S 1111APPLICANTTO.FILL IN INFORMATION WITHIN RED LINES USE BALL POINT PEN ONLY,
CITY OF CUPERTINO " -- - BUILDING - ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL
•';, BUILDINGPROJECTIDENTIFICATION„'
PERMIFNO,
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BU DINGADDRESS:
UI Ca r
- -
rC(- L►�.
SANITARY NO.
APPLICA'110N SUBMITTAL DATE.
0 N •R'S
1
NAM : PI NC:
-
CON CfOR'S AME: ' LIC NO:
NIC
C(JNTROLp
' ARC TECT/F,NGINEER: LIC NOP
S' -A 11209CS A31
CONTACT: PHONE: +
• -
Q Consultant Few Paid by Applicant (Initial)
” , -BUILDING PERMIT INFO
BLDG a.G'T PLUMB MF,CH
❑
E]LICENSED
CONTRACTORS
RS DECLARATION ;
1 hebin I licensed de p [ Ch ptcr 9 (commencing
L with Section 9(M10)af D'rstan3 of theBuslne.', nJ Pndese On. Cade and my lice: v
in full forceandeRecl
License Class L.ic.N
y Dme' Contractor
.!
QTY. ,<•' EEECTRIC PERMIT! FEE
� q
JOB DESCRIPTIOherebyaffirm
RESIDENTIAL -
❑SFDWL ❑ KITCHEN REMODEL
❑ADDITION - El PLUMB ING RE -PI Pii
El MULTIUNIT ❑STRUCTURAL
- MODIFICATION
❑INPERLOR - C1 CHIMNEY REPAIR
IMPROVEMENT ❑ SWIMMING POOLS
❑ PATH REMODEL/REPAIR (]DEMOLITION
El OTHER
-
PERMITISSUANCE
APPLIANCES -RESIDENTIAL
ARCHITECT'S DECLARATION
I understand my plans shut] be used as publ i, .,,ad,
`
PANELS
UPT02W
zi Licensed Professional
.I OWNER -BUILDER DECLARATION
6 � 1 hereby affirm that exem
I am exempt from the Contractors License Law Far the
hall. , vmram. (Section 7031 .5, Btainicsind Pr, f Core: Arv,,rioi or county
whmh roquir . al) 'n t t aim p d 1.1 apo r Y 'I ours
pro t t t. man is q therMlic tf hPermitt fl asigned statement
that he licensed I , tells, provisions fth Contractor s Lc rt Law (Chapter 9
(connemmng with Seen.. 700B.f Division 3 ottfic Brammsad Profession, Code)m
y' that he Is exempt therefrom and the basis for the alleged exemption. Any violation of
n Section 7031.5 by any applicant fora Permit subjects the applicant penalty of
not mora Non five hundred dollora ($500).
(] I, as owner of the property, or my employees with wages as their sulecmnpensation,
will do the work. mr! the stmeture is not atended oroffered fmrsale (Sec.904 L Busina,w
and Professions Code: The Cmntmmara License Law docs not apply man towner of
property who builds or improves thereon, and who does such work himself or through
his own nnpinyees, provided that such improvements are not intended or offered for
sala.lf,however, the building orimprnvement is sold wllhinnne year of compleaian,the
wneclatu der will have the harden of proving that be did not build or improve for purr-
tasse of sale)
❑ 1, as owner of the prprty, an culasively contracting wrthtr I cetsed ancturcturs t
construct the project (See. 9044 Business and Pr Uso Cde) The Contractor L
se Law does not apply[ an owner fproperty h builds n
ds omprovev thereon d
who contracts for such prlecrc with a commands) licensed pursuant to the Contract
LcenseLaw
❑ I am exempt under Sec - , B & P C for this reason
201-IfN10AMPS PS
OVER 1000 AMPS
r
SIGNS ELECTRICAL _
SPECIAL CIRCUI OMISC.
TEMP. METER OR POLE INST
COMMFR IA
❑TENANT ADDITION El DEMOLITION
❑EANT El FOOD SERVICE
IMPROVEMENT
EIGHTIES
'
- -
POWER DEVICES
SWIMMING POOL ELECT RIC
OUTLETS -SWITCHES -FIXTURES
NEW RESIDENTIAL ELECTR SQ
-
SQ. FT. FLOOR AREA
0
$/SQ. EI'r
-
DOTAL
- . ,,. s h
QTY • ', PLUMBING PERM IT i'•, PEE'
'-
PERMITISSUANCE
ALTER -DRAIN & VENT -WATER (EA)
Owner pate
I'VY VALUATION
C"U(yA
V
WORKER'S on DECLARATION
Wm under ne pedary one of the followingre or tledatasmm:
' have andhereby affirm maintain a Conaltydamine
sure,pro will for bymeCmi 3700 of the Laorent to seldefartfarscramWorkers (1 Ii,ari-
oa provided for mi Ss I...a3'!00 of the Labor Code, [or the performance of the
work
work have and this permit isiorker by Section
❑ 1 have and will maintain Workers Compensationce ofthe
hw Insurance, h this
My ophe Labor Coda, for lM1c petl6rmanw of 0awock forwhich0is permit is issued.
