31499 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY '
CITY OP CUPERTINO BUILDING-ELECTRICAL PERMITNO. 99
31 p
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. �(J 44J�V•1
BUILDING PROJECT IDENTIFICATION
,PCILDINGADDRMS: / ) SANITARY NO. APPLICATION SUBMITTAL DATk
'S NAMEE: 6 C PUT O 'S AM§ D w , LIC NO: 6
G N/C CONTROL
121 ARCHITEC N is ER: r LICN ADDRESS: ❑
CQN'rACr: PHONE: BUILDING PERMIT INFO
Dp e / / OO C ❑ Consultant Fees Paid by Applicant(Initial)• BLDG ELECT PLUMB MECH
LICENS CONTRACTORS DECLARATION v QTY. ELECTRIC PERMIT FEE ❑ � ❑
I hereby affirm that 1 vm licensed under pmviairns of Chapmr 9(commencing JOB DESCRIPTION
{�{�mZ aifallforr]deffecDivision3ofthe Business and Professions Code,vndm license is
in y PERMIT ISSUANCE RESIDENTIAL:
full force and effect.
W� CSFDWL El KITCHEN REMODEL
License Class Lick
an W0. Date - Comracmr APPLIANCES-RESIDENTIAL []ADDITION [I PLUMBING RE-PIPE
ARCHITECTS DECLARATION PANELS
E, ❑MULTI-UNIT ❑STRUCTURAL. ,
ns shall be used ns MODIFICATION
public records -
O nI understand my plaz UP TO 2M AMPS
[I INTERIOR ❑CHIMNEY REPAIR
[-'"irk/ u) Licensed Professional - 201-IIIfN1AMPSPROVEMENT
OWNER-BUILDER DECLARATION OYER IOW AMPS ({MATH REMODEUREPAIR C DEMOLITION
1 hereby affirm that 1 am exempt from the Contractor's License Law for the P
3 6 U fdaso
luwing ren.(Section]031.5,Business and Professions Code:Any city......ty SIGNS ELECTRICAL C OTHER
which requires a permit to construct,alter,improve,demolish,or repair any structure
prior to its issuance,also requires the applicant for such permit to file o signed statement SPECIAL CIRCUIT/MISC.
'j that he ie Ilcensed pursuant m the provisions of the Cantreemr's License Lew(Chapter 9
Q� (commencing with SedionIDW)of Divisian3of the Businees and Professions Code)., TEMP.METER OR POLE INST. COMMERCIAL:
that he is exempt therefrom and the basis for the alleged exemption.Any violation of C NEW BLDG/ADDITION C DEMOLITION
M Section 7031.5 by any applicant for a permit subjects the applicant to a civil Penalty of POWER DEVICES [-]TENANT [I FOOD SERVICE
I,zy not more than live hundred dollos(SSW). IMPROVEMENT
Dl,as owner of the pmpeZ.,my employees with wages calmomle compensation, SWIMMING POOL ELECTRIC
will do lhewmk,..d 1ho slructure is not intended or offered mrsale(Sec.7044,Business C OTHER
3 m and Professions Code:The Contractors License Law does not apply to en owner of OUTLETS-SWITCHES-FIXTURES
p' property who builds 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 FE.
sale.If,however.the building or improvement is sold within one year ofcompletion,the Ps{V 0 FUR FUR AREA $/SQ.FT.
owner-builder will have the burden of proving that he did not build or improve for put-
posy of sale.).
