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24132 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building Project Identification PERMIT N Building Address: �j 413 2 /®� � ©� c/ wners ame: hone: A A CITY OF CUPERTINO-BUILDING DIVISION con or'sName: Lic.No: APPLICATION /PERMIT BUILDING-ELECTRICAL-PLUMBING-MECHANICAL CATEGORY CONTROL M Archited/Engineer. Lic.No: J QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO Addres• J PERMIT ISSUANCE 1:1ElLICENSED CONTRACTOR'S DECLARATION I hereby affirm that I am licensed under provisions of Chapter 9(comment APPLIANCES-RESIDENTIAL JOB DESCRIPTION ing with Section 7000)of Division 3 of the Business and ProfessionsCode,and my I icense is in full once and effect. : � PANELS License Class Lic# l /� Date Contractor Z/ _ ABCHITECT ECLARATION 201-1000 AMPS r/ P4 O I understand my plans shall be u d as public records. OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.Fr. ZU Licensed Professional SIGNS ELECTRICAL �1 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC E, I hereby affirm that I am exempt from the Contractor's License Law for the 0.1 Up p�p following reason.(Section 7031.5,Business and Professions Code:Any city or �p��OR POLE INST. L Z H W county which requires a permit to construct,alter,improve,demolish,or repair �j any structure prior to its issuance,also requires the applicant for such permit to POWER DEVICES D f L I PA O 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 0 sion 3 of the Business and Professions Code)orthat he is exempt therefrom and VALUAT!Q& the basis for the alleged exemption. Any violation of Section 70315 by any OUTLETS-SWITCHES-FIXTURES 2 o applicant fora permit subjects the applicant to a civil penalty of not morethan O five hundred dollars($500). —SQFr. STORIES TYPE CONSTRUCTION rn�*" ..� ❑I,as owner of the property,or my employees with wages as their sole NEW RESIDENTIAL ELECTR Z compensation,will do the work,and the structure is not intended or offered for p 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 RES.UNITS r, who doessuchworkhimself orthroughhisownemployees,provided thatsuch improvements are not intended or offered for sale.If,however,the building or TOTAL: improvement is sold within one yearof completion,the owner-builderwill have tl)e burden of proving that he did not build or improve for purpose of sale.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN U 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 contractors)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE ❑I am exempt under Sec. B&P C for this reason OUTSIDEFEES DRAINS-FLOOR,ROOF,AREA,COND. SANITARY Y— N Owner Date RECEII'T# WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCI�OOLTAX Y_ N ❑I hereby affirm that I have a certificate of consent to self-insure,ora 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.) RECEIPT IF Policy# / ��� GAS EA.SYSTEM-OVER 4(EA) Com any ( BUILDING DIVISION FEES Certified copy is hereby furnished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE �2>srtified 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.) WATERHFAIFRW/VENT/ELECIR 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 OTC Applicant Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you NEW RESIDENTIAL PLMB. SQ.F1'. Date Recei t# should become subject to the Workers'Compensation provisions of the Labor TOTAL: W Code,you must forthwith comply with such provisions or this permit shall be BUILDING FEE deemed revoked. u � L � CONSTRUCTION LINDING AGENCY SEISMIC FEE t I hereby affirm that there is a construction lending agency for the perform- TOTAL: ELECTRIC FEE D Z ante of the work for which this permit is issued(Sec.3097,Civ.C.) .) o Lender's Name PLUMBING FEE F Lender's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE ' W 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 PERMIT ISSUANCE FEES PAID: Nrelating 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# against liabilities,judgments,costs and expenses which may in anyway accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL: Fist said ' in ons ence granting of t)q t)' permit. AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX Signature of pplicant/Con a ate EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID: HAZARDO ATERIALS ISCLOSURE Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date Recej 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 ❑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(3HP OR 100,000 BTU) ❑Yes M No I have read the hazar ous materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) P A ,Jh, the California Health&Safety Code,Sections 25505,25533 and 25534.1 I.i understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.Ff. responsibilitynotify the occupant of the requirements which must be met Os- prior �P 6 prior to issuance of a Certificate of Occupancy. #"• Y 9 Owner or authorized agent Date ` 8 TOTAL: ISSUED BY: � t u v u OFFICE COPY