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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL
PLUMBING - MECHANICAL
BUILDING DIVISION APPLICATION/PERMIT__25194
BUILDING PROJECT IDENTIFICATION
PERMIT NO.
2 519 4
BUILDING ADDRESS:
�• LOT #
SANITARY NO.
AP/PILICATION SUBMITTAL DATE
/ A
V
O NERS NAME- /y OP2S
-1
CO OR'S NAME: LIC NO:
N/C
E
CONTROL #
,
A CHITS GINEER: LIC NO:
ADDRESS:
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
14E E
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with
Section 7000) of Division 3 of the Business and Professions Code, and my license is in
full force and effect.
License Class Lic. #
Date Contractor
APPLIANCES - RESIDENTIAL
JOB DESCRIPTION
,
• ' V
PANELS
UP TO 200 AMPS
201 - 1000 AMPS
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.`
OVER 1000 AMPS
SQ. FT. FLOOR AREA
4r
-
$/SQ. Fir..
1
SIGNS ELECTRICAL
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the. Contractor's License Law for the
following reason. (Section 703 1.5, 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 Contractor's License Law (Chapter
9 (commencing with Section 7000) of Division 3 of the 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 five hundred dollars ($500).
El I, as owner ofthe property, ormy employees with wages as theirsole compensation,
will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business
and Professions Code: The Contractors License Law does not apply to an owner of
property who builds orimprovesthermn,and who does such work himselfor through his
own employees, provided that such improvements are notintended or offered for sale. If,
however, the building or improvement is sold within one year of completion, the owner-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ I, as owner of the property, am exclusively contracting with licensed contractors to
construct the projeet (Sec. 7044, Business and Professions Code:) The Contractor's
License LawdoesnotappIytoanownerofpropertywhobuildsorimprovesthereon,and
who contracts for such projects with a contractor(s) licensed pursuant to the Contractor's
License Law.
❑ I am exempt under Sec. , B & P C for this reason
SPECIAL CIRCUIT/MISC.
TEMP: METER OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
VALUATION
OUTLETS - SWITCHES - FIXTURES
NEW RESIDENTIAL ELECTR S . FT.
Q
STORIES
TYPE CONSTRUCTION
OCC. GROUP
,
RES. UNITS
TOTAL:
QTY. PLUMBING PERMIT FEE
FLOOD ZONE
APN
PERMIT ISSUANCE
ALTER - DRAIN & VENT - WATER (EA)
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
OUTSIDE FEES
SANITARY Y N
RECEIPT #
Owner Date
DRAINS - FLOOR, ROOF, AREA, COND.
WORKMAN COMPENSATION DECLARATION
❑ I hereby affirm that I have a certificate of eonsent to self -insure, ora certificate of
Workers Compensation Insurance or a certified copy thereof (See. 3800, Lab C.) which
covers all employee's under this permit.
Policy #
SCHOOL TAX Y N
RECEIPT #
FIXTURES - PER TRAP -
PARK FEE Y N
RECEIPT #
GAS - EA. SYSTEM -1 INC. 4 OUTLETS
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.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars ($100)
or less.)
I certify that in the performance of the work for which this permit is issued, I shall
not employ any person in any manner so as to become subject to the Workers
Compensation Laws of California. Date
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject to the Workers Compensation provisions of the Labor Code, you mus[
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
GREASWINDUSTRL WASTE INTERCEPTOR
GRADING FEE -
GREASE TRAP
SOILS FEE
SEWER - SANITARY - STORM EA. 200FT.
ENERGY FEE
WATER HEATER W/VENT/ELECTR
PAID
Re ' t#
J TOTAL:
WATER SYSTEWI'REATING
NEW RESIDENTIAL PLMB. SQ. FT.
BUILD FE
SEIS
TOTAL:
ELE F E
Lenders Name
Lender's Address
QTY. MECHANICAL PERMIT FEE
ING FEE
I certify that I have read this application and state that the above information isME
correct. I agree to comply with all city and county ordinances and state laws 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 and 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.
PERMIT ISSUANCE
CAL FEE
ALTER OR ADD TO MECH.
CONSTRUCTION TAX
AIR HANDLING UNIT (TO 10,000 CFM)
AIR HANDLING UNIT (OVER 10,000 CFM)
Signature of Applicant/Contractor Date
HAZARDOUS MATERIALS DISCLOSURE
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)?
El Yes El No
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
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 responsibility notify the
occupant of the requirements which must be met prior to issuance of a Certificate of
Occupancy.
EXHAUST HOOD (W/DUCT)
PAID
Date Receipt #
HEATING UNIT (TO 100,000 BTU)
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
VENTILATION FAN (SINGLE RESID)
BOILER - COMP (3HP OR 100,000 BTU)
ISSUANCEmDATE
i
/
/
}
ISSUED BY /
BOILER - COMP (OVER 100,000 BTU)
NEW RESIDENTIAL MECH. SQ. FT.
Owner or authorized agent Date
TOTAL:
OFFIGL
CITY`OF CUPERTIN_0
`.; CERTIF 11CATE .'0 F COMPLETION.
- BUILDING INSPECTOR'S .OFFICE
Date <___ ____________ 19. ac_. - Building Permit No.
:•The Building Located at . r . .. - - - --- -----------------
AT
-_-
. by-- --- ----------------------------------------------------
(Completed) ' ,). �-� . v , f, " �
Has Been For Use As: .... s,'r_ .. .........� `I
- - (Altered).• . :`
...
--_-•--------------=------------------------------- ...........................................
PD-7' "` BUILDING ` IlNSPEMR -