S 1032 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL - PETT No
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL. 1032
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: /�� - SANITARY NO. APPLICATION SUBMITTAL DATE
/06&91 I�nntj 1`7
O jR;'S AME�,
�r PHONE: CO RACfOR'S NA�': LIC NO:
s -5-4 V/') -rf,.Jr N/C CONTROL#
ARCHITFAT/ENGINER: LIC NO: I]DRE _T❑
CONTAct: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ Q— ❑
LICENSED CONTRACTOR'S DECLARATION QT, ELECTRIC PERMIT FEE
1 hereby affirm that 1 am f be Bd ander provisions of Chapter 9(commencing JOB DESCRIPTION
FQWZ with Section 7")of DivisionJonhe Businessand ProfessionaCMe,and mylicenu is RESIDENTIAL
UO Licene full rce Class
eRecr. PERMIT ISSUANCE ❑SFDWL ❑KITCHEN REMODEL
Q U V License Class Lin X
Dace Contrncmr APPLIANCES-NF.SIDENTIAL '(]ADDITION GRE-PIPE
p,prn ARCHITECTS DECLARATION ❑MULTI-UNIT STRUCfURAI,
OP37�-'Z 1 understand my plans shall he used m blic records PANELS
:1 Pn MODIFICATION
UP TO 200 AMPS
4 E'W Licensed Profeswonal - El INTERIOR ❑CHIMNEY REPAIR
`� OWNER-BUILDER DECLARATION 201-1000AMPS IMPROVEMENT SWIMMING POOLS
ay' , OVER 1000 AMPS ❑BATH REMODEUREPAIR El DEMOLITION
^' W Q 1 hereby affirm that I am exempt from the Cessions o License Law for the
O y U following reason.(genion]B)L5,Business and Professions Code:Any citynr county ❑OTHER
F L,O F which re a rmit to concoct,alter,int SIGNS ELECTRICAL
quires pe prove,demolish, file
repair any structure
prior toits issuance,also requires the applicant for such permit fileasigned smmmrnt SPECIAL CIRCUIT/MISC.
y that he is licensed pursuant to the provisions of fie Contractor's License Law(ChaPmr9
d� (emmnencing with Section 70M)of Division 3 of the Business and Professions Gule)or
TEMP.METER OR POLE INST.
Q.p,o y that Section
is exempt therefrom and the Noesis for the alleged exemption.Any violation of W RLDG/ADDITION ❑DEMOLITION
tizll {yZ
not
five
any hundred
dollars($50nt for a 0)
subjects the applicant to acivil penalty of POWER DEVICES T ❑FOODSERVICE
y t main than f ft h Prope dollars yempl IMP M T
TD �Lo the owner work,
kRnd Property.or myemployees With offimm for sale
sole compensiiess SWIMMING POOL ELECTRIC
[3E andwildothewons node The Cont is not s License Law does of apply to an Business TH
iZ and Professions Cade:The Comment's License Lew does not apply asif owner of OUTLETS-SWITCHES-FIXTURES
.. his..a whoi,ces,m improves thereon,and who does such tints himself or through
his own employeese provided that such improvements ere not intended.,offered for NEW RESIDENTIAL ELECTR SQ FT.
owner-however,Neveth hunen improvement isat hedid non build or improve
the SQ. .F RAREA $/SQ.FT.
