S 0271 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING'-ELECTRICAI, PERMIT NO.
APPLICATION/PERMIT
PLUMBING
PROD-MECHANICAL S 0271 2 7 1
BUILDING DIVISION BUILDING PROJECT tDEMI'IFICATION G 1 1
III BUILDINGAL�Pee'.� ��/) I' , _�I SANITARY NO. APPLICATION SUBMITTAL DATE
OWNERS NAM : \JJ ,TIPHONE: �p CONTRACTOR'S NAME: LIC NO:
e" J NIC CON'I'kOLk
AR HITEiENO1NHER LIC N : ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ K ❑
LICENSED CONTRACTORS DECLARATION QTY_ ELECTRIC PERMIT FEE
I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
0aZ with Section 9fot0 ovisien3ofthe Business and Professions Code,and my license is RESIDENTIAL'
WOO PERMIT ISSUANCE
FWD in lull force and effect. ❑SFDWL ❑KITCHEN REMODEL
OF License Class Lie.If APPLIANCES—RESIDENTIAL ❑ADDITION /p�pLUMBING RE-PIPE
set a Uate Commcmr ❑MULTI-UNIT ` I�STRUC URAL
ARCHITECT'S DECLARATION MODIFICATION
y p ti 4 1 understand my plans shall be used as public records PANELS
y UPT02MAMPS
' py..� El INTERIOR CHIMNEY REPAIR
.�yj Licensed Professional 201-IMMAMPS IMPROVEMENT ❑SWIMMING POOLS
6y4aaw 6 OWNER-BUILDER DECLARATION OVER 10W AMPS E]BATH REMODEUREPAIR (]DEMOLITION
o 1 hereby aRirm that 1 am exempt from the Contractor's License Law for the
qxx O L U following reason.(Section 7031.5,Business and Professions Cade:Any it,or county 'SIGNS[LF.CTRICAL ElOTHER
I++a W E' which requires a Permit to construct,alter,improve,demolish,or repair any structure
t,L 00 prior In its issuance,also raoites the applicant for such permit to file a signed statement SPECIAL CIRCUITIM ISC
y that he is licensed pursuant o the previsions of the Connector's License Low(Chapter 9
<� (commencing with Section INKE of Division 3 of the Businessond Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL:
exempt d Qo that he is therefrom and the basis for he alleged exemption.Any violation of F]NEW BLDGIADDITION ❑DEMOLITION
WSection 9031applicant.5 by any applicant for a permit subjects the applicano a civil penalty of POWER DEVICES We ❑'TENANT ❑FOOD SERVICE
F' 6m mere than five hundred dollars 0 SWEL 1MPROVL'MENT
ElI,as ownernf the property,ormyempinyees wi0 wages astheirsolecompensntinn, SWIMMING FOOLF.LECTRIC
_0 will do Ne work,and the structure is not intended.roffered for side(Sea 9044,Business ❑OTHER
6'3m and Professions Code:The Contractor's License Law does not apply In an owner of OUTLETS—SWITCHES—FIXTUR..
property who huilds or Improves thereon,and who does such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECfR SQ
sale.If,however,the building or improvement issold within one year ofcampletion.the FL EA 8/SQ.FT
owner-builder will have the burden of proving that he did not build or improve for pur- M '�
pore of mley (�
TOTAL'
El1,as owner of the property,am exclusively contracting with licensed contractors to
consume(the project(Sec,9044,Business and Professions Crb:)'Ihe Contractors Li-
cense
i-c se Law does not apply to an owner ofproperty who builds or improves thereon,and QTY. PLUMBING PERMIT
who contracts for such projects with a comranm(e)licensed pursuant to the Contractors
License Law. PERMIT ISSUANCE 0
❑ 1 am exempt under Sec. ,B&P C far this reason
ALTER—DRAIN&VENT—WATER(EA) VALUATION
Owner Date
OR OMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby alfnn undo(penalty of Darply one ch its¢following declarations:
❑ (have and will maintain a Cenilicme of Consennn self-insure for Worker's Compen- DRAINS—FLOOR,ROOF.AREA,COND. STORIES TYPECONSTRUCfION
sation,as provided for by Section 37M of the Labor Cade,for the performance of the
work for which this permit is issued. FIXTURES—PER TRAP
❑I have and will maintain Worker's Compensation Insurance,as reyuirW by Suction
370onfthe Labor Cale,for lheperferance afttse work for which this permit laloevcd. GAS—EA.SYSTEM-I INC.4 OUTLETS OCO.GROUP APN
My Worker's Compensation Insurance carrier and Policy number are:
Candice Policy No.: GAS—EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASL/INDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BIJiLU1NG DIVISION FEES _
Hot section need not be completedif(he pemat is for nnc hundred dollars($100) GREASETRAP
PLANCHECK PEC
or Its,.)
I cenify(hatur he performance at the work for which this Permit is issued,l slash SEWER—SANITARY—STORM EA.20d FT.
not employ any person in any manner so as to became subject to the Workers Common- ENERGY FEE
,Z cation Laws of California Date WATER HEATER WNENTIELECTR
zApplicant t GRADING FEE
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,yen should WATER SYSTEMO REATING SOILS FEE
a ^I become subject to the Worker's Compensation previsions of the Labor Code,you mum
mit
G forthwith comply with such povismal.1 this pershall b,deemedmvakcd. WATER SERVICE
LL CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID Data ReceiptN
U O Ihereby affirm that is a construction lending agency for the performance of
Ne work for which this poout[is issued(See.319],Civ.CJ
QE" Lender's Name TOTAL:
* Lender's Address
I certify that I have read this application and state that the above information is mt
HE
%1 correct.l agree to comply with a0 city and county ordinances and state laws relating m QTY, MECHANICAL PERMIT FEE
U G building construction,and hereby andamim representatives of this city m enter upon the EE
above-mentioned property for impeclum purposes. PERMIT ISSU NCE.
(We)agree to save,Indemnify and keep harmless the City of Cupertino against PEE
liabilities,judgments,Costs and expenses which may in any way accrue against said City ALTER ORADD TO MECH, FEE
in consequence of the grunting of this peril.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT OG 10,000 CFM) AL FEE
SOURCE REGULATION lll��T
,/ AIR HANDLING UNIT(OVER 14000 CFM) TION TAX
gt'gtpdt�e.d APPliy:p Syatra Date i/ EXHAUST HOOD(W/DUCT) MITIGATED FEE
Il III MUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hourcous material HEATING UNIT(TO 100,(X01 BT UI
as defined by the Celluino Municipal Gale,Chapter 9.12,and the Health mad Safety -
Cone,Section 25532(e)Y HEATING UNIT(OVER 100,000 BTU)
El Yea ❑No VENTILATION FAN(SINGLE RESID)
Date Receipip
Will the applicant or future building occupant use equipment or devices whicM1 BOILER—GDMP(3HP OR 100,01W BTU)
emit hazardous air contaminants as defined by the Bay Area Air Quality Management TOTAL:
Dlmfim9 BOILER—COMP(OVER 100.000 BTU)
❑Yen ❑Nu
I have readthe hazardous mmeriAs requirements under Chapter 6.95 ofthe Cali- AIRCONDITIONER ISSUANCE DATE
fomie Health&Safety Code,Sections 25505,25533 and 25534.1 understand(M1m if the NEW RESIDENTIAL MECH. SQ.FT.
building does nor currently have a tenant,that It is my responsibility m notify the sccupam
of the requirements whish mom be at prior m issuance of a Cenificmte of Occupancy.
Owner or authorized agent Date TOTAL ISSUED BY:
OFFICE