S 0343 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CIEY OF CUPERTINO - - BUILDING.P;LECTRICAI, Pr.RMn'No.
BUILDING DIVISION APPLICATIONIPERMIT PING PRll:-NIED NTIFIC S 0343
NUILDINO PROJIiCT IDENTIFICATION
BUILDINGDDRESS: SAN[TA BY NO. APPLICATION SUBMI'IT'AL DAT
OWNER'S NAME: PHONE: CONTRAC'IUR'S NAMH: LIC NO:
( CONTSULp
ARCHITECT/ENGINEER: LIC NO. ADDRESS: ❑
CONTACT: PHONE BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MliCH
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE JO DESCRIPTION
1 hereby affirm Nat I am licensed under provision of Chapler 9(commencing
Q0Z with Saim.7OAy.fDivision Softhe Basinessand Professions CcxR,and mylicene is RESIDENTIAL
O
{{�s�p PERMIT ISSUANCE
FUF in full Triennial efloel.j 57�� ❑SPDWL ❑KITCHIiN RCMODIA.
�UU License Cias Lic.M ` APPLIANCES-RIiSIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
F 7{il Dale C S DECLARATION
E
❑MUTTFUNIT []STRUCTURAL
F O y ARCHITECT'S DECLARATION PANELS
MODIFICATION
O Z'-�N 4 1 understand my plans shall be used as public records UP TO 2W AMPS
❑INTERIOR ❑CHIMN17Y REPAIR
r a,iF0, Licensed Professional 2111-IIXXIAMI'S IMPROVEMENT OSWIMMING IDOLS
gild
OWNER-BUILDER DECLARATION OV BR IBES AMPS ❑BATII RF.MODELIREPAIR ❑DEMOLITION
W 6 1 hereby affirm that I an exempt from the Conlmnors License Law far the
aqS O c.U following reason.(Section 7031.5,Business and Professions Code:Any city or manly SIGNS ELECTRICAL OTHER
u+'31L F' which requires a Permit to construct,alter,improve,demolish,at repair any structure
prior to its issuance,also requires the applicant for such permit to rile a signed statement SPECIAL CIRCUIT/MISC.
} that be is licensed pursuant 3o be provisions ofthe Contractors License Law(Chapter 9 COMMERCIAL
Iv00 (commencing wiNSntion 700o)nfDivision Sof the Business and Pmfessions Code)or TEMP.METER OR POLE INST.
a q K that he is exempt therefrom and the basis for the alleged exemption.Any violation of C1 NEW BLDG/ADDITION ❑DEMOLITIONtIX1 1+.
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penally of POWER DEVICES []TENANT ❑FOOD SERVICE
=>>sc not more than five hundred dollars 15500). IMPROVEMHNT
�aG ❑I,as owner ofthe property,or my employees with wagesas their sole compensation. SWIMMING POOL ELRCTRIC
will do the work,and the suuctute is not intended or offered for sale(Sec.]044,Business ❑OTHER
� � end professions Cade:The Commerce,License Law does not apply,,an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements arc not intended or offered for NEW RESIDENTIAL ELECTS SQ FT.
sale.If,however the building or improvement is sold within one year ofcomplaim,the SQ.FT.FLOOR AREA SIgQ.PT.
owner-builder will have the burden of moving that he did not build or improve for par
pone of sale.). T.TIZ
❑1,as owner of the property,am exclusively contracting with licensed contractors to
summer the project(Sea 7044.Business and Pmfessions Code:) he Colnme.c.,'s l.l-
nseLawdoesnotapplytoanownerofpropenywhohuildsorimprovesthemon,and QTY. PLUMBING PERMIT
who contracts Por such projects with a conwmons)licensed pursuant to the Contractors
License law. PERMIT ISSUANCE 10,
❑1 an exempt under Sec. ,B&P C for this reason
ALTER-DRAIN&VENT-WATER IEA) VALUATION
/ Owner .Date Ow
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE /� B
I hereby aRum under penalty of perjury one ofthe following declarations:
- � I have and will maintain a Certificate of Consent to selbovate for Workers Compen- DRAINS-FLOOR,ROOF,AREA,GOND. � B :S TYPE CONS'18UCT10
smam.as provided far by Section 37M of the Labor Code,for the perfonance of the srh�
work for which this permit is issued. FIXTURES-PER TRAP q
❑I have and will maintain Workers Compensation Insurance,as required by Section
37(X1 ofthe labor Code,forthe performence of be work for which this permit is issued. GAS-EA.SYSTEM-1 INC.4 OUTLETS GROUP APN
My Workers Compsnsatiogl sumnce�emer and Policy number arc: IrV�`
Camee 1T.ti /G�.u/7 P "3PIU1f-1G GAS 4(GA)
Policy Nn:
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASFIINUUSTRL WASTE INTERCEPTOR V
COMPENSATION INSURANCE BUILDING DIVISION FEES
(ThissaIinn rear,hecompleted ifthepermit is borrow hundreddollars P$10) GRFASETRAP
rr less.) PLANCHF.CK IEE
I certify that in be performance ofthe work for which this permit is issued,I shall SEWER-SANITARY-STORM EA.200 FI'.
not employ any person in any manner so as to become subject m the Workeri Compete ENERGY FEE
snfirm laws of California.Date WATER HEATER SINtiffiLRCTR
GRADING PEE
Z Applicant t
N NOTICE TO APPLICANT:IL after making this Cenificate of Exemption,you should WATER SYSTEM/TREATING
become subject to Nrk
Him Waees Compensation provisions of the Labor Code,you must SOILS PEE
Lail forthwith comply with such previsions or Nis permit shall be deemed revoked WATER SERVICE
0
7 z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLATE. SQ.FT. PAID Date Receipt 1
U 0 Iher whichnnthallhere isoco(sce.3nlendiurgency for the performance of
the woh for which this pcnnit is issued(Sn.3D9),Co..CJ
Lenders Name TOTAL:
WW1
TOTAL:
Lenders Address
I certify that 1 have read this application and state that the above Infrnnmion is BUILDING FEE
i..saA correct.)agae to comply with all city and county ordinances and suite laws calming ,, QTY. MECHANICAL PERMIT FEE
U Z building construction.and hthu rivesob
ereby auodmiscmathis city m pe
enter on the SIi15MIC PFiF;
above-mentioned propeny for inspection purposes. PERMIT ISSUANCE ELECTRIC IEC
(We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilifies,judgments,costs and expenses which may in any way Name against said City ALTER OR ADD TO MECH. PLUMBING FEE
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT GO III."CPM) MECHANICAL FEE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCTION TAX
Signature of Applicant/Contmcmr ateJ EXHAUST HOOD(WMUCD HOUSING MITIGATION FRE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle haeardous material HEATING UNIT(TO 100,000 BTU)
m defined by the Cupcnino Municipal Code,Chapter 9.12,and be Health and Safety
Code.Section 25532(07 HEATING UNIT(OVER 100.000 BTU)
El Yes ❑No VENTILATION FAN(SINGLE RESID) PAID
Date Receipt
Will the applicant car future building occupant um equipment or devices which BOILER-COMP OHP OR 100.000 BTU)
mil hazardous air contaminants as defined by be Bay Area Air Quality Management TOTAL:
District, BOILER-COME(OVER 1011,0011 BTU)
❑Yes ON.
I have read the hvardous mmerad, equire un
ts der Chapin 6.95 of Ne Cali- AIR CONDITIONER ISSUANCE DATE:
fomiaHealth gdoes&Safery Cadaea raso 25505,is25533
myend25531.1 understand rutifthe NEW RESIDENTIAL MECH. SQ.FT.
building does not currency have b,ran
that o is ua responsibility o notify the eccapam
of be rryuirements which most be son pdor,o issuance of a Certificate of Qculwncy.
Owner or auNoriud agent Date TOTALISSUED By.
OFFICE