I,as owner of the propsit,run exclusively contmcting with licensed contractors to TOTAL: ®� 0 _
onswm the project(Sec.]044,Business and Professions Code:)The Contractors Li- 1896
cense Lawdoes n.tapplymanownerefpmpedy whobuildsorimprovesthereon,and QTY, PLUMBING PERMIT PEE
who contracts for such projects with a contractions)licensed pursuant w the Contractor's
License Law. �koPERMIT ISSUANCEC11 Y OF (,Ur-rrII Ill()
❑1 am exam under Sec. B&P C for this reason
ALTER-DRAIN&VENT-WATER(EA)AV VALUATION/
Dote
woes ,P SATION DECLARATION '/71 ,BACK FLOW PROTECT.DEVICE a�S�
Iherebyaff underpenalmofperjuryorm fine following deck lions:
El I have and will maintain a Ceriticare of Consent to self-imine for Workers Compem DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPECONSTRUCf10N
'sation,as provided for by Section 37W of Ne Labor Code,for the performance of tare
Work far which This Permit is issued. FIXTURES-PER TRAP
C 1 have and will maintain Worker's Compensation Insurance,ns required by Section
3]00of[he Labor Cush,for the performance ofthe work for which this permit is issued GAS-EA.SYSTEM-1 INC.4 OUTLETS OCCGROUP APN
My Worker's Compensation Insurance carrier and Policy number are:
Carior. Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' -
COMPENSATION INSURANCE GREASErNDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FEES
section need not be completed if the permit is for one hundred dollars 1$1 W) GREASETRAP
or less.) PLANCHECK FEE
I,saythotintin Perany frmanecof the Nessus,subject
this do,Wigeba W,I'liallrpair SEWER-SANITARY-STORM EA.2W FT
not employ any person in any manner so as m become subject to Ne Workers'Compen- ENERGY HE
zZsation Laws of California.Date
O Applicant WATERHEATERW VEN ELECTR GRADING FEE
rw y NOTICE TO APPLICANT:If,after making this Cer ificme of Exemption,you should WATER SYSTENUTREATING
become subject to the Worker's Compensation provisions of the Labor Code,you most SOILS FEC
LW4 Iti forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
Q
CONSTRUCTION
LENDINGAGENCY NEW RESIDENTIAL PLMB. SQ.Pf. PAID
fJ Q hareby thi thin there iso ed(See 3097,Cit.agency for the perfommnce of .Date Recciptk
wL� the work for which this permit is Issued(Sec.3W],Civ.CJ ,
0 IIU�� Lenders Name TOTAL:
Lender's Address T
1
1 certify that 1 have read this application and state Nat the above information is BUILDING FEE
TUBI correct.I agree to comply with all city and county ordinances and Stam laws relating to QTT, MECHANICAL PERMIT FEE
U building construction,and hereby sidearm representatives ofthis city to enter upon the SEISMIC FEE
above-mentioned propery for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Capetian against ELECTRIC FEE
liabilities,judgments,casts and expenses whichmay in any way aerva. ainmsaid City ALTER OR ADD TO MECH.
in ansequence of the starting of this permit PLUMBING FEE C5 1
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO Hindu CPM)
SO RCE REGULATIONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER I Bppo CPM) CONSTRUCTIONTAX
'Sil,raditneof ApplicandOmamemr Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEB
HAZARDOUS MATERIALS DISCLOSURE
Will theapplicanmrforms building bccupamstore or handle hazardous material HEATING UNIT GO 100,00ad BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,unit the Health and Safely
Code,Section 25532(.)? HEATING UNIT(OVER 1010,000 BTU) ,
C Yes ❑No VENTILATION PAN(SINGLE REBID) PAID
Will the applicant or(.tore building occupant use equipment or devices which Date Receipt It
BOILER COMP OHP OR I W,OW BTU)
emit hazardous m
air nmminnnts as defined -
by the Bay Area Air Quality Management TOTAL:
Dealer?
❑Yes CNo BOILBR-COMP(OVP.R 100,000 BTU) -
I have read 0e hazard9m materials mquirements under Chapter 6.95 of the Cid- AIR CONDITIONER ISSUANCE DATE
forms Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.ET
building does not currently have a term,that it is my responsibility o notify the occupant
of the requirements which must he met prior to Issuance of a Certificate of Occupancy.
Owner or authorized agent Date TOTAL: ISSUED BY:
OFFICE