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29251 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 29251 BUILDING PROJECT IDENTIFICATION DING A/ /,�iD�DRESS: rf ( SANITARY NO. APPLICArTION SUBMITTAL DAT 001, ER' NAME: %%� PHONE; 7 -77C R`TOR'S NAME: LIC NO: NIC CONTROL# CHITECT/E GINEER: LIC NO: ESS: ❑ CONTACT: PHONE: BUILDING PERMIT INFO ❑ Consultant Fees Paid by Applicant(Initial) BLDG I_ ELECT PLUM CH LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE I hereby affirm that I am licensed under provisions of Chapter 9(commencing J0DESCR.IPTION W O O ) q x Z with Section 7000 of Division 3 of the Business and Professions Code,and my license is PERMIT ISSUANCE RESIDENTIAL: F W= in full force and effect IE KSM WL ❑KITCHEN REMODEL H U U License Class Co # APPLIANCES—RESIDENTIAL ITION ❑PLUMBING RE-PIPE �Q a Date Contractor ARCHITECT'S DECLARATION LTI-UNIT ❑STRUCTURAL F-rn Z I understand my plans shall be used as public records PANELS MODIFICATION Z in— UP TO 200AMPS q El INTERIOR ❑CHIMNEY REPAIR 1 W Licensed Professional 201-1000 AMPS IMPROVEMENT "I OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the OVER 1000 AMPS ❑BATH REMODEL/REPAIR ❑DEMOLITION WO 0.U following reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER G y which requires a permit to construct,alter,improve,demolish,or repair any structure aprior to its issuance,also requires the applicant for such permit to file a signed statement SPECIAL CIRCUIT/MISC. y that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 A 0 (commencing with Section 7000)of Division 3 of the Business and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL: p,o that he is exempt therefrom and the basis for the alleged exemption.Any violation of El NEW BLDG/ADDITION El DEMOLITION W r' Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE F Z y not more than five hundred dollars($500). IMPROVEMENT A ❑I,as owner of the property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC a rF.o will do the work,and the structure is not intended or offered for sale(Sec.7044,Business ❑OTHER W 3 and Professions Code:The Contractor's License Law does not apply to an owner of OUTLETS—SWITCHES—FIXTURES property who builds or improves thereon,and who does such work himself or through his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ FT. sale.If,however,the building or improvement is sold within one year of completion,the SQ.FT.FLOOR AREA $/SQ.FT. owner-builder will have the burden of proving that he did not build or improve for pur- poseof a I,asale.). ❑ s owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business and Professions Code:)The Contractor's Li- cense Law does not apply to an owner of property who builds or improves thereon,and QZy- PLUMBING PERMIT FEE who contracts for such projects with a contractor(s)licensed pursuant to the Contractors License Law. PERMIT ISSUANCE ❑I ama and B&P C r this r son ALTER—DRAIN&VENT—WATER(EA) A N wrier Date It WORKS S kOMPENS AT]ON DF6 ARATION BACK FLOW PROTECT.DEVICE I hereby affirm under penalty of perjury one of the following declarations: V ❑I have and will maintain a Certificate of Consent to self-insure for Worker's Compen- DRAINS—FLOOR,ROOF REA,COND. STORIES TYPE CONSTRUCTION sation,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. FIXTURES—P ❑I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. GAS—EA.SYS IN 4 UTLETS OCC.GROUP APN My Workers Compensation Insurance carrier and Policy number are: Carrier: Policy No.: GAS—EA. ST -OVER ) Ier CERTIFICATE OF EXEMPTION FROM WORKERS' 'q COMPENSATION INSURANCE INSURANCE GREAS STRL WASTE I 4 BUILDING DIVISION FEES (This section need not be completed if the permit is for one hundred dollars($100) GREASE TRAP AM Ap or less.) PLANCHEC ltd I certify that in the performance of the work for which this permit is issued,I shall SEWER—SANITA Y S EA 00 FT. not employ any person in any manner so as to become subject to the Workers'Compen- ENERGY- . Z sation Laws of California.Date WATER HEATER WNENT/EL O Applicant GRADING FEE t �f.~i�; Z f j NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you should WATER SYSTEM/TREATING (~ 0-4 become subject to the Worker's Compensation provisions of the Labor Code,you must SOILS FEE wA forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE Z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID U O I hereby affirm that there is a construction lending agency for the performance of Date ece t# %- GIr H the work for which this permit is issued(Sec.3097,Civ.C.) TOTAL: O ULender's Name ULender's Address TOTAL: GL I certify that I have read this application and state that the above information is BUILDING �� I/1 correct.I agree to comply with all city and county ordinances and state laws relating to Q'Iy, MECHANICAL PERMIT FEE U Z building construction,and hereby authorize representatives of this city to enter upon the SEISMIC E ~ above-mentioned property for inspection purposes. (We)agree to save,indemnify and keep harmless the City of Cupertino against PERMIT ISSUANCE ELECTRIC FEE liabilities,judgments,costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECH. in consequence of the granting of this permit. PLUMBING FEE r� APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) [HOUSING ECHANICAL E SOURCE REGULATIONS. AIR HANDLING UNIT(OVER 10,000 CFM) ONSTRUCfI N TAX Signature of Applicant/Contractor Date EXHAUST HOOD(W/DUCT) M IGATION FEE HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(TO 100,000 BTU) 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) ❑Yes ❑No VENTILATION FAN(SINGLE RESID) PAID Date —Receipt. 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 BOILER—COMP QHP OR 100,000 BTU) District? F-1 Yes F1 No BOILER—COMP(OVER 100,000 BTU) I have read the hazardous materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE fomia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.FT. building does not currently have a tenant,that it is my responsibility to notify the occupant rfs71 of the requirements which must be met prior to issuance of a Certificate of Occupancy. �f`� Owner or authorized agent Date TOTAL: ISSUED BY: OFFICE