99080219APPLIE$NTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY C4 610 S0rY /G
CITY OF CUPERTINO BUILDING - ELECTRICAL
HUILDING DIVISION APPLICATION/PERMIT PLUMBING -MECHANICAL
BUILDING PROJECT IDENTIFICATION,
PERMIT NO.
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SANITARY NO.
APPLICATIONS�'ITTAL DATE
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❑ Consultant Feed; Paid by Applicant (Initial)
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm mat 1 am licensed under pmvlsloev of Chapter 9 (eomtnenoldg
with Section7000)of Division3nf the Business and Professions Crode, and mylicense is
n full force and etfec J 7
j License Class Lic.#
1 Data Commcow
j ARCHITECTSDF.CLARATION
I understand my plans shill be used as public records
1
QTY ELECTRIC PERMIT FEE
JOB DESCRIPTION
RESIDENTIAL,
C SFDWL D KITCHEN REMODEL
CADDITION El PLUMBING RE -PIPE
OMULTI-UNIT OSTRUCTURAL
MODIFICATION
ElINTERIOR CCHIMNEY REPAIR
IMPROVEMENT
ODEMOLSWIMMING POOLS
❑BATH REMODEL/REPAIR El DEMOLITION
OTHER
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL -
PANELS
UP TO 200 AMPS
4censed Professional -
OWNER-BUILDERDECLARATIONthe Commences
I hereby aBinn that 1 am exempt from the Contmaors Licence Law for the
I following reason (Section 9031.5, Business and Professions Code: Any city or county
which requires a Permit to Construct, alter, improve, demolish, or repair any structuret
prior to its issuance, also requires me applicant for such Permit to file a signed statement
that he is licensed pursuant to the provisions ofine Committees License Use (Chapter 9
(commencing with Sermon 7") of Division 3 ofthe Business and Professions Code) nr
I that he is exedtpt therefrom and the basis for the alleged exemption. Any violation of
Section 7031S by any applicant for a permit subjects the applicant to a civil Penalty of
not more than five hundred dollars ($500).
C1, as owner of mepmpery. ormy employees wish wages es their sole compensation,
will do the work, and the structure is not intended oreffered for sale (Sec. 9044, Business
and Professions Code: The Commcmrs License Law does not ePP1Y to an owner of
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
sale. If, however the building nr improvement it sold within one yearofcompletion,the
towner-bafifider will have the burden of proving that he did not build or improve for par.
Pave of sale.).
❑ 1, as owner of the property, am exclusively connecting with licensed contractors to
consumer the project (Sec. 7044. Business and Professions Code:) The Contractor's Li-
cense Law does not apply to an owner of property who builds or improves thereon, and
who contracts for such projects with a contractors) licensed pursuant to the Contractor's
LicenseLaw.
El 1 am exempt under Sec , B & P C for IN, used
201-1 AMPS
OVER 1000 AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC.
,
TEMP. METER OR POLE INST.
COMMERCIAL'
D NEW BLDG/ADDITION D DEMOLITION
CTENANT CFOOD SERVICE
IMPROVEMENT
COT
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS -SWITCHES -FIXTURES
NEW RESIDENTIAL- ELECTR SQ ET.
SQ. FT FLOOR AREA
-
$/SQ. PT.
TOTAL:
QTY, PLUMBING PERMIT FEE
PERMIT ISSUANCE
ALTER -DRAIN & VENT- WATER (EA)
Owner Date
VALUATION
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a Certificate of Consent to self- insure for Worker's Cooper-
action, as provided for by Section 37M of the Labor Cade, for the performance of the
is rk for which this permit is issued.
I have and will maintain Worker's Compensation Insurance, us required by Section
ofthe Labor Cale, for the performance ofthe work for which this permit is issued.
My Worker's pen lion In m�eec r'terand Policy ntyrlberpre�No,� 7p_
-lSi to A
Carie: PION FROM
CF,RTIFICCO OF TION INSURANCE
(•Ihis secdon need not be Completed ifthepermit is for due hundred dollars(8100)
or less)
Ioyanythatpersnthe ns issued,
not employ any person in any manner so as to become subject m the Woheri Co.,.-Compen-
anymannerofthe wmkfm which this the Worker,'
sutinn Laws of California Data
Applicant
BACK FLOW PROTECT. DEVICE
DRAINS- FLOOR, ROOF, AREA, COED.
STORIES
PCC. GROUP
TYPE CONSTRUCTION
APN
301IDYq
FIXTURES - PER TRAP
GAS - EA. SYSTEM -1 INC. 4 OUTLETS
GAS - EA. SYSTEM -OVER 4(EA)
GREASFJINDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
GREASETRAP
pLANCHECK FEP-
SEWER - SANITARY - STORM G. 200 FT.
ENERGY FEE
WATER HEATER WNENT/HLECTR
GRADING FEE
NOTICE TO APPLICANT. If, after making this Certificate of Exemption, you should
become subject to the Workers Compensation previsions of the Labor Code, you must
forthwith comply with such previsions or this permit shall b, deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm thin them is x construction lending agency frame performance of
the work for which this permit is issued (See. 3097. Civ. C)
Lender's Name
WATER SYSTEMITREATING
-
SOILS FEE
WATER SERVICE
PAID
Date Receipt#
NEW RESIDENTIAL PLMIU SQ. FT
TOTAL
Lender's Address
1 certify that 1 have read this application and sora that the above information is
erect. I agree a comply with all city and county ordinancessof and state laws relining e
building conswetiro and hereby auction p representatives of ibis city to enter upon the
above-mentioned property for inspection purposes.
(We) agreo to save, indemnify and keep harmless me City of Cupertino against
Ii abilities, judgments, costs and expenses which may in any way acerae against said City
in consequence of the gmming of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGU�IyygTIO�NS. r C
V xhi (S
TOTAL:
BUILDING FEE
QTY. MECHANICAL PERMIT FEE
SEISMIC FEE
7k sit
ELECTRIC HE
PERMIT ISSUANCE
ALTER ORADD TO MECH.
PLUMBING FEE
AIR HANDLING UNIT (TO IO,IX10 CFM)
MECHANICALFEE
AIR HANDLING UNIT (OVER IMOW CFM)
CONSTRUCTION
Signature of APPlicaRData
HAZARDODO US MATERIALS DISCLOSURE
HAZARDOUS
Willy the Capam or Pomm buildingde, Chapter
tsmre or andthe Health us andSafematerial
as defined io the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Sermon 25532(x)?
❑yes CNo
Will thea lie o, or future building pan cimpmen
pp g occu fusee tar devices which
mil hazardous air contaminame rte tlefined by the Bay Area Air Quality Managemem
District?
EJ Yes 7 N
I have read the hazardous materials p
requirements under Chapter of
Health & Safety Cale, Sections 25505, is 11 and 25534.1 understand that if the
building does not cuwhich have a tenant that n is my responsibility m notify the arm
/Tr
of u�st ba met priormissuenee o[a Ce��of O�n�
EXHAUST HOOD (W/DUC13
HOUSING MITIGATION FEE
HEATING UNIT TO 100,030 BTU)
HEATING UNIT (OVER 100,000 BTU)
PAID
Dare Receipt #
VENTILATION PAN (SINGLE RESID)
OR UXT" BTU BOILER -COMP 3HP
( )
TOTAL:
BOILER -COMP (OVER 100.000BTU)
AIR CONDITIONER
- ISSUANCE DATE
ISSUED BY:
NEW RESIDENTIAL SUCH. SQ. FT.
W, aumorzed agent ate
TOTAL:
OFFICE