21917APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification
But Ing Address:
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CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BUILDING.ELECTRICALPLUMBINC.MECHAMCAL
Q r /
nt 'e I • LI N.:
Architect/Engl r. Lk. No:
CATEGORY
CONTROL Y
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Address: -
PERNIHISSUANCE
/
❑ ❑ ❑ I,y
h
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter9(commse-
IngwithS d on7000)of Divi lon3ofthe Buslnmand PmfeW=,Code, and my
Iicense bin fu deflect s
Limn C k. YJC,�a•a7s 71 .V
Dat Contracio
ARCHITECTS DECLARAT N
I understand my psro dull be used as public records.
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Conlraclor's License law for the
fallowing mum. (Section 70315, Business and Professions Code: Any city or
county which requires a permit to oorutroct, alter, Improve, demolish, or repair
any structure prior to its Issuance, also requires the applicant forsuch permit to
file a signed statement that he Is licensed pursuant to the provisions of the
Contrectars License Law (Chapter 9(commenMg with Section MOB) of Divi-
3 of the Business..d Pm emim eCode) or that he b exempt thercfromand
the basis for the alleged exemption. Any Violation of Section 70715 by any
applicant for a permit subjects the applicant to a civil penalty of not more than
Ove 1, as demodollarthepr. wk
I, as owner will
the property, or my employes with wages r offered
compensation, Busite the work and the structure b not Intended or offered (or
dale (Sec. apply to a now and Prooperty Code: The Contractor's Chiron law
does whorl nottepchy rkht morph propertywho
nempoym,pimproves idedt at and
whodoes docs workhim eBorlhrwghed ownemp, how.providedilding h
Improvements arenm intended mediatedfor ole.If,however, Uder ilI haw
Improvement scold within.neyrarofcomplcibRtheowner-bu0derwlll save
tlI,Lktrden of proving that he did not build or improve for purpose of ole.).
u L as owner of the property, am exclusively exntracting with licensed
contractor to construct the project(Sec. 7044, Business and Profmlov Code:
The Contractors License Law dos net apply to an owner of property who
build. or'improves thereon, and who cmueds for such ptojecia waft a
CffgplTaduels)licene.d pursuant 1. the Contractors License law.
I em exempt under Sec. B & P C for this reason
APPLIANCMRESIDENTIAL
6;E
PANELS
AMPS
OVER
OVER IOW AMPS
SQ, FT. FLOOR ARTA
S/SQ. FT.
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC
TEMP METER OR POLE INST.
OWER DEVICES.
SWIMMING POOL ELECTRICsion
OITI'I.EISSWITCIIESFIXTURES
VALUATION
NEW RESIDENTIAL ELECTR SQ.FT.
STORIES
TYPECONSTRUCTION
TOTAL:
QTY. PLUMBING PERMIT FEE
OCC. GROUP
RES. UNITS
PERMITISSUANCE
ALTER -DRAIN &VENT. WATER (FA)
FLOOD TONE
APN
FEE SUMMARY
BACK PLOW PROTECT. DEVICE
FLOOR, ROOF, AREA, COND.
FIX•IURESte PER.IRAI'
SANITARY Y N
RECEIIs7 Y
OwnerDRAINS
Data
WORKMAN COMPENSATION DECLARATION
QI hereby affirm ce
that 1 have a nifiure
of consent to selMndu , or
ceniftuteof Worker'Com'`pematimlmumnmoramnifledmpythemf&c.
� Yb Gl`
Compan tet'
Y
SCI100L TA% Y N
RECEE NM
GAS EASYBTEM IINC60UTLETS
PARK FEE RECEIPT#
GAS EA. SYSTEM-OVERA(EA)
BUILDING DIVISION FEES
❑ ni0ed ropy b herebyfurnished.the city
enlfied ropy b flied with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Ghl.sectlon need not be completed if the pdonit toluenes hundred dollen
(SIW)mless,
Icertlfythat lntheperformameso(lheworkforwMchlhlspernitl.bdued,
I shall not employ any person In any manner ao u to became subject t. the
Workers' Compensation law. of California. Date
Applicant
NOTICE TO APPLICANT: If, after making this Certiflute of Exemption, you
should become subject to the Wo,xam'Compeneatlon provisions of the Labor
Cade, you mu.t forthwith comply with each pr.vblos.,thb permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the perform
ance ofthe work for which this permit Is Issued (Sec. 3097, Cie. C.)
Lender's Nam
Leader's Addrew
I canlfythat I have readthisapplicatlonand state Ihattheabove Information
isconect. I agmto comply with all city and county ordinances and este law.
relating to buliding construction, and hereby suthodre representatives of this
city to enter upon the abovo-mntioned property for impaction purposes.
(We) agree to save, Indemnify an d keep harmleas the City of Cu pen inn
agalretllabNtkd,judgmnb,coet... dexpensswhlch mylnanyway accrue
age dCitysconsaquence (th grantln .(this semi
IS a rcol Applicant/Contractor ate
HAZARDOUS MATERIALSI IASURE
Will the applicant or future buliding occupan oroor handl mous
materslasdefined bythe Cuport! an Murdcipal Code, Chapter 9,17, and the
Health and Safety Code Section 25532(x)7
Yea MN.
Will the appBuntor ,air contaminants ndby the Ba Area devices
as defined
whkheMahare ent airrict? ens ae defined by the Ray Arca Air
Quality Management D'uMci7
4 Yee No
of
haveread Health
nus Code, Serequircrrenb5533 and 25534.
lM California Health &Safety Code, EMIOn9 75505, 75533 and 75534. 1
understand that if the building does nut currently have a tenant, that it is my
responsibility to notify the occupant of the requirements which must be met
pi tobsuanceofa CenifkateofOmpanq.
CREASEANDUSTRL WASTE INTERCEPTOR
PLANCHECKFEE
PA)� ate RCCCI (#
IYYssNYY��
GREASE TRAP r -
gEWER SANCfARI' 5T0
WATER HEATER W/V
ate,
•LVI:rtRart(FEE Y N
P... 1B �\
PT
Dat Recei t#
_
TOTAL:
WATER SYSIEM/TREA
NEW RESID PCMB.
BUILDING
SEISMIC FEE
TOTAL:
ELECI•RICFEE
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
MECIIANICAL FEE
PERMIT ISSUANCE TCT51TEES
ALTIRORADDTOMECH.
PAID:
Da[e Recei [#
AIR HANDLING UNIT (170 10,000CFM)
SUBTOTAL:
AIRHANDLING UNIT(OVER 10,000CFM)
CONSTRUCTION TAX
E(HAUSTHOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HEATING UNIT (TO 100,000 BTU) ��
-
Date Recei t#
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
VENTILATION FAN (SINGLE REBID)
ISqut� DA•I•E
7 �%
^
��
MAR
Z'1!{ '%V (`f ;on
'J'tY
Ate
1_TPWb
iTp�
ISSUE
BOILER -COMP pl-B'GR 100,000 BTU)
BOILER-COMP(OVER100,000BN)
NEW RESIDENTIAL MECH. SQ.FT
Owner or authorlred agent Date
TOTAL:
OFFICE COPY