S 0756 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PtOITNO.
BUILDING DIVISION APPLICATION/PERMIT, - PLUMBING-MECHANICAL J 0756
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMI'CI'AL HATE
QrooK .ra- C.w vp /1 .
OWNER'SNAME: P�P�E CO CTOR'S NA ICN
t` lJ.. '37 NEC CONTROL#
IN AR TECf/ENGINEER: _ LIC NO: - ppCO 4� �� �� .,� ❑ `y��(�'
CONTACT PHONE: �L `/f_/ ll��� BUILDIDNC PERJMIT INFO
I `—„ ❑ Consultant Fecs Paid by Applicant(Initial) BUIG ELECT PLUMB MECH
S�(OA"�' � V Pa, ❑
LICENSED CONTRACTOR'S DECLARATIOryQT'Y ELECTRIC PERMIT FEEL
1 hereby affirm that 1 am licensed under provisions of Chapter 9 mommenci.s JOB DESCRIPTION /'
WpZ with Section 9(100)of Division 3 ofthe Business and Professions Code.and my license i'x - RESIDENTIAL' C3'IC(/
F U L full force and eRect PERMIT ISSUANCE SFDWL TCHEN REMODEL
�Vz License Class Lie.M APPLIANCES-RESIDENTIAL
yQ Dam C.mmct ❑ADDITION ❑PLUMBING RE-PIPE
'z CSSSS> AR EFFECT'S DEC R TION Ll MULTI-UNIT [I STRUCTURAL
N C 1 understand my plans shall be used as public records PANELS MODIFICATION
O z UP TO 2MAMPS
,4l`" Licensed PromWeard _ [I INTERIOR 11 CHIMNEY REPAIR
aV 201-1000AMPS IMPR VEMENT SWIMMING POOLS
W OWNER-BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contrasonfa Licence Law for the OVER 10(X1 AMPS REMODEVREPAIR DEMOLITION
O y V m1l.ing reason.(Section 703[,5.Business and Professions Code Any city or county SIGNS ELECTRICAL ❑OTHER
a k.E"
O which requires a permit to construct,alcor,improve,demolish,or repair any structure
Sprior to its issuance,also the applicant for such s+y requires pp petorss License
Law
SPECIAL CIRCUITIMISC.
5�. y that bels licensed pursuamrothe provisions of the Contmetor's License Law(Chopmr9
w G� (commencing with Section 7")of Division 3 ofthe Business and Pmfiasirm,Cwie)or TEMP.METER OR POLE INST. COMMERCIAL'
a a that he is exempt therefrom and the basis for the alleged exemption.Any violation of NEW BLDGIADDITION El DEMOLITION
W
Section 7031.5 by any applicant for a Permit subjects the applicant a civil penalty of POWER DEVICES
i+ not more than five hundred dollars($500). 1 ANT ❑FOOD SERVICE.
O (]
has owner of the property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC I OV
will do the work,and the monotone is not intanded or°ffered fors.le(SecJ044,Business 0 0TH
S and Professions Cade:The Contractors License Law does not apply m an owner of OUTI.E'rs-SWITCHES-FIXTURES
property who builds or improves thenen°,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.ILhowever,the building(it improvement is sold within one year of completion.the A SQ.FT.
owner-builder will have the harden of proving that he did not build or improve for per. �-.
°a°°`'°'`' DEC 171997
El 1,as owner of the property,am exclusively contracting with licensed cammd°n to TOTAL:
construct theprojee,(Sec 9044,Business and Professions Codc)Tom Contractor's I.,
c nve Law does not apply to an owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT FEE tjV�
who contracts f.rsueh projects with a cootracmr(s)licensed personator the Contractor's 171
License Law. PERMIT ISSUANCE.
I am exempt under Sec. ,B&P C 1'nr this reason
Owner Dam ALTER,-DRAIN&VENT-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE /�
I hereby affirm under Penalty of perjury one of the following declarations: - 60
E-1I have and will maintain a Certificate of Consen[[°self-insure for Worker ////JJJJ's Compen- DRAINS-FLOOR,ROOF,AREA,COND. .TORIES TYPE CONSTRUCTION
sation,as provided for by Section 37X0 of the Labor Code,for the Performance of the
w k for which this permit is issued. FIXTURES-PER TRAP -
I have and will maintain Worker's Compensation Insurance,ax required by Sechim
300 of the Labor Code,for the performonce mine work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP "ANN
My Wor ns tion Insurance carmen and Policy
Cnmier: ���Policy N°.: /�/ GAS-EA.SVSTEA1-0VES4(BA)
ER JCATE F EXEMPTION FROM—W R ERS'
COMPENSATION INSURANCE GREASFIINUUSTRL WASTE INTERCEPTOR
(This section need notM completed if the permit Is furore hundred dollars($11g)) BUILDING DIVISION FEES
unless) GREASE TRAP PLANCHECK FEE
I certify that in the Performance ofthe work for which this Permit is issued,I shall SEWER-SANITARY-STORM EA. FT.
not employ any person in any manner s°as to become subject to the Workers'Compare- .
n- ENERGY FEE
z an..Laws of Cnllfornid Data
O Applicant 1 WATER HEATER WNENT/ELEcTR GRADING FEN
y NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEM,TREp'rING
abecome subjecr to the Workers Compensation provisions of the Labor Code,you must SOILS FEE
{T-I forthwith comply with such provisions or this permit shall be deemed revoked. , WATER SERVICE
Q
r0 CONSTRUCTION LENDINGng ENCYagency NEW RESIDENTIAL PCMB. SQ.FT. PAID
L)Q l for
reby which ran Nnuhereissued(See.307..ding agency for performance of Date. H
W
the work for which this permit is issued(See.3097.Civ.CJ
Under,Name 'TOTAL:
o Lenders Address TOTA
FP-^' 1 certify that 1 have read this application and state that the above information is BUILDING FEE
Ta7d correct.I agree to comply with all city and county ordinances and state laws relating to QTY, MECHANICAL PERMIT FEE
V G building construction,and hereby authorize representatives ofthis city to enter upon the SEISMIC FEE
aMve-mentioned property fur inspection purposes. PERMIT ISSUANCE
(We)agree to save.Indemnify and keep harmless the City of Cupertino against ELECTRIC FEE I
Iiabilities,judgments,costs and expenses which may in any way accme against said City ALTER OR ADD TO MECH.
in consequence of the granting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.fMN1 CFM)
SOURCE REG41'
L TIONS. � MECHANICAL FEE
vf�}� �--L/ w 1214h:7�� AIR HANDLING UNIT 111,(X10 CFM)
1 („� r_� 1 CONSTRUCTION TAX
Sign n1 IApplic ot/Cmicacmr f— F • t s� EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCL SURE
Will the applicant or future building occupant store or handle hazardous material HEATING ON['1'(TO 100.0idl BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Coca Section 25532m)P HEATING UNIT(OVER 100,000 BTU)
L]Yea 0NVENTILATION FAN(SINGLE RESID) PAID
Will the applicant or future building occupant use equipment or devices which Date Re.eiptit
emit hazardous air contaminants as headed by the Bay Area Air Quality Management BOILER-COMP(3HP OR 100,000,BTU)
DistricO 'TOTAL:
❑Yes No BOILER-COME(OVER 100,000 BTU)
1 have read the hamrdous materials requirements under Cha ter 6.95 of the Cali- AIR CONDITIONER
P ