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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification
PERMIT NO.
Building Address:
V 33 W
22343
,Hers Name: ^ hone:
V,
V ��_ I9j /5
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BUILDING-ELECnUCAIrPLUMBING-MECHANICAL
A A A
/ /
6 ^' � C
C; ctor'sName- Lic. No:
)V�l 01A) ( -/
CATEGORY
CONTROL 8
Archited/Ea 'neer. Lic. No:
ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Address:
PERMIT ISSUANCE �
❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commenc-
ing with Section 7000) of Division 3 of the Business and ProfessionsCode, and my
license is in full force and effect.
License lass Lic. #
APPLIANCES -RESIDENTIAL
JOB DFSC ON
&�_
PANELS
r
Date Contractor
201-1000 AMPS
ARCHITECTS DECLARATION
I understand my plans shall be used as public records.
OVER 1000 AMPS
SQ. FT. FLOOR AREA
$/SQ. FT.
SIGNS ELECTRICAL
Licensed Professional
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 construct, alter, improve, demolish, or repair
TEMP. METER OR POLE INST.
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
POWER DEVICES
Contractor's License Law (Chapter 9 (commencing with Section 7000) of Divi-
sion 3 of the Business and Professions Code) orthat he is exempt therefrom and
the basis for the alleged exemption. Any violation of Section 70315 by any
applicant for a permit subjects the applicant to a civil penalty of not more than
SWIMMING POOL ELECTRIC
VALUATION
I
( - D V
OUTLETSSWITCHESFIXTURFS �J
`-' `�
NEW RESIDENTIAL ELECTR SQ Fl.
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
3
sale (Sec. 7044, Business and Professions Code: The Contractors 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
improvements are not intended oroffered for sale. If, however, the building or
improvement is sold within one yearof completion, the owner-builderwill have
TOTAL: 7
OQC.GROUP
-1
RES. UNITS
tht.urden 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 project (Sec. 7044, Business and Professions Code:
QTY, PY ING PERMIT FEE
D ZONE
APN
PERMIT ISSUANCE
f
The Contractors License Law does not apply to an owner of property who
builds or improves thereon, and who contracts for such projects with a
contractors) licensed pursuant to the Contractor's License Law.
❑ I am exempt under Sec B & P C for this reason
1
ALTER -D & VENT - WATER (EA) ZQ(%
.- -
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
OUTSIDE FEES
DRAINS- FLOOR, ROOF, AREA, COND.
SANITARY Y N
RECEIPT 8
Owner Date
WORKMAN COMPENSATION DECLARATION
❑I 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
N
FlxTuRag PER TRAP 1$00
SCHOOL TAX Y N
RECEIPT li
GAS EA. SYSTEM -1 INCA OUTLETS
PARK FEE Y _ N _
RECEIPT
#Policy
GAS 4 (A) EA. SYSTEM -OVER E
Com ny
BUILDING DIVISION FEES
Certified copy is hereby furnished.
r-1 Certified copy is filed with the city inspection division.
GREASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE
I GREASE TRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
PAID
SEWER -SANITARY -STORM EA.200FT.
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars
Date Recei t#
WATER HEATER W/VENT/ELECTR
ENERGY FEE Y N
($100) or less.)
I certify that In the performance of the work for which this permit is issued,
I WATER SYSTEM/TREATING (� 0
`
I shall not employ any person in any manner so as to become subject to the
Workers' Compensation Laws of California. Date
PAID
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you
Date Recei t#
NEW RESIDENTIAL PLMB. SQ.FI•.
TOTAL:
should become subject to the Workers' Compensation provisions of the Labor
Code, you must forthwith comply with such provisions or this permit shall be
deemed revoked.
BUILDING FEE
S
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the perform. -TOTAL:
ance of the work for which this permit is issued (Sec. 3097, Civ. C.)
Lender's Name
LendeisAddress
I certifythatI have read this application and state that the above information
is correct. I agree to comply with all city and county ordinances and state laws
O,
ELECTRIC FEE
PLUMBING FEE
!� 0
QTY. -MECHANICAL PERMIT FEE
ECHANICAL FEE
n ►� n, h i "
ANCE -' R
F$ES PAID:
relating to building construction, and hereby authorize representatives of this
city to enter upon the above-mentioned property for inspection purposes.
(We) agree t n ,e:=., an d keep harmless the City of Cupertino
against liabilities, d nts, costs and expenses which may in anyway accrue
d
Date Receipt#
ALTER OR ADD TO MECH.
AIR HANDLING UNIT (TO 10,000 CFMj ` z'
SUBTOTAL:
against said C' nsequence of the granting of this permit.
AIR, HANDLjWG iN (OVER 10,000 CFM)
C NSTRUCTION TAX
Sign o pphcant/Contractor Date
EXHAUST HOOD (W/DUCT)
NSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (TO 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 N No
Will the applicant or future building occupant use equipment or devices
Date Recej t#
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
3.
VENTILATION FAN (SINGLE RESID)
ISW#OQDATE
which emit hazardous air contaminants as defined by the Bay Area Air
BOILER -COMP (3HP OR 100,000 BTU)
Quality Management District?
nhave Yes No
7 �� 1
BOILER -COMP (OVER 100,000 BTU)
read the haza ous materials requirements under Chapter 6.95 of
the California Health & Safety Code, Sections 25505, 25533 and 25534. I
NEW RESIDENTIAL MECH. SQ.FT.
understand that if the building does not currently have a tenant, that it is my
�,j
responsibility to notify the occupant of the requirements which must be met
YF.
prior to issuance of a Certificate of Occupancy.
BY:
L) q4A 11 7Q1 Y
Owner or authorized agent DateISSUED
TOTAL:-A\A-
OFFICE COPY