S 44620'
Oz
z2
�o
VO_
OF
Fa
UZ
APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL.
BUILDING PROJECT IDENTIFICATION
PERMH'NO.
S4462
BUILDING AUURESS:
SANITARY NO.
APPLICATION SUBMITTAL DATE
OVNER'S NAME C cap IPHONE: �
J'NI
CQXIRACTORJ l"140 rT: S '/PINS 1 37�/
ate^
���T/V� I�,r�
NIC
❑
CONTROL
ARCHflU T/EN'GINEER: LIC NO:
A(I�)RI�J
-/
�o C�e -I b
CONTACT: PHONE:
❑ Consultant Pres Paid by Applicant (Initial)
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
❑ 1 ❑
LICENSED CONTRACTORS DECLARATION
I hereby Mo. Out 1 am licensed under provisions of Chapter 9 (commencing
wimseatiun]IntpnfDviuion3ufthe Business.ad Nefecs,i c emylicenu is
infullforceandelLl46 % 3�}O an
License Class Li, p
QTY. ELECTRIC PERMIT FEE
JOB DESCRIPTION
RESIDENTIAL:
C1SFDWL ❑KITCHEN REMODEL
❑ADDITION ❑PLUMBING RE -PIPE
❑MULTI -UNIT []STRUCTURAL
MODIFICATION
El INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT []SWIMMING POOLS
❑ BATH REMODRUREPAIR ❑DEMOLITION
OTHER
PERMIT ISSUANCE
APPLIANCES -RESIDENTIAL
Dem ` }�--ntrastar
/ rgRCHITELTS DECLARATION
1 understand my plans shall be used as public recuNs
PANELS
UPM 200AMPS
Licensed Professional
OWNER-BUILDERDECLARATIONtheCom ate
1 hcmby affirm ohm I am exempt from the Commuter's License Law for the
following mason. (Section 7031.5, Business and Professions Code: Any city or county❑
which requires a permit to construct, alter, improve, demolish, or repair any structure
prior t0 its issuance, also requires me applicant for such lemmino file a signed statement
that he is licensed purmant to the provisions of the Contractors License Law (Chapter 9
(commencing with Section 7")of Division 3 of the Business and Protessimns Colo)or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 1031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars ($500).
❑ I, as owner ofthe property, or my employees with wages as their sole compensation,
will do the work, and the structure is not intended oroffer d for sale (Sea. 1044, Business
and Professions Code. The Contractor's License Law does not apply 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 An, not intended or offered for
sale. If, however the building or improvement is wild within one year ofcompletion.the
cornmetwildet will have the burden of proving that he did not build in improve for pur-
pme of sole.).
❑ 1, as owner of the property, am exclusively contracting with licensed contractors toTOTAL:
constructthe project (Sec. 1614, Business and Professions CW W The Contractors Li-
nse Law eras not apply to an owner of property who builds or improves thereon, and
contracts for such projects with a contractor(s) licensed pursuant to the Contractors
License Low.
I am exempt under Sec. ,B& P C for this reason
201-i"AMPS
OVER I" AMPS
SIGNS ELECTRICAL
PECIAL CIRCUIT/MISC.
TEMP METER OR POLE INST.
❑ NEW BLDG/ADDITION ❑ DEMOLITION
[I TENANT ❑ FOOD SERVICE
IMPROVEMENT
❑ OTHER
POWER DEVICES
SWIMMING POOL ELEMRIC
OUTLETS - SWITCHES - FIXTURES
NEW RESIDENTIAL ELEC E SQ FT.
SQ. FL FLOOR AREA
S/SQ. FT.
QTY PI, INF IT FEE
PERMIT ISSUAC
ALTER - DRAIN&Vii W (E s-rQ—Tfimff
kis
Owner Dam
WORKER'S COMPENSATION DECLARATIONBACK
1 hereby arm under penalty of perjury one of the following declarations:
I have and will maintain a Certificate of Comento self -insure lin Workers Compen-
soldier. as provided for by Scalia. 3]00 of the Ube, Code, for the performance of the
work for which this permit is issued.
