22111APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification
Building Adde,xv
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22111
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CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BUILDING-ELECTRICALPLUMBING-MFCHAMCAL
A
1
cont or'sNanne:
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CATEGORY CO Lraz
Y
Archite t/Engineer. Lic. No:
QTY ELECTRICPERMIT FEE
BUILDING PERMIT INFO
Addresa:
F -1F
PERMITISSUANCEZ.OD
LICENSED CONTRACTOR'S DECLARATION
I hereby atllrm that tem Ecenaed underprovIslone of Chapter9 (commenc
APPLIANCESRFSIDENTIAL
JOB DESCR11rrION
PANELS
ingwith Section 7000)of Division ofthe Businessand Professions Code, and my
Erem�Isi e,u rarganaLdlceN_�
Lice O
e Contactor LQN
7
201-1000 AMPS
-ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed Professional
OVER1000AMP5
SQ. FT. FLOOR AREA
39 d
Sr/SSQ. FT.
SIGNSELECTRICAL
SPECULCIRCUIT/MLSC
OWNER -BUILDER DECLARATION
IherebyafRrnthat I am exempt from the Contractor's License Law for the
%3��ka-1 W1W+Ow
TEMP, METER OR POLE INST.
following reason. (Section 7031.5, Business and Professions Code: Any city or
county which requiresa permittomrutrut, alter, Improve, demolish, ormpalr
1
5 :.{
r
anystructure prtortolts Issuance, also rejulosthe applinumfor such permit to
toe a signed statement that he Is licensed pursuant to the provisions of the
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETSSWI'ICHESFIXTURES
Contractors License Lavehapter9(commencing with Section 7000) of DIW-
sion3 of the Business and Profeudmu Cade) orthat he Is exempt therefromand
the basis for the alleged exemption. Any violation of Section 7031.5 by any
applicant fora permit subjects the applicant to a civil peralty of not more than
VALUATION
l 8 00
"I t
five hundred dollxa($SM.
I, as owner of the property, or my employees with wages as their sole
NEW RESIDENTIAL ELECTR SQ.FI',
STORIES
TYPECONSTRUCTION
compensation, will do the work and the structure Isnot Intended or offered for
sale (Sec. 7044, Business and Professlow Code: The Contractor. Llmwe Law
does not apply to an owner of property who Wilds or improves themoq and
who docssuch work himself or through his own employees, provided that such
OCCGROUP
RES. UNITS
Improvements are not Intended oroflered for vale. If, however,thebulldleg or
TOTAL:
ImpmvementIssoid Mthinooeyearofcompletb theowner-buBderwillhave
I�usdcn of proving that he did not build or Improve for purpose of axle.).
LJ I, as owner of the property, am exclusively contracting with licensed
contractors to construct the perjet (Sec. 7040 Business and Professions Code:
QTY. PLUMBING PERMIT FEE
FLOOD ZONE
APN
PERMIT ISSUANCE
The Contactors License Law does not apply to an owner of property who
Wilda or Improves thereoq and who contain for such pk jets with a
r,taBBIator(s)Braved puauant to the Contractors License Law.
t -J I am exempt under Sec B k P C for this reasonOUTSIDE
ALTER -DRAW k VENT WATER (Ea)
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
FEES
DRAIN
SANITARY Y N
RECEIPT
Owner Date
WORKMAN COMPENSATION DECLARATIONSC3HOOL
❑1 hereby .((icon that 1 have a certificate of consent to eel! -Inure, ora
certificate of WorkerJ�Cs�osmpensation Insurance or a certified copythemof(Sec.
3800, Isis C.) I�MZ,w
"O
TAX Y N_
RECEYT N
GAS EA. SYSrE,M-1 INCA OUTLETS
PARK FEE Y N
RECEIPTi
Pull'
cam acts rP FvwaP i�v+ -.�
GAS EA. SYSTEM-OVER4CEA)
BUI LDING D I VISION FE ES
cd <opybhemby Furnished.
tided copy Is filed with the city Inspection division.
GREASE/WDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE
GREASE TRAP
CERTIFICATE OF EI(EMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thisaetlon need not becompleted if the permit Istor one hundred dollars
($10(fimless.)
I certify that In the performance of the work forwhich this permit is Issued,
PAID
Date Recei t#
I a
(,ZJY
SEWER -SANITARY -STORM EA 200FC
WATER HEATIR W/VENT/ELFCTR
ENERGYFEE Y_ N_
WATER SY53EM/TREATING
1 shall not employ any person In any manner so as to become subject to the
Workca' Compensation laws of Call(omb. Date
PAID
'�
S
NEW RESIDENTIAL PLMB. SQJ.T.
Applicant
NOTICETO APPLICANT: IL after nuking this Certificate of Exemption, you
should become subject to the Workers'Campeosatlon provIsioro o(the Labor
Code, you must(otM1with comply with such provisions orthis permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
Date Recei t#
TOTAL'
BUILDING7
SEISMIC FEE
3x4s..�A
TOTAL:
ELECTRIC FEE
I hereby affirm that them is a construction lending agency for the perform-
of the work for which this permit Is Loved (Sec. 3097, Civ. C.)
1<m ndere Name
Lender.Aeerea.
I cetifythat I have read this application and state thattheabove inforrtation
iscormt I agree to comply with all city and county ordinances and state laws
PLUMBING FEE
QTY. I MECHANICAL PERMIT FEE
MECHANICAL FEE
_ D
PERMIT ISSUANCE Z, -off
FEES PAID:
relattngtob (ding corattsction, and herebyauthodm representatives ofthIs
citytoe ru Nes cmentloned property for inspection Purposes.
(W a e t savq a I!y an keep harmiem he City of Cupertino
again Ilabl pd g to expenses which may In anywayattme
„
( ALTER OR ADD TO METH. SOV
Dale RCCCIFlti7
AIR HANDLING UNIT (TO 10,00OCr M)
SUBTOTAL:
agaimats e I Ism en grant god Nlapennut
AIR HANDLING I1MT (OVER 10,000CFM)
CONSTRUCTION TAX
AJ
Signatu ppli /Co tactor Date
EXHAUSTHOOD(W/DUCT)
CONSTRUCTION TAX PAID:
11 RDOUSM ERIALS DISCLOSURE
WIII the applicant or future build g occupant store or handle hazardous
HEATING UNIT (TO 100,000 BTU)
-
Date Recei tic
material as defined by the Cupertino Municipal Code, Chapter 9.12, and the
Health and Safety Code Section 25532(a)7
❑ Yo N -
F1
Will the applicant o. lum Wilding occupant use equipment or devices
HEATING UNIT (OVER IW,000 BTU)
TOTAL:
Ja-
ELI
VENTILATION FAN(SINGLE REBID)
ISS MATE
which emit hazardous air contaminants as dented by the Bay Area Air
Quality Management Diststjrit7
1_1 Yes
7o
Ihave reait the hav-usmaterialsrequlrcmentsunderChapter6.95of
tr�r
HOILFR-COMP OHP OR 1 W,IXU BTI)
BOILER-COMP(OVERIW,000BTU)
the Califomnis Health k Safety Code, Sections 25505, 25533 and 25534. I
understand that if the Wilding does not currently have a tenant, that it is my
Q� _<p,�_y�
NEW RESIDENTIAL MECH.SQ.FT
rmponsibility, to notify the occupant of the requboments which must be mot
Mi3 peffi
prior to Issuance of a Certificate of Occupancy.
_k��
ISSUED BY:_ -s
Owner orawhoriud agent Date
TOTAL: .. D
OFFICE COPY