24171Mw
Building Project Identification I
PERMITNO.
4171
-g—uilding Address:
ner a acne: 42o�ne:
Lkitue-ni il" :
CITY
A TT
OF CUPERTINO-BUILDING DIVISION PPE A-M—
_
or"sName- No.
C ntra Lic
'Y
BUILDING-ELECTRICAT-PLUMBIN(3-MECHANICAL CATEGORY Co
I
9 P" LA i I'[' Imts M ECH
Architect/Engineer. Lie. No:
Address:
PERMITISSUANCF F❑ 0 0
APPLIANCES -RESIDENTIAL JOB DESCRIPTION
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter (ocinurninc.
_
ingwith Section 7000) of Division3 oftheBusiness andProfessionsCode, and my
license is in full force and effect.
PANELS
6-Qm
License Class Lic. It
I\kn
Date ------------- Contractor
ARCHITECTS
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
AMPS
OVER 1000 AMPS SQ. Fr. FLOOR AREA f_/ - �FF
—
1201-1000
—
Licensed Professional
SIGNS ELECTRICAL
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
SPECIALCIRCUIT/MISC
following reason. (Section 7031.5, Business and Professions Code: Any city or
countywhich requires a permit to construct, alter, improve, demolish, or repair
TEMP. METER OR POLE INST.
any structure priorto its issuance, also requires the appbcantfor such permit to
file a signed statement that he is licensed pursuant to the provisions of the
POWER DEVICES
Contractor's License Law (Chapter 9 (commencing with Section 7000) of Divi-
sion 3 of the Business and ProfesslonsCode) orthat he is exempttherefromand
SWIMMING POOL ELECTRIC VALUATION'
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
OUTLETS -SWITCHES -FIXTURES
five hundred dollars ($500).
® 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
NEW RESIDENTIAL ELFCTR _SQ.FT. STORIES TYPE CONSTRUCTION
sale (Sec. 70K 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
TOTAL:
improvement issold within one yearofcompletion, the owner-builderwill have
the burden of proving that he did not build or improve for purpose of sale.).
M L as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business and Professions Code:
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{piects, with a
contractor(s) licen.—.d pursuant to the Contractor's License Law.
E31 am exempt under Sec. — B & P C for this reason
AL17ER-DRAIN & VENT - WATER {EA)
X
BACK FLOW PROTECT. DEVICE
DRAINS -FLOOR ROOF, AREA, COND. SANITARY Y_ N_
RECEIPT #
Owner -----Date
WORKMAN COMPENSATION DECLARATION
MI hereby affirm that I have a certificate of consent to self -insure, or a
certificate of Workers' Compensation Insurance or a certified copy thereof (Sec.
3800, Lab Q
FIXTURES. PER TRAP SCHOOL TAX Y_ N_
_LZp�EIFT#
GAS -EA SYSTEM-1 INCA OUTLETS PARKFEE Y_ N_
RECEIPT #
GAS- EA. SYSTEM -OVER 4 (EA) BUILDING DIVISION FEE'S
GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Policy #
Coco
Co
copy is hereby furnished.
Certified copy is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
GREASE TRAP PAID
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,
SEWER -SANITARY STORM EA. 200FT -40% ate ecel Dig
WATER HEATER W/VF-NT/ELWTR ENI*&Y FEE A
I shall not employ any person in any manner so as to become subject to the
Workers'Compensation Laws of California. Date
WATER SYSTEM/TREATING PAID
Applicant
NOTICE TO APPLICANT, If, after making this Certificate of Exemption, you
should become subject to the Workers' Compensation provisions of the Labor
NEWRESIDENTIALPLMB. ET, Date eceipt#
—SQ
TOTAL:
Code, you must forthwith comply with such provisions orthis permit shall be
deemed revoked. CONSTRUCTION LENDING AGENCY
BUILDING FEE
SEISMIC FEE
I hereby affirm that there is aconstrirction lending agency for the perform-
ante of the work for which this permit is issued (Sec. 3097, Civ. C.}TOTAL:
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 city and county ordinances and state laws
ELECTRIC FEE
PLUMING FEE
MECHANICAL FEE
PERMIT LSSUA NCE FEES PAID:
7!�
1��
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, in dgments, costs and expenses which may in any way accrue
ALTER OR ADD TO MECH.
Date Receipt#
AIR HANDLING UNIT (TO 10,000 CFM) SUBTOTAL:
against said City in consequence of the granting of this permit.
AIR HANDLING UNIT (OVER 10,000 CFM) CONSTRUCTION TAX
EXHAUST HOOD (W/DUCT) CONSTRUCTION TAX PAID:
Sig_natuW_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)?
r--J yes N No
HEATING UNIT (TO 100,000 BTU) Date
HEATING UNIT (OVER 100,000 BTU) TOTAL:
,
Will the applicant or future building occupant use equipment or devices
VENTILATION PAN (SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants as defined bythe Bay Area Air
Quality Management District?
M Yes
PNo
Thave read hiz'usmaterials requirements under Chapter 6.95 of
BOILER -COMP QHP OR 100,000 BM
BOILER -COMP (OVER 100,000 BTU)
the California Health & Safety Code, Sections 25505, 25533 and 25534. 1
understand that if the building does not currently have a tenant, that it is my
1
NEW RESIDENTIAL MECH.—SQST
responsibility to notify the occupant of the requirements which must be met
prior to issuance of a Certificate of Occupancy.
TOTAL:11--1 ISSUED
Owner or authorized agent Date
OFFICE COPY