1 have sad will maintain Workers Compensation Imuanec...... ired by Section
l] l of the Labor Axle, for the perfommnce ofthe work fm which this permit is issued.
My M'mr -c)ra t sauonl ce carieroli Policy Nnl�rarV�f�l4�%
Carrier/A Policy No.:
CERTIFICATE FEXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This action need not W completed if the permit is for one hundred dollars is UID)
less.)GREASETRAP
I certify that in the performance of the work for which this permit is issued, l shall
not employ any person in any manner see as to #come subject m the Workers' Cnmpen-
,.tion Laws of California. Data
Applicant
FLOW PROTECT. DEVIC
DRAINS- FLOOR, ROORAREA, CO
1 RIES
1a�99
9
TYPE CONSTRUCTION
FI%TURES - PER TRAP JUL
GAS-EA.SYSTEM-1 INC. 4 OUTLETS
OCC. GROUP �'
APN
GAS -G.SYSTF:M-OVER4(EA) y
GREASE/INDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
PLANCHECK FEE
SEWER -SANITARY -STORM EA. 200 FT.
ENERGY FEE
WATER HEATER WNEN'TIIiLECTR
GRADING FEE
NOTICE TO APPLICANT: IL after making this Certificate of Exemption, you should
become mbjat to the Worker's Compensation provisions of the Luber Coat, you most
forthwith comply with such provisions or this permit shall W deemed revoked.
CONSTRUCTION LENDING AGENCY
I herthyafftm mm there isaconswnion lending agcncY for the performance of
the work for which this permit is issued (Sec. 3097, Civ. CJ
U.dcrs Nome
WATER SYSTEM/ REA'1'ING
WATER SERVICE
SOILS FEE
PAID
Date Receipt#
NEW RESIDENTIAL PLMB. SQ. PC
TOTAL:
finders Address
TOTAL:
BUILDING FEE
1 certify that 1 lime read this application and slum that me oWs, infommtion is
correct, l agree to comply with all city and county ordinances unit state laws relating to
building construction, and hereby authorize repraentatism of this city to enter upon the
above-mentioneda
property for inspection purpr s.
(We) agree m p
save, indemnify and keep harmless the City of Cupertino against
liubilities,)udgmenu, costs and expenses which may in any way weroc against said City
mseyuencetftue 6raming mf thins perm..
APPLICANT UNDERSTA D D COk LTH ALL NON-PoINT
SOURCES 1
/ ]Date
QTY. MECHANICAL PERMIT FEE
SEISMIC FEE
PERMIT ISSUANCE .7
♦y
ELECTRIC FEE ^ate V
PLUMBING FEE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT (TO 10,000 CFM)
MECHANICAL FEE
AIR HANDLING UNIT (OVER I0,000 CFM)
CONSTRUCTION TAX
Signature of Applicant/Contmctor
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, teed the Health it Safety
CrWe, Section 2553200?
❑Yes F1 No
Will thea applicant or future Wilding occupant use t or devices which
pp g e e. Air n
Dist hazardous air contaminants m defined by me Ray Aree Air Quality Management
Dmmnnl
❑Yes FIN.BOILER
1 have read the hazardous materials m9uircmesns under Chapter 6.95 of the Cali-
Cantu IIDu10h & Safety Coda. Sections 25505, 25533 and 25534. 1 understand that if the
building does not curremly have a tenant, ohm it only gm
y ressibility m notify the o¢uprot
of the requirements which must W met foot issuance a1a Certificate of Occupancy.
EXHAUST HOOD(WMUCT)
HOUSING MITIGATION FEE
HEATING UNIT (TO I W.000 BTU) 0
HEATING UNIT (OVER 100,000 BTU)
PAID' -
Date' Raeipt #
VENTILATION FAN (SINGLE RESID)
BOILER- COMP(3HP OR 100000 BTU)
TOTAL:
- COMP (OVER 100,000 BTU)
O
AIR CONDITIONER /
ISSUANCE DATE
ISSUED BY:
NEW RESIDENT IAL MECH. SQ. FT.
Ownersnamlimmed a gent Date
TOTAL: ♦
OFFICE