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24143a4 Z OO zU U) (n oo�z < U O p, :J �30`n _ZZ (n W LLI 0 a :D U_0 LL. ~ OW a f' N UZ APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE RALI.. POIkN ` PL -N. 0"P Building Project Identification Building Address: PERMIT NO. -7><; �— ;�r>✓-,a;;,-- �� 24143 .WwnerName: Phone: �'7 / / L i ,� •?�� - / ' ,! CITY OF CUPERTINO BUILDING DIVISION APPLICATION / PERMIT BUILDING -ELECTRICAL PLUMBING -MECHANICAL APPLICATION SUBMITTAL DATE C tractor's Name:-_ t j,,. -1 Lic.No: CATEGORY CONTROL # Architect/Engineer: o• QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO Address: IF PERMIT ISSUANCE LICENSED CONTRACTOR'S DECLARATION I hereby affirm that I am licensed under provisions of Chapter 9 (comment- li rise infullf000) of orceandivision3oftheBusinessandProfessionsCode,andmy license is in full force and effect. APPLIANCES -RESIDENTIAL JOB DESCRIPTION PANELS Lice Contractor UP TO 200 ANTS 201-1000 AMPS ,pate- ARCHITECTS DECLARATION I understand my plans shall be used as public records. OVER 1000 AMPS SQ. FT. FLOOR AREA $/SQ. FT. SIGNS ELECTRICAL Licensed Professional SPECIAL CIRCUIT/MISC i TEMP. METER OR POLE INST. OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the following reason. (Section 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair n any structure prior to its issuance, also requires the applicant for such permit to file a signed statement that he is licensed pursuant to the provisions of the POWER DEVICES 1-4 Contractor's License Law (Chapter 9 (commencing with Section 7000) of Divi- sion 3 of the Business and Professions Code) orthat he is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than SWIMMING POOL ELECTRIC OUTLETSSWITCHESFIXTURES , U NEW RESIDENTIAL ELECTR �'� five hundred dollars ($500). I, as owner of the property, or my employees with wages as their sole — CONSTRUCTION compensation, will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or through his own employees, provided that such OCC. GROUP RFS. UNITS improvements are not intended or offered for sale. If, however, the building or T improvement is sold within one year of completion, the owner-builderwill have C2TY, PLUMBING PERMIT FEE the burden of proving that he did not build or improve for purpose of sale.). El I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, Business and Professions Code: FLOOD ZONE APN PERMIT ISSUANCE The Contractor's License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such p{ojects with a contractor(s) licensed pursuant to the Contractor's License Law. F -1I am exempt under Sec. B & P C for this reason ALTER -DRAIN & VENT - WATER (EA) FEE SUMMARY BACK FLOW PROTECT. DEVICE OUTSI DE FEES DRAINS• FLOOR, ROOF, AREA, COND. SANITARY Y N RECEIPT # Owner Date WORKMAN COMPENSATION DECLARATION F-11 hereby affirm that I have a certificate of consent to self -insure, ora certificate of Workers' Compensation Insurance or a certified copy thereof (Sec. 3800, Lab C.) FIXTURES- PER TRAP SCHOOL TAX Y N RECEIPT # GAS F11. SYSTEM -1 INCA OUTLETS PARK FEE Y N RECEIPT # Policy q Com any GAS- EA. SYSTEM -OVER 4 (EA) BUILDING DIVISION FEES Certified copy is hereby furnished. F-1Certifiedcopy is filed with the city inspection division. GREASE/INDUSTRL WASTE INTERCEPTOR Y PLANCHECK FEE GREASE TRAP CERTIFICATE OF EXEMPTION FROM WORKERS' PAID COMPENSATION INSURANCE (This section need not be completed if the permit is for one hundred dollars Date Recei t# SEWER -SANITARY -STORM EA. 200FT. WATER HEATER W/VENT/ELECTR ENERGY FEE Y N ($100) or less.) I certify that in the performance of the work for which this permit is issued, WATER SYSTEM/TREATING I shaljaot employ any person in any manner so as to become subject to the o ers' Compegs�jgr LaM of Californi e _ PAID li''++ �r Lam— TICETO APP er aftmaking is Certificate of Exemption, you should become subject to the Workers' Compensation provisions of the Labor Date Recei t# NEW RESIDENTIAL PLMB. SQ.FT. TOTAL: BUILDING FEE Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY SEISMIC FEE I hereby affirm that there is a construction lending agency for the perform ante of the work for which this permit is issued (Sec. 3097, Civ. C.) Lender's Name Lender's Address 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 ELECTRIC FEE T PLUMBING FEE .... QTY. MECHANICAL PERMIT FEE MECHANICAL FEE �w -.00 PERMIT ISSUANCE PERMIT FEES PAID: relating to building construction, and hereby authorize representatives of this city to enter upon the above-mentioned property for inspection purposes. (We) agree to save, indemnify an d keep harmless the City of Cupertino against liabilities, judgments, costs and expenses which may in anyway accrue ALTER OR ADD TO MECH. Date Receipt# AIR HANDLING UNIT (TO 10,000 CFM) SUBTOTAL: against said City in consequence of thetgranting of this permit. Y J 2 1 / AIR HANDLING UNIT (OVER 10,000 CFM) CONSTRUCTION TAX w( SigndftLre 6f7Wie&ht?C.nR1ffGr Date EXHAUST HOOD (W/DUCT) CONSTRUCTION TAX PAID: HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT (TO 100,000 BTU) Date Recei Will the applicant or future building occupant store or handle hazardous material as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety Code Section 25532(a)? ❑ Yes N No HEATING UNIT (OVER 100,000 BTU) TOT VENTILATION FAN (SINGLE RESID) ISSUANCE DATE Will the applicant or future building occupant use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District? ❑ Yes ❑ No 3 BOILER -COMP QHP OR 100,000 BTU) BOILER -COMP (OVER 100,000 BTU) ::T I have read the hazardous materials requirements under Chapter 6.95 of 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 RFSIDENUAL MECH. SQ.FT.i responsibility to notify the occupant of the requirements which must be met prior to issuance of a Certificate of Occupancy. } ISSUED BY: Owner or authorized agent Date L OFFICE COPY