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Building Prefect Identification
Building Address:� � � -
PERMIT NO.
22694
caner s N ame: Phone:
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
APPLICATION SUBMITTAL DAZE
[�
Contractor's Name: Lic. No:
BUILDING -ELECTRICAL PLUMBING -MECHANICAL
CATEGORY
CONTRO /I
(�
Architect/Engineer: Lic. No:
QTY EI EeTRTC PERritT7c FEE
BUILDING PERMIT;I1Vfio # s
Address -PERMIT
ISSUANCE
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (comment-
- APPLIANCES -RESIDENTIAL
JOB DESCRIPTION
PANELS
ingwith Section 7000) of Division 3 of the Business and Professionscode, and my
license 1s in full force and effect.
��®Twp
W
License Class Lic. #
-
CJ
Date Contractor
UP TO 200 AMPS
201-1000 AMPS
ARCHITECTS DECLARATION
I understand my plans shall be used as public records.
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
''
SQ. FT. FLOOR ARP d $/SQ. FT.
OVER 1000 AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC
. .
TEMPMETER OR INST
POWER DEVICES
-"
following reason. (Section 7031.5, Business and Professions Code: Any city or
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
file a signed statement that he is licensed pursuant to the provisions of the
`L I
®46,
Contractors License Law (Chapter 9 (commencing with Section 7000) of Divi-
sion3oftheBusinessandProfessionsCode)orthatheisexempttherefromand
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
OUTLETSSWITCHESFIXTURFS
N '1
five hundred dollars ($500).
F] I, as owner of the property, or my employees with wages as their sole
NEW RESIDENTIAL ELECTR SQ9r.
STORIES
TYPE CONSTRUCTION
/tR
V
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 orthrough his own employees, provided that such
OCC. GROUP
RES. UNITS
Improvements are not intended or offered for sale. If, however, the building or
improvement issoldwithin one yearofcompletion,the owner-builderwillhave-
the burden of proving that he did not build or improve for purpose ofsale.).
❑ L as owner of the property, am exclusively contracting with licensed
rontractors to construct the project,(Sec. 7044, Business and Professions Code:
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= zzn7X
Q`Y PI:"IJ1yI�iC 1'ER. MLT +E,; `
FAD 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 pTjects with a
contractor(s) licensed pursuant to the Contractor's License Law.
❑ I am exempt under Sec. . B & P C for this reason
ALTER -DRAIN &VENT -WATER (EA)
"
ER '
,� MARY
BACK FLAW PROTECT. DEVICE
OtJTSIDE FEE
DRAINS FLOOR, ROOF, AREA, COND.
SANITARY Y N
RECEIPT #
Owner Date
" WORKMAN COMPENSATION DECLARATION
❑I hereby affirm that I have a certificate of consent to self -insure, ora�rr
certificate of Workers' Compensation Insurance or a certified copy thereof (Sec.
3800, Lab CJ
Policy #
FIX.liIItFSPER.IRAP
SCHOOL TAX Y N
N
GAS EA. SYSTEM -1 INCA OUTLETS
PARK FEE Y N_
RECEIPT #
GAS EA. SYSTEM -OVER 4 (EA)
Com any
BUILDING DIVISION FEES
Certified copy is hereby furnished.
❑ Certified copy is filed with the city inspection division.
GREASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE
GREASE TRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
PAID
SEWER -SANITARY -STORM EA.200FT.
COMPENSATION INSURANCE -
- (This section need not be completed if the permit is for one hundred dollars
Date Recei t
WATER HEATER W/VENT/ELECTIi
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 shall not employ any person in any manner so as to become subject to the
Workers' Compensation Laws of California. Date
PAID
Applicant
Date Recei t#
NEW RESIDENTIAL PI MB. SQ Fr.
NOTICE TO APPLICANT. If, after making this Certificate of Exemption, you
should become subject to the Workers' Compensation provisions of the Labor
O AL:
Code, you must forthwith comply with such provisions or this permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
BUILDING FE
SEISMIC FEE '
I hereby affirm that there is a construction lending agency for the perform-
ELECTRIC FEE
insLendeisNamoPLUMBING
ante ofthe work forwhich this permit is issued (Sec. 3097, Civ. C.)
I certifythatI have read this application and state thatthe above information
is correct. I agree to comply with all city and county ordinances and state laws
FEE 111T 111TLender'sAddressMECHANICAL
NPI
FEE
PERMIT ISSUANCE
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 any way accrue
against said City in consequence of the granting of this permit.
- Date Receipt#
ALTER OR ADD TO MECH.
AIR HANDLING UNIT (TO 10,000 CFM)
SUBTOTAL:
AIR HANDLING UNIT (OVER 10,000 CFM)
CONSTRUCTION TAX
Signature of Applicant/Contractor Date
EXHAUST HOOD (W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
'
HEATING UNIT (TO 100,000 BTU)
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 Cade Section 25532(a)?
❑ Yes M No
Datece t#
HEATING UNIT (OVER 100,000 BTU)
I
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?
❑ Yrs ❑ No
BOILER -COMP (3HP OR 100,000 BTU)
BOILER -COMP (OVER 100,000 BTU)
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 RESIDENTIAL MECH. SQ.FT.
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
TO
OFFICE COPY
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