owner-builder Iter will have the burden of proving that he did not buil)or improve for par- PAID proo of sale). r N
❑ 1,as owner of the Property,but exclusively contacting with licensed comrncmrs m TOTAL:
construct the project(Sec.7044,Business and Professions Cos&)The Contractor's Li-
cause Law does not apply to an owner of property who builds or improves thereon,and
i-censeLawduesnotapplytoanownerofpropertywhobuildsorimprovesthereon,and QTY. PLUMBING PERMIT FEE CT 15_ REGI®
who contracts for such projects with a contrampursuant n Contractor's ons)licensed t the C
License Law. PERMIT ISSUANCE CI �. tat
El am exempt under Sec. ,B&P C for this reason �UrtH))
No
ALTER-DRAIN&VENT-WATER(EA)
Owner Dam VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby iffrtn under penalty of perjury one or the following declarations:
❑ I have and will maintain a Cenificme of Consent to self-insure for Workers Compet. DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
Nation,as provided for by Section 37W of the Labor Cade,for the performance of the /�
Work for which this permit is issued. n7 FIXTURES-PER TRAP
❑I have and will maintain Worker's Compensation Insurance,as required by Section
37W of the Labor Coale,for the Performance of the work for which this permutes issued. GAS-EA.SYSTEM.I INC.4 OUTLETS
My Wor Come satin OCC.GROUP APN
caierand Policyn �A,�{p�
Cartier: iz aicy Na:I' ° gGo� GAS—EA.SYSTEM-OVER 4(EA) '
CERTIFI EOF EXEA ION FROM WORKERS'
COMPENSATION INSURANCE GREASFFANDUSTRLWASTE INTERCEPTOR -
BUILUING
Max section need but he completed ifthe pemtiLLs for one hundred dollars I$Iraq) GREASE TRAP
DIVISION FEES
or In,,.) PLANCHECK FEE
(certify that inthe Performaany
nce rof the work for which this thepermitWorker,
Cookwoll SEWER-SANITARY-STORM EA,2(0 FT
not employ any parson in any manner so as n become subject lathe Workers Compen- ENERGY PEE
Z Nation Lawx of California.Date
O O Applicant I WATER HEATER WNF.NT/[iLECTR GRADING FEE
If) NOTICE TO APPLICANT:If,after making Nix Certificate of Exemption,you should WATER SYSTEMOEEATING
Fx became subject to the Worker's Compensation provisions of the Lahr Code,you must SOILS FEE
W forthwith comply with such provisions or this Permit shall he deemed revoked. WATER SERVICE
Q
Pr
�
CONSTRUCTION LENDING AGENCY z NEW RESIDENTIAL PLMB. SQ.PT - PAID
V l for
reby which rmNorthemmiti issued( ec.30lending agency for the performance of Date ReceipON
IL tti the work for which this permit is issued(Sec.309].Cu,CJ
O U Lenders Name TOTAL:
W Lenders Address TOTAL:
1 certify that 1 have read this application and state that the above information is BUILDING FEE
L41 correct.l agree to comply with all city and county ordinances and state laws minting to QTY. MECHANICAL PERMIT FEE
V 7 building construction,and hereby authorize representatives of this city toenter upon the SEISMIC FEE
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEC
liabllities,judgments,costs and expenses which may in any way accrue against said City ANTER OR ADD TO MECH.
in consequence of the granting of this Permit. PLUMBING FEE
APPLICANT UNDERSTAND AND WIAIR HANDLING UNIT 10
COMPLY WITH ALL NON-POINT ,(X0 CFM)
SOURCE REGULA IS. ///IJ/� MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,"CFM) CONSTRUCTION TAX
Signature ..no mmc r L Date EXHAUST HOOD(W/DUCT)
H ARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Will the applicant or future building occupant smrc or handle hazardous material HEATING UNIT DO I00,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cade,Section 25532m)) HEATING UNIT(OVER I(NDYN)BTI)
F]Yes ❑No
VENTILATION FAN(SINGLE RESID) PAID -- i
Will the applicant or future building occupant use equipment or devices which Date Receipt k
01 emit hazardous air contaminants as defined by the Day Area Air Quality Management BOILER-COMP(311POR I(0,000BTU)
Ld�x
TOTAL:
s Fl No BOILER-COMP(OVER WOOS)BTU)
rend the hazardous materials rc virements under Chapter 6.95 of the Call- AIR CONDITIONER
q P ISSUANCE DATE
&Safety Code,e a Sections 25505,25533 and 25534.I to notify
that if the NEW RESIDENTIAL MECH. SQ,CE I'n
nale nently haveatenant,Nat it is my respnsiM1ilityronoufy the nccupam ments whichmuxt be met prior n issuance of a Certift of occupancy. lkc
horized agent Dam TOTAL: ISSUED BY:
OFFICE