20663 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLYmc
Building Project Identification PERVIITNO.
Building Address: q O
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APPLICATION SUBMITTAL A
A,' /Y7 le X `C, CITY OF CUPERTINO-BUILDING DIVISION
Contractor's Name: Lic.No: APPLICATION /PERMIT
BUILDING-ELECTRICAL-PLUMBING.,MECHANICAL CATEGORY CONTROL#
Architect/Engineer. Lic.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: m PERNI[ITISSUANCE ❑ �1
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I alicensed under provisions of Chapter 9(comment APPLIANCES-RESID . L F777JOB DFSCRII'IION
ing with Section 7000)of Division 3 of the Business and ProfessionsCode,and my
license is in full force and effect. PAIv-IIS
License Class Lic#
Date Contractor
ARCHITECTS DECLARATION 201-1000 AMPS
O I understand my plans shall be used as public records. OVER I AMPS SQ.FT.FLOOR AREA $/SQ.FT.
d U Licensed Professional SIGNS EL TRI `
�¢ OWNER-BUILDER DECLARATION l/
F O Z I hereby affirm that I aexempt from the Contractor's License Law for the SPECIAL C /.
0 O m following reason.(Section 70315,Business and Professions Code:Any city or T.MP M POL INS
r�„ a county which requires a permit to construct,alter,improve,demolish,or repair
tt OQanystructurepriortoitsissuance,alsorequirestheapplicantforsuchpermitto POWER DEW
d J file a signed statement that he is licensed pursuant to the provisions of the
mu F Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi- SN IIv1MING POOL ELE
O sion3oftheBusinessandProfessionsCode)orthatheisexempttherefromand VALUATION
j r the basis for the alleged exemption. Any violation of Section 703IS by any
OUTLETSSWITCHESFIX'fURES
C O applicant for a permit subjects the applicant to a civil penalty of not more than
c fivED e hundred dollars I, pr. NEW RESIDENTIAL ELECTR SQ.Fr. S'T'ORIES TYPE CONSTRUCTION
as owner of the
property,or my employees with wages as their sole
t� ¢ corfipensation,will do the work,and the structure is not intended or offered for
t,O sale(Sec 7044,Business and Professions Code:The Contractors License law
(j does not apply to an owner of property who builds or improves thereon,and
who doessuch work himself orthrough his own employees,provided that such OCC.GROUP RFS.UNTTS
improvements are not intended oroffered for sale.If,however,the building or TOTAL:
improvement is sold within one yearofcompl etion,the owner-builderwill have
the burden of proving that he did not build or improve for purpose of sale.). QTY, PLUMBING PERMIT FEE FLOOD ZONE A,N
I,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec 7044,Business and Professions Code:
The Contractors License Law does not apply to an owner of property who AI TER DRAIN&VENT-WATER(EA)
builds or improves thereon,and who contracts for such p{ojects with a
contractor(s)licensed pursuant to the Contractors License Law. FEE SUMMARY
ElI am exempt under Sec. B&P C for this reason BACK FLOW PROTECT.DEVICE
OUTSIDE FEES
DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y_ N_
:weer �.h., �,�, 4�cCcc Date 7- - G) RECEIPT#
WORKMAN COMPENSATION DECLARATI N
Ji hereby affirm that I have a certificate of consent to self-insure,or a FIXTURES-MTRAP SCHOOLTAX Y_ N_
rtificate of Workers Compensation Insurance or a certified copy thereof(Sec. RECEFr#
3800,Lab CJ GAS EA.SYSTEM-1 INC.40UTLETS PARK FEE Y N
Policy# RECEIPT#
Com any GAS EA.SYSTEM-OVER 4(EA) BUILDING DIVISION FEES
Certified copy is hereby furnished. GREASEANDUSTRL WASTE INTERCEPTOR PLANCHECK FEE /�#
Certified ropy is filed with the city inspection division. I
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 200FT Date Revel
(This section need not be completed if the permit is forone hundred dollars
($100)or certify
.) WATER HEATER W/VFN'T/ELECTR ENERGY FEE Y N
I certify that in the performance of the work for which this permit is issued, —
I shall not employ any person in any manner so as to become subject to the WATER SYSTEM/TREATING
Workers'Compensation Laws of California.Date PAID
O Z Applicant
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you NEW RESIDENTIAL PLIv18. SQ.FT. Date Reeei t#
should become subject to the Workers'Compensation provisions of the Labor TOTAL:
W~ Code,you must forthwith comply with such provisions or this permit shall be O,Li
BUILDING FEE> deemed revoked.
O. a CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there is a construction lending agency for the perform TOTAL: ELECTRIC FEE
M Z ante of the work for which this permit is issued(Sec.3097,Civ.C.)
Q LD Lender's Name PLUMBING FEE
IL H Lender's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O 0 Tcert ifythat Ihave read this application and state that the above information is correct.I agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
} 0' relating to building construction,and hereby authorize representatives of this
j— city to enter upon the above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
Z (We)agree to save,indemnify an d keep harmless the City of Cupertino Date Receipt#
V against liabilities,judgments,costs and expenses which may in anyway accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
against said City in consequence of the granting of this permit.
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signature of Applicant/Contractor Date E)(HAUST HOOD(W/DUC) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health and Safety Code Section 25532(a)? HEATING UNIT(OVER 100,000 BTU) r
0 Yes 0 No
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air (1
Quality Management District? BOILER-COMP(3HPOR 100,000 BTU) g
Yes S No
have read the hazardous materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU)
the California Health&Safety Code,Sections 25505,25533 and 25534.I 1 of
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.F1
responsibility to notify the occupaaa of the requirements which must be met
prior to-issuance of a Certific#teof Occupancy. >
O er or authorized agent Date ISSUED BY:
TOTAL:
OFFICE COPY