Carrie rk yrs en�on n�un� arrjerayd POlicYn �',Q
n y No.:
CERTIFICAT OF EXE. 1PTION FROM WORKERS'
COMPENSATION INSURANCE
Obit,ceioo need oat be completed ifthe permit is foromehmndred dollars 10")
or less)GREASETRAP
Iterrify that in the performance ofthe work for which this permit is issued. I shall but employ any person in my manner so as to become subject to the Workers Conspen-
of California. Dote
Applicant 1 -
BACK FLOW PROTECT. DEVICE
-
DRAINS -FLOOR, ROOF, AREA, COND.
STORIES
TYPE CONSTRUCTION
FI%TURES - PER TRAP
GAS EA. SYSTEM -1 INC. 4OUTLETS
OCC GROUP
APN
GAS-EA.SYSTEM-OVER4(EA)
GREASIVINDUSTRL WASTE INTERCEPTOR,.
x
x @ R ;� g BIIILUINO'DIVISION FE"
x
PLANCHF.CK PEG
SEWER- SANITARY -STORM EA. 200 FF.
ENERGY FTE
WATER HEATER WNENT/ELECTR
-
GRADING FEB
i NOTICE
NOTICE TO APPLICANT. after making this Certin,of of Exemption, you should
become subject m the Workers Compensation provisions of the Lahr Code, you most
fanhwith comply wird such previsions or this permit shall be Deemed rovokeJ.'-
CONSTRUCTION LENDING AGENCY
I hereby affirm that hem is a construction lending agency far the performance of
the work for which this permit is issued (Sec. 3099, Civ. Cr)
Lender's Name
WATER SYS'GMTREATING
SOILS FEE
WATER SERVICE
-
PAID
Dam Receipt#
NEW RESIDENTIAL PLMB. SQ. FT
,. ,.
Lender's Address
- I certify that 1 have rood this application ane state that the clumic informations
comet 1 agree to comply with all city and county ordinances and state laws r I ting to
building constracuan and hereby amhorimactresentatves ofthis city toenterupon the
ahovc-mentioned property tot inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities,judgments, costsmd expenses which navy inany way accrue againsl said City
in onsequenm of the granting ofthis permit. +
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALLNEON-POINT
TOTAL:
BUILDING FEE
- ,,. t
QTY. , MECHANICAL, PERMIT .FEE
-
SEISMIC PEE
_
PERMIT ISSUANCE
ELECTRIC FEE
RIF
-ALTER ORADD TO MECH.
-
PLUMBING FE �+'
PEE
AIR HANDLING UNIT (TO IO,IIgI CFM)
AIR HANDLING UNIT (OVER 10,000 GPM)
CONS UC'1'ION TAX
SignatureafApplicausContmedul' Data
HAZARDOUS MATERIALS DISCLOSURE.
Will theapplicantor future building aecnpam since or handle hazardous roman
as loaned by the Cupertino Municipal Code, Chapter 9.12, and the Hrallh and Safety
Cade, Section 25532do i
- ❑Yes - ❑Nm
'
Will the applicant or future building occupant use equipment or devices wM1leh
Iemit hazardous air contaminants as deftoed by the Bay Area Alr Quality Management
District' _ -
El Yes - L]No
I have re;ul the hazardous materialsAIR'
requirements under Chapter 6.95', lhe Cali-
fornia Health & Safety Coda Smions 255(15, 25533 and 25534, j undersand that if the
building does nm currently have'a mount. Ihat it is or, respmmibilhy to maify the oecupard
of the communicant which must be met prior to issuance of u Cerific:ne of Occupancy.
- EXHAUST HOOD(W/DUCT)
HOUSIN ITIGATION FEF,
_
HEATING UNI'T(TO 100,010 BTU)
BEAT ING UNIT (OVER 100,000 BTU)
_
,
PAID
- Date Receipt A
VENTILATION FAN (SINGLE RES] On
BOILER -COMP QHP OR 100,000 BTU)
TOTAL:
BOILER- COMP(OVER 100,000 BTU)
-
CONDITIONER
ISSUANCE DATE
ISSUED BY:
NEW RESIDENTIAL, MECH. SQ. IT
Owmacramthonzed agent Data
- TOTAL
OFFICE