S 0664 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.ELECTRICALLL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECBANICAI. 0 6 6 4
BUILDING PROJECT IDENTIFICATION BUILDINGADDRESSN SUBMITTAL DATE
a s o � 1,u O- 0 AAL STOWNER'S NAME: �� OPF(ONF CONTRACI'O 'S AM �� ^L CND:
�r�� 3 'IC/ ROL#ARCHITECTIENGINEER: I,IC NO: ADDRESS:hCONTACT. PHONE: INFO
�� �� ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERM IT FEE
1 hereby affirm that I um licensed under provision of Chapter 9(commencing SOB DESCRIPTION _
DaZ with Section]BOB)of Division 3 ofthe Business and pndessionc Coda,and my license is R IF�DENTIAL:
¢100 ^ PERMIT ISSUANCE
CWF in full force and effem /� V ❑SFDWI. ❑KITCHEN REMODEL
aUU License Clea Liap— APPLIANCES-RESIDENTIAL ❑AUDITION EJ PLUMBING RF.-PIPE
P {ssii Date Contmetnr
rn F [:1 MULTI-UNIT ❑STRUCTURAL
F 7 i ARCHITECT'S DECLARATION PANELS
Z0,04 I understand my plans shall be used as pub(ie records MODIFICATION
- UP T0200AMPS
0 Z-Q 1 ❑INTERIOR El CHIMNEY REPAIR
Ir, :W Licensed Professional 201-IWBAMPS IMPROVEMENT CSWIMMING POOLS
Y � OWNER-BUILDER DECLARATION OVER["AMPS C BATH REMODEWWAIRDEMO ITI N
C I hereby affirm that 1 ton exempt from the Cornfmmr's License Law for the -k
O y U following reason.(Section 4031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL C OTHER
'31L F which requires a permit to construct,alter,improve,demolish,or repair any stmclum T�0 ^ e`n AS1--- ''
prior to its issuance,also requires the applicant for such permit to file a signed statement SPECIAL CIRCUIT/MISC b
F.
that he is licenced pursuant to the provisions of the Contractor's License Law(Chapter9}
aa1 �2 (commencing with Section]Onlp of Division 3of the Business and Professions Code)or TEMP.METER OR INST.- COMMERCIAL'
C m z that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION C DEMOLITION
y Section](131.5 by any applicant for a Permit subjects the applicant to a civil penalty of POWER DEVIC ❑TENANT El FOOD SERVICE
F Qnot more than five hundred dollars($500). IMPROVEMENT
❑I,as mancrolth,pmleoy,ormyemployeeswithwagesnthelrsolecentramdin, SWINISH OOL ELECTRIC
will Bathe wok,ra d the swctur,x nm intended or offered for sale(Sm.]044.Business OTHER
W and Professions Code:The Contractor's License Law docs not apply m an owner of OU S-SWITCHES-FIXTURES
�' .. property who builds or improves Thereon,and who does such work himself nr through
his own employees,provided that such improvements are not intended ar offered for W RESIDENTIAL ELECTR SQ FT
sale.IL however,the building., issold within one year ofeomrledonthe SQ.FT.FLOOR AREA $/SQ.PT.
owner-builder will have the burden of proving that he did not build or improve far pur-
7 1,a sm..),rte TOTAL'.
❑I,as owner of the property,.B aimpsovely contracting with licensed contractors m
cease La the project(Sea.]Bodo Business sod Professions Gdeq pro Canoudon,Li-
c ase Law does not apply to an owner of popery who builds or improves thereon,erJ QTY, PLUMBING PERMIT FEE
who iverseadsfor such pro)ecu'with vwmmctnr(s)licensed Pursuant mthe Computers AID
_
License low. PERMIT ISSUANCE . I�
❑1 em exempt under Sec. .B&P C for this reason
OwneDDate ^�'s `
ALTER-DRAIN&VENT-WAFER(EA) .VtlW tL
r D.IV41YtlB JL
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
S I hereby affon beca nderpenalry of perjory id ofthe elf-in me ing it'lootians:
ve tad will far by Section
CansanuoCodenfareforWmkeraceof he DRAINS-FLOOR,ROOF,AREA.GOND. ONSTRUCfION
71,hf.
