HANDLING UNIT(OVER 10,000 CFM)
t/
Signature ofApplicant/Contractor j / Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MAT6iAI S DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) I 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 10Q000 BTU) 'I'O IAirl
❑Yes In No
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) I ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management District? BOILER-COMP QHP OR 100,000 BTU)
❑Yes ❑No
I have read the hazardous 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. SQFT.
responsibility to notify the occupant of the requirements which must be met
prior to issuance of a Certificate of Occupancy.
Owner or authorized agent Date ISSUED BY:
TOTAL:
OFFICE COPY