21904APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification
Building Address:
1112
PERMIT NO.
1 21904
era ante: J E I -hose:
f�
CITY OFCUPERTINO-BUILDING DIVISION��
APPLICATION / PERMIT
BUILDING-ELECTRICAL-PLUMBINC-MECHANICAL
C. -.N.— Lie, N.
CATEGORY
CONTROL X
Architect/Engineer. Lic. No:
QrY ELECTRIC PERMIT FT6
BUILDING PERMIT INFO
Address: -
pERA9TI55IlANCE (�%
❑ 171 MUMS --- WffrrT—
❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hehSydio affirm that lam licensed under B.g essand mfodn.rwCdc,mmrnc
It...I I. full to )of DIvW°n3ofthe Buolnenandlko(enI°nsCode, and my
Ilmnse is In s force and effect.
LI Date Clan Loc tr
Date Contractor
ARCHITECT'S DECLARATION -
I understand my plans shall W used as public remrdL
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm Chet lam exempt from the Contractors Llmnse law for the
following reason.(Section 7011.5, Business and Professions Code: Any ety or
countywhich requires a permit to comtruct, altep Improve, demolish, or repair
anystructure prior to its bsoance,abo requbestheappilant forsuch permit to
file a signed statement that he b Becosed pursuant to the provisions of the
Contractor's License Law (Chapter 9(commencing with Section 7000) of Divi-
sion 3 of the Business and Prof nations Code)mthat he M 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 pem@y of not more than
flue bundred dollars wnerelite pr).
I, as owner will of property, or my employees with wages thele sole
not Intended or coffered for
compensation, Buldothe work and the structure The
sale (notap l4, to anoaandf property Code:The Contractors License law
don not apply wean owner of througywhon ilds emorimprovnled that and
who does such work himself edoroughhisors employees,
Improvementsarenm Intended earofco fdrsale.TLh er-gtheerildingve
Improvement boold wilhinoneyearofcompldion,theowner-buaderwill have
t on of proving that he did not build or Improve for purpose of sale.).
, as owner of the property, am exclusively contracting with licensed
c tract ors to construct the projM(Sce. 7044, Business and Professions Code:
' Contractors License law don not apply to an owner of property who
ads or improves thereon, and who contracts for such p9ojects with a
rga4actor(s) licensed pursuant to the Contractor's Llmnx Law.
LJ I am exempt under Sec, B & P C for this Tea»n
-
MPLIANCESRESIDENTTAL
JOB
JOB DESCRIPTION
'
—{ 5A4-� SPP--y..(�j/•,(T
1 C/� \ t
PANELS
UP TO 200 AbTS
—
701"1000 AMPS
OVER 1000 AMPS
SQ. FT. FLOOR AREA
Pic
S/SQ. FT.
I SIGNS ELECTRICAL
SPECIALCIRCUIT/MISC
TIMP•METMORPOLEINST.
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS -SWITCH SSFIXTURES
VALUATION
NEW RESIDENTIAL ELECTR �'�'
STORIES
TYPE CONSTRUCTION
TOTAL:
QTY, PLUMBING PERMIT FEE
OCC.CROUP
RFS UNITS
PERMIT ISSUANCE
ALTER -DRAIN VENT WATER BEMW
FIDODZDNE
APN
"
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
DRAINS. FLOOR ROOF, AREA, COND.
FDnIJRES. PER TRAP
SANITARY Y_ N_
RECEIPT#
Owner Date
WORKMAN COMPENSATION DECLARATION
❑1 hereby affirm that I have a certificate of consent to self -Insure, or a
-dig-toofWorkers'Comperuatlontmumnmoracortlfk mpythereof(&L
3300,[.6C.)
X
SCHOOL TAX Y_ N_
RECEIPT
CAS EA. SYSTEM -1 INCA OUTLETS
PARK FTE Y_ N
RECEIPTp
GAS EA. SYSTEM -OVER
Ce
Com any
BUILDING DIVISION FEES
Certified copy b hereby furnished.
❑CcrtBied copy bfiled with the city, inspection division.'
CERTIFICATE OF EXEMPT ION FROM WORKERS'
COMPENSATION INSURANCE
(Thlssectlon need not be completed lithe permit M (Drone hundred dollars
($11 otifyth ordt inWATER
booed,
that employ In anye of so as to betonh this subject
J an person mannworer
I shale not employ any person In any manner ao u to become eub)ed to the
Workers'Compensation laws of California. Date
Applicant
NOTICE co APPLICANT: a alter makingthio etionlpro is Exemption, you
Code, become subject tothe Woken' Compewtlonprovhlonofthe Labor
Code yourthwith comply with such provisions or this permit shall be
dremed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency forthe pedorun
.race of the work for which thio permit b issued (&c. 3D97, Clv. C.)
Lender's Name
Lender's Address
1 ardlythat I have read this appliationand Gate thauheabove Information
Is cormet. l a gree to comply with all city and county ordinances and Gate laws
relating to building construction, and hereby authorize representatives of this
city to enter upon the abovo-mentloned property for Inspection purposes.
(We) agree to rave, Ind emnlfy an d keep harmless the City of Cu pert Ino
against liabilities, fodgrrtgnts,mxs and expenses which may In any way accrue
agoI t Id City I. nsequence of egr ting o(thb rmlt.
Big reo Applicant/Contractor Date
HAZARDOUS MATERIALS DISCLOSURE
Willt applicant or future building occupant sore or handle hazardous
as defined by the Cupertino Municipal Code Chapter 9.17, and the
ITealth and &foy Code Section 25532(a)7
❑ Yes M No
Will the applicant orfmm building ccmpant use equipment or devices
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management District?
Qyes _ I—I No
i"ve read the hazar °us materials requirements undcrCh.pter6.95 of
IM Calif.M Health & Safety Code, Stolons 25505, 25533 and 75534. I
understand that if the building does not cvrmotly have a tenant, that it is my
responsibility to costly the occupant of the requirements which must be rant
prior to issuance d a Certlflcate of Occupancy.
GREASEANDUSTRL WASTE INTERCEPTOR
PLANCHECIC FEE
Pp1D
Date Recei tq
GREASE TRAP
SEWER -SANITARY -STORM FA NpFI.
HEATER W/VENT/ELECTR
ENERGYFEE Y N—
PAID
Date Recei t#
WATER SYSTEM/TREATING
NEW RESIDENTIAL PLMB.SQ.FT.
TOTAL:
BU NG '
SEISMIC FEE
TOTAL:
ELECTRIC FEE
-
Cry. MECHANICAL PERMIT FEE
PLUMBING FEE
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID:
ALTERORADDTOMECH.
Dale Recei t#
P
AIR HANDLING UNIT (TO I D,0D0 CFM)
SUBTOTAL:
AIR HANDLING UNIT(OVER 1g0e0CFM)
CONSTRUCTION TAX
EXHAUST HOOD (W/DUCT)
CONSTRUCTION TAX PAID:
HEATINGUNTT(T0100,O)OBTU)
Date Recei t#
HEATING UNIT (OVER 100,000 BTU)
TAL:7?
CID
VENTILATION FAN (SINGLE RESID)
ISSUANfi
MAR
AR
ysfJO
Xs(Is
of .tlll tl •RA
-
��•'
ISSUED BY:
BOILER -COMP D1m OR 100,000 BTU)
BOILER -COMP (OVER 100,f100BN)
NEW RFADEhMAL MECH. SQ.FT.
Owner or authorized agent Date�\
TOTAL:
OFFICE COPY