24173APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project identification
Building Address: s��
PERMIT NO.
24173
caner s Phone:
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
APPLICATION SUBM11 AL DA
-
Contractor's Name: Lic. No:
BUILDING-ELECTRICAI,PLUMBING-MECHANICAL
CATEGORY
eBp1'T�Qs�i
Architect/Engineer: Lic. No:
QTY ELECTRIC PERMIT FEE
BUILDING PERMITINE6FO
Address: -
PERMITISSUANCE
❑ ❑ ❑ ''.............
JOB DESCRIPTION '....
LICENSED CONTRACTOR'S DECLARATION
Ihereby afffrmthatIamlicensedunder provisions ofChapter9(comment-
APPLIANCES -RESIDENTIAL
PANELS
fn ease i Benton force of d effeon3 of the Business and ProfessionsCode, and my
license is In full force and effect.
''.....
''...
License Class Lic. q
Date Contractor
200 AMPS''..
201-1000 AMPS
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed Professional
OVER 1000 AMPS
SQ. FT. FLOOR AREA
G®o
V
®SQ, Ff.
(/^ '.''..........
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors License Law for the
'......
following reason. (Section 7031.5, Business and Professions Code: Any city or
county which requires a permit to constnrct, alter, improve, demolish, or repair
TEMP. MEI -EK OR POLE INST.
''......
any structure prior to its issuance, aIso requires the applicantfor such permit to
file a signed statement that he is licensed pursuant to the provisions of the
POWER DEVICES
'.....
SWIMMING POOL ELECTRIC
Contractor's License Law (Chapter 9 (commencing with Section 7000) of Divi-
sion 3 ofthe Business and Professions Code) or that 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
VALUATION '.........
'....
®®�
OUTLETSSWITCHESFIXTURES
NEW RESIDENTIAL ELECTR SQ'Ff.
five hundred dollars ($500).
❑ I, as owner of the property, or my employees with wages as their sole
STORIES
TYPE 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
TOTAL:
improvements are not intended or offered for sale. If, however, thebuilding or
improvement is sold within one yearofcompletiontheowner-builderwillhave
the burden of proving that he did not build or improve for purpose of sale.).
❑ L as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 70JA Business and Professions Code:
QTY., PLUMBING PERMIT FEE
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.
EJI am exempt under Sec. B & P C for this reason
ALTER -DRAIN & VENT -WATER (EA)
FEE SUMMARY
Y
BACK FLOW PROTECT. DEVICE
SID FEE
DRAINS -FLOOR, ROOF, AREA,COND.
SANITARY Y N__._
RECEIPT q
Owner Date
WORKMAN COMPENSATION DECLARATION
❑I hereby affirm that I have a certificate of consent to self -insure, ora
certificate of Workers'Compensationinsurance oracertified copy thereof (Sec.
3800, Lab CJ
�.�ES�.�,
SCHOOL TAX Y_ N_
RECEIPT q
GAS EA.SYS1"EM-lINC.40U1LEI'S
PARK FEE Y_ N_
RECEIPT q
Policy q CoffanGAS
Com any
EA. SYSTEM -OVER 4 (FA)
BUILDING DIVISION FEES
Certified copy is hereby famished.
Certified copy i9 filed with the city inspection division.
GREASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE
GREASETRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
PAID
COMPENSATION INSURANCE
(Thissection need not be completed if the permit is for one hundred dollars
Date Recei t#
SEWER -SANITARY -STORM EA.200Ff.
WATERHEATERW/VENT/ELECTR
ENERGY FEE Y_ N_
($100)orless.7
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
Workem'Compensation Laws of California. Date
PAID
NEWRESIDENTIALPLMB. SQ.Fr.
Applicant
NOTICE TO APPLICANT: If, ager making this Certificate of Exemption, you
should become subject to the Workers Compensation provisions of the Labor
Date Recei t#
TO L:
BUILDING FEE
Code, you must forthwith comply with such provisions or this permit shall be
deemed revoked.
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
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 statethat the above information
is correct. I agree to comply with all cityand county ordinances and state laws
TOTAL:
ELECTRIC FEE
PLUMBING FEE
QTY. `MECHANICAL PER FEE
MECHANICAL FEE
''. PERMITISSUANCE
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 anywayaccrue
against said City in consequence of the granting of this permit.
Date Receipt#
ALTER OR ADD TO MECH.
AIR HANDLING UNIT CIO 10,000 CFM)
SUBTOTAL:
A1R FL1NC)LING UNIT (OVER 10,000 CFM)
CONSTRUCTION TAX
Signature of Applicant/Contractor Date
EXHAUST HOOD (W1 DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
DATING UNIT (IO 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 Code Section 25532(a)?
❑ Yes NN.
Will the applicant or future building occupant use equipment or devices
Date Recej t#
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
VEN17LATION FAN (SINGLE RESID)
ISSUANCE DATE
-which emifhazardous air contaminants as defined by the Bay Area Air
Quality Management District?
❑ Yes ❑ No
I have read the hazardous materials requirements under Chapter 6.95 of
BOILER -CAMP (3HP OR 100,000 BTU)
BOILER -COMP (OVER 100,000 BTU)
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.Fr.
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
TOTAL:
OFFICE COPY