S 0062 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL G2_
BUILDING PROJECT IDENTIFICATION
BUILDING AUUBESS SANITARY NO. APPLICATION SUBMITTAL DATE
Cd
OW ER NATV PHONE: CONTRACTOR'S NAME: LIC NO:
CONTROL#
lei ARCHITECT/ENGINEER: LIC NO. ABUSE S: L-1 1 ❑
O SdZ/4 ✓
CONTACT. PHONE: BUILDING PERMIT INFO
❑ CassaBaby Fees Paid by Applicant(Initial) BLDG ELECT XUMB CH
❑ ❑ ❑
LICENSED CONTRACTORS DECLARATION /'--
I hereby ali m that I am licensed under provisions of(Sumter 9(commencing QTY. ELECTRIC PER JOB DESCRIPTION
n=ZO wilh Section 90tH))of Division 3 of the Business and Professions Cede,and my license is RESIDENTIAL;
�W F in full force and effect �n PERMIT ISSUANCE
GUU Li cense Class Lic.# 10� X USFDWL ❑KITCHE DEL
IF�4 Uatc Contactor UA . APPLIANCES-RESIDENTIAL El ADDITION BING RE-PIPE
AltCHITECTS DECLARATIO PANELS El MULTI-UNIT El STRUCTURAL
Z O m 1 understood my plans shall he used as public records MODIFICATION
14tG UP TO 200 AMPS
F+�`L'W Licensed Professaonm ❑INTERIOR DSWCHIMNEY
MING PPAIR
OOL
C`,G�'"'� OWNER-BUILDER DECLARATION OVER 10h)AM IMPROVEMENT El DEMOLITION POOLS
pp�d,,O a a I hereby affirm that I am exempt from the Contractor's License Law for the OVER IU(10 AMPS ❑HATH RF:MODEUREPAIR DEMOLITION
W 3 following moron.(Section 90315,Business and Professions Code:Any city or county SIGNS ELECTRICAL D OTHER
6F1=G y¢ which requires a permit to amsvuct alter,improve,demolish,or repair any structure
Crn.] prior to it,kincnce,nleerequites lhenppllcant far such ptrmluo fi le a snucdeammen, SPECIAL CIRCUFUMISC.
CS That he is licensed pursocntrathe provinionsof,he Contractor.,License Law(Chapter 9
qp (commencing with Section Soap of Division 3 of the Basi ness and Professions Code)or TEMP.METER OR POLE IN COMMERCIAL,:
d y es y thot he is exempt therefrom and the basis for the alleged exemption.Any violation of D NEW BLDG/ADDITION D DEMOLITION
��N
Section 70315 by any applicant for a pemtitsubjects the eppllcam 1, ivil penallyof POWER DEV ICES
t more than rive hundred dollars($500). D TENANT ❑FOOD SERVICE
�yC ❑ I,as owner of the property,or my employees with wages as Their sole compensation, SWIMMING POOjs,11LECIIUC .IMPROVEMENT
will do the work,and the structure is not intended oreff sed forsele(See.9044,Business D OTHER
mand Professions Cade:The Con,aaor'n License Law Jaen nor apply to un owner of OUTLETS- ITCHES-FIXTU S A Y
property who builds or improves thereon,and who does such work himself or through �m
his An employees,pnwidetl that such improvements ore oar intended nr offered for NF.W .'IDENTIAL ELE SQ FT.
,tole.It,however.the building arimprovement ithath wltbineneyeaor imprvetfomthe SQ.rR'-FLYR9REA �� S/SQ.FT.
Pwner-builder will have rhe burden of proving that he did sol build or improve for Aur- �I!'rrlJfrNQ C-Ip�IRE^�T71Jf/I
pose of arta].
D h as owner of the Property.am exclusively contracting with licensed cormorants,to L: CITY,
IP
conswenhe project(Sec]00ale:
4,Business and Professions C )The Contractor's Li- - Uri �UN[HI�N
come Law does naapplytorn ownerof property who huilds or improves threon
e .aPERF FEE QTY. PLUMBING PEFEE i,
who contracts for such projects with o Commands)licensed punuan,home Contractor's
License Law.