�which
this
for mi Section 3]00 of the Labor Code,for the performance of theveand this permit ix issued. FIXTURES-PER TRAP
ve end will maintain Worker's anceo thew Insurance,ux hisrequired
rr by Section
the Lahm Coda for the perlommncc of the work for which this permit is issued GAS-EA.SYSTEM-I INC.40UTLETS OCGGROUPkc1! C�tget�0ystylnWraq.ryyTttepd,Policy ntaal�ETM�3130' GAS-EA.SYSTEM-OVER 4(EA)
GI VYl9 IJ —.rG F10 `'1 1_' J JCERTIFICATE OF EXEMPTION FROM WORKERS' GREAS[%INDUSTRL WASTE,INTERCEPTORCOMPENSATION INSURANCE BUILDING DIVI(This section neodnot be completed lfthepemtitisforonehundreddollars($IW) OREASE TRAP) PLANCHF,CK FEE
I certify Nat in the perfornanceofthe work forwhich this permit is issued,Ishall SEWER-SANITARY-STORM EA.200 FTploy any person in any manner so as to become subject to the Workers'Compen- ENERGY FEE
Z sation Laws of California.Date WATER HEATER WNENT/ELECTR
Q ( ' GRADING FEE
Applicant
Vj NOTICE TO APPLICANT:IL after making this Cenificam of Exemption,you should WATER SYSTERIMEATING -
I--t SOILS FEE
became subject to the Worker's Compensation provisions of the Labor Code,yen must
Wforthwith comply with such previsions or this Permit shall be deemed revoked.: WATER SERVICE -
Q
ppp❑...rr CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
.0 0 Ihueby efflrm the them lsaconstruction lending agency for the Per'onnenca of Date kewlpa#
rt the work for which this permit is issued(See.3097,Civ.C.)
Q U Lender's Name TOTAL:
Lender's Address TOTAL:
i BUILDING FEE
[.a 1 certify That 1 have read This application and site that the above information relating ix
'rail cored 1 agree c comely with all city and roomy ordinances and cmm laws relating e QTY, MECHANICAL PERMIT FEE
U �
building constmctinn,and hereby pmhorim represematives of this cirymenter upon the SEISMIC FEE
above-mentioned properly for inspection purposes. PERMIT ISSUANCE
(We)agree m save,indemnify trod keep harmless the City of Cupertino against 'ELECTRIC PRP.
liabilities,judgments,costs and expenses which may in my way rectum against said City AUTERORADDTOMECH.
inconsequence of the brining ofthis permit - - PLUMBING FEE
APL .ANT UNDERSTA S �WTLMMPIAITH ALL N-POINT AIR HANDLING UNIT(TO 10,IU0CFSO MECHANICAL HE
R. . 12 AIR HANDLING UNIT(OVER 10,1100 CFM) CONSTRUCTION TAX
Signature ol'Applmant/ antmctor Da EXHAUST HOOD(WMUCf) HOUSING MITIGATION FEE, x
HAZARDOUS MATERIALS DISCL SURE
Will the applicant or future building eccurant store or handle hazardous material HEATING UNIT(TO 100,000 BTU
as defined by the Corcoran Municipal Code,Unifier 9.12,and the Health and Safety
Code,Section 25532(a)7 HEATING UNIT(OVER I W I BTU) -
CYes ON. VENTILATION FAN( GLE RESID) PAI Date ecetpt# •
Will the applicant or future building occupant use equipment or devices which
emBOILER-COM HP OR 100,000 PTU)
it hamidefined hazardous air concomitants as ned by the Bay Area Air Quality ManagementTOTAL: /
District'
❑Yes FIN. BOILER' ME(OVER 100,00)BTU) '
-
I have read We limitations materials requirements under Chapter 6.95 of the Cali- AI NDITIONER ;IS /CEATE
fomin Health&Safety Code Sections 25505,25533 and 25534.1 understand that Hine NEW RESIDENTIAL MECH. SQ.Er.
building does not currently have a tenant that it is my responsibility to notify Ne occupant
of the rgnirement which must be met labor to issuance of a Certificate of Camoreancy.
Owner or authorized agent Date TOTAL: ISSUED BY:
OFFICE