25773 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
--- --- ------- - ---- - ----- ------ - -------- ---------- L _.----- PERMIT NO.
CITY OF CUPERTINO APPLICATION/PERMIT PLUMBING-MECHANICAL 25773
BUILDING DIVISION BUILDING PROJECT MENTMCATION
(BUILDING ADDRESS:
O $ SANITARY NO. APPLICATTON SUBMITTAL DATE
V&} W
UNIT# LOT#
OWNERS NAME: PHONE: CONTRACTQ2'S NAME: LIC NO: N/C CONTROL#
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ARCHITECT/ENGINEER: LIC NO: ADQ$FSS,, W3
CONTACT: PHONE: ``LLii l {yam$ $GILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
JOB DESCRIPTION
A C:z I hereby affirm that I am licensed under provisions of Chapter 9(commencing with
WOO Section 7000)of Division 3 of the Business and Professions Code,and my license is in PANELS
Z W full force and effect., / / 1 Up TO 200 AMPS � 1 /
F z W License Class��(Q Lic.# F�r�
V)¢n' Date Contractor 201-1000 AMPS
F- Z ARCHITECT'S DECLARATION OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
z O v)`"
OZ—G1 1 understand my plans shall be used as public records.
SIGNS ELECTRICAL
Licensed Professional
a w a Q OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
XC:)y U I hereby affirm that I am exempt from the Contractor's License Law for the fr
W 3 Gr.r/) following reason.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
F-' a 7 P INJ
which requires a permit to construct,alter,improve,demolish,or repair any structure
57 W Q� prior to its issuance,also requires the applicant for such permit to file a signed statement POWER DEVICES
W g4 O that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter
n. 04 9(commencing with Section 7000)of Division 3 of the Business and Professions Code)
q SWIMMING POOL ELECTRIC A TION
a o
W " or that he is exempt therefrom and the basis for the alleged exemption.Any violation of
rn OUTLETS-SWITCHES-FIXTURES
F Z 4Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
5F< not more than five hundred dollars($5001. .-.1
NEW RESIDENTIAL ELECTR SQ.FT. STORIES TYPE CONSTRUCTION
CY,F_o ❑ 1,as owner of the property,or my employees with wages as their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sec.7044,Business
and Professions Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work himself or through his
OCC.GROUP RES.UNITS
own employees,provided that such improvements are not intended or offered for sale.If,
however,the budding or improvement is sold within one year of completion,the owner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sale.). PLCTM$ING PERMIT FEE FLOOD ZONE APN
E] 1,as owner of the property,am exclusively contracting with licensed contractors to QW.
construct the project(Sec.7044,Business and Professions Code:)The Contractor's
I License Law does not apply to an owner of property who builds or improves thereon,and PERMIT ISSUANCE
who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
License Law.
❑ I am exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE FEES
SANITARY Y N
Owner Date DRAINS-FLOOR,ROOF,AREA,COND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
ElI hereby affirm that I have a certificate of consent to self-insure,or a certificate of FIXTURES-PER TRAP / RECEIPT#
Workers Compensation Insurance or a certified copy thereof(Sec.3800,Lab C.)which PARK FEE Y N
covers all employee's under this permit. GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT#
i Policy#
BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Certified copy is hereby furnished.
❑ Certified copy is filed with the city inspection division. GREASE/INDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars($100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or less.)
I certify that in the performance of the work for which this permit is issued,I shall WA T ATER W/VENT/ELECTR
not employ any person in any manner so as to become subject to the Workers' PAID
Compensation Laws of California. Date R S EM/TREATING Date Receipt#
OZ Applicant
0 NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should RESIDENTIAL PLMB. SQ.FC. TOTAL:
1%] become subject to the Workers Compensation provisions of the Labor Code,you must
forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE
W ;
Q. Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
U z ! I hereby affirm that there is a construction lending agency for the performance of ELECTRIC FEE
the work for which this permit is issued(Sec.3097,Civ.C.)
w Lender's Name PLUMBING FEE
0 F+ Lender's Address QTY. MECHANICAL PERMIT FEE
U 1 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 relating to PERMIT ISSUANCE MECHANICAL FEE
building construction,and hereby authorize representatives of this city to enter upon the CONSTRUCTION TAX
U Z
above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
�--� (We)agree to save,indemnify and keep harml City of Cupertino against
liabilities,judgments,costs and expenses which n way accrue against said City AIR HANDLING UNIT(TO 10,000 CFM)
m cons ueA�ofthe emit.
AIR HANDLING UNIT(OVER 10,000 CFM)
ILL 117
Sig Lure ant/Contractor Date EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Receipt#
Will the applicant or future building occupant store or handle hazardous materialHEATING UNIT(OVER 100,000 BTU) TOTAL:
as defined by the Cupertino Municipal Code,Chapter 9,12,and the Health and Safety
Code,Section 25532(a)? VENTILATION FAN(SINGLE RESID)
❑Yes ❑No
ISSUANCIrDATE
Will the applicant or future building occupant use equipment or devices which emit BOILER-COMP(3HP OR 100,000 BTU)
hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU) ,
i District?
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT.
i
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533 and 25534. 1 understand that
.i if the building does not currently have a tenant,that it is my 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 TOTAL: ISSUED BY:
- - - - -
OFFICE