D lam exempt under Sec. ,B&P C for nus reason PERMIT ISSUANCE k�
Owner Dom ALTER-DRAIN&VENT-WATER(EA) If VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECP.DEVICE
I hereby affirm interatomic of perjury one of the following declarations:
❑ I have bad will maintain a Certificate of Consent to self-insure for Worker'.,Coutpen- DRAINS-FLOOR,ROOF,AREA,COND,
cation,as provided for by Section 3900 of the Labor Code,for the Performance of the STORIES 'TYPE CONSTRUCTION
work for which this panni,is issued. FIXTURES-PER TRAP
I have and will maintain Worker's Compensation Insurance,as required by Section
3900 ofihc Lahor Code,fonhepuformmce of the work for which his permit is lvsued, GAS-EA.SYSTEM-1 INC.4 OUTLETS OCCGROUP APN
My Work e� o mer and Policy o
Curries Policy Na. V` GASB-EA.SYSTEM-OVER 4(EA)
C CERTIM ATE6 MPTION FROM WORKERS'
G COMPENSATION INSURANCE GREASEIINDUSTRI.WASTE INTERCEPTOR
(This section need not he completed lithe permit is for onehundreddallars($100) BUILDING DIVISION FEES
or late.) GREASETRAP PLANCHECK FEE
Toy any thatininthe performance nfrhe work for which thispermitW.1issueglshall SEWER-SANITARY-STORM EA.200 FT
not employ any person in any manner ,apeeume nu4e7 the Warkeri Compen- ENERGY FEE
0 smionlatws Dae 6V' ^-�/
z O Applicum 1 � eWATER HEATER WNENT/F.LFiCTR
kigg tGRADING FEE
rjJ NOTICE TO APP LIC ANT(If,ager makidg this a Ceniof n,youold WATER SYSTEMREA'TINC beeome subject to the Worker's Compensation provisionsnscif of the linea Code,youu most /fSOILS PEE
Lkl forthwith comply with such provisions nr this national be deemed revoked.
WATER SERVICE
Q
� zCONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. PAID
UQ I for
rm mauhemissued( ee.constructionleadingagency fanheperfonnenceof Receipt#
Wt H the work for which this permit ix issued(Sec.3(19],Civ.CJ
C) U Lender's Name TOTAL:
Lender's Address 1 certify Ther 1 have read this application and stem that the above infcarmiu onin BUILDING FEE
rA comet'.l agree to comply with all city and county contacts and state laws relating to QTY. MECHANICAL PER1gTOTTAL.-
91.
FEE
U z building construction,and he,ebyaathorre representatives of this city to enter upon the SEISM
abovcmrntinneJ property fur inspection purposes. PERMIT ISSUANCE
(We)agree III indemnify and keep harmless He City of Cupenlno against ELECTRIC FEE
liabilitles,judgments,costs and expenses which may in any way came against said City ALTER OR ADD TO MECH.
in consequence of the gaming of this Permit PLUMBINGFEE 671�q0
APPLICA UNDERSTAND. U PLY WI ALL NON-POINT AUR HANDLING SNIT(TO IQIIUU CFM)
SOUKGULATION. ��Vs-r fMECHANICAL FEE
AIR HANDLING U T(OVER 10,000CF CONSTRUCTION TAX
re ofppp U anuaor Dam EXHAUST HOOD OVIDUCT) HOUSING MITIGATION FEE
HAZARDOUS ATERIALS DISCLOSURE,
Will the Aileen,or fu'om building eccupam trotter handle huzmJous material HEATING UNIT GO 1(1(1.000 U)
us derineA by t Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cade,Section 5532(.)'! HEATING UNIT(OV E ,00(1 BTU)
Yes ❑No VENTILATION F
(SINGLERESID) P Dae Rceeip,#
Will the applicant or Fare building occupant use equipment or devices which
s emit hazanliaw air contaminants as dtfined by the Bay Area All Quality Management ROIL
. P(3HPOR 100,000BTU)
District? TOTAL:
D Yea EINo BGILE -COMP(OVER 100,000 BTU)
Ihavemonth,haeardue,materials requirements coder Chapter 6.95 of the Cali- CONDITIONER ISSUANCE DATE.
form Health-&Seftay C�bt
255]4.1 understand that if the NEW RESIDENTIAL MECH. SQ.FT. y `
buildingdose nm c ntlsI Inym no'ify theoceupan,ofthe hickaCe woe
Owner er 'hnriz am g I TOTAL: I I ISSUED BY:
OFFICE C