24205APPLICANT TOFILL IN INFORMATION WITHIN RED LINES — WSE BALL POINT PEN ONLY
Building Project identification j 4
PERMIT NQZ
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Building Address: - 1
42 0 5
rs are: I 1 one:
A A A
CITY
OF CUPERTINO BUILDING DIVISION
APPLICATION / PERMIT
`904 2
ontractor'sNa : Lic•No:
BUILDING-ELECTRICALPLUMBING-MECHANICAL
CATEGORY
CONTROL N
A t ne Enee
I Lia No:
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QTY
ELECTRIC PERMIT
FEE
BUILDING PERMIT INFO
Address:
PERMIT ISSUANCE
MR.. I PLUMB MELH
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (comment
Ing with Section 7000) of Division 3 ofthe Business and ProfessionsCode, and my
license 1s In full force and effect.
APP11ANCES-RESIDFNTIAL
JOB DESCRIPTION
.
PANELS6FOW
License Class Lic. N
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Date Contractor
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
following reason. (Section 703IS, Business and Professions Code: Any city or
county which requires a permit to construct, alter, improve, demolish, or repair
any stnutureprior toits issuance, also requiresthe applicantfor such pemritto
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 Divi-
slon3oftheBusinessandProfessionsCode)orthatheisexempttherefromand
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
UP TO 200 AMPS
201-1000 AMPS
OVER 1000 AMPS
SQ. FT. FLOOR AREA -,
$/SQ. FT.
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u
SIGNS ELECTRICAL�Q
SPECIAL CIRCUIT/MISC
IFMgr METER OR POLE INSf.
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS -SWITCHES -FIXTURES
VALUATION
�tr%
`-'I
�y
Q
psale
five hundred dollars (S500).
I, 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
(Sec 7044, Business and Professions Code: The Contractor's License Law
NEW RESIDENTIAL ELECTR
STORIES
TYPE CONSTRUCTION
^
does not apply to an owner of property who builds or improves thereon, and
who doessuchworkhimselforthroughhis own employees, provided that such
OCC. GROUP
RES. UNITS
Improvements are not intended orofferedfor sale. If, however, thebuildingor
TOTAL:
improvement issold within oneyearof completion, the owner -builder will have
QTY.
-
PLUMBING PERMIT
FEE
th
p4urden of proving that he did not build or improve for purpose of sale.).
LJ L as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 70K 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 piojects with a
coactor(s)licensedpursuanttotheContractor'sLicenseLaw.
15I am exempt under Sec. B & P C for this reason
ALTER -DRAIN &VENT -WATER (EA)
FEE SUMMARY
BACK FLOW PROTECT.
OUTSIDE FEES
DRAINS- FLOOR ROOF, AREA; COND.
......
SANITARY Y _ N
RECEIPT p
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.
Polic Lab CJ
N
FIX.I'UJRES PER TRAP
SCHOOL TAX Y N
RF-CIIP'r N
T
GAS EA. SYSTEM-1 INCA OUTLETS
PARK FEE Y _ _
RECEIPT N
GAS EA. SYSTEM -OVER 4 (EA) -
Coliq
Cco any �
BUILDIN DIVISI FEES
Certified copy is hereby furnished.
❑ Certified copy is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
CREASE/INDUSTRL WASTE INTERCEPTOR
PLANCHEC E
SEC
PAID
GREASE TRAP
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars
SEWER -SANITARY -STORM EA. 200FT.
I mint Recei t#
WATER HEATERW/VENT/IIFCTR
E R F Y N
($100) or less.) form
I certify that in the perance of the work for which this permit is issued,
WATER SYSTEM /TREATING
Z Z
N
—
LLIdeemed
(L ?
4. Z
Z
V O
LL H
O W
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V
I shall not employ any person in any manner so as to become subject to the
Workers' Compensation Laws of California. Date
icantDate
PA_T,p� '��
-
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NEW RESIDENTIAL PLMB. SQ.FT.
NOTICE E TO APPLICANT: If, after making this Certificate of Exemption, you
should become subject to the Workers' Compensation provisions of the Labor
Code, you must forthwith comply with such provisions or this permit shall becc
revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the perform-
ance of the work for which this permit is Issued (Sec. 3097, Civ. C.)
Lender's Name
Lender's Address
Icertify that Ihave read this application and statethat the above Information
is correct. I agree to comply with all city and county ordinances and state laws
relating to building construction, and hereby authorize representatives of this
cityto enter upon the above -mentioned property for inspection purposes.
p° P p ha P� p"`Eu
(We) agree to save, Indemnify an d keep harmless the City of Cupertino
against liabilities, judgments, costs and expenses which may in any way accrue
TOTAL:
BUILDING FEE
SEISMIC FEE
TOTAL:
ELECTRIC FEE
PLUMBING FEE
QTY.
MECHANICAL PERMIT
FEE
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID:
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 1QOo0CFM)
CONSTRUCTION TAX
Signature of Applicant/Contractor Date
Da-IAUSTHOOD (W/DUCT)
CONSTRUCTION TAX PAID:
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)t
Yes - 0 No
Will the applicant or future building occupant use equipment or devices
Date Recei t#
HEATING UNIT (TO 100,000 BTU)
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
VENTILATION FAN (SINGLE RESID) -.
ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management District?
h I Yes d No
ave read the hazar ous materials requirements under Chapter 6.95 of
_
BOILER -CAMP (3HPOR 100,000 BTU)
BOILER -COMP (OVER 100,000 BTU)
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
NEW RESIDENTIAL MECH. SQ.FI
responsibility to notify the occupant of the requirements which must be met
-
prior to issuance of a Certificate of Occupancy.
e
ISSUED BY. f
Owner or authorized agent Date
TOTAL:I
OFFICE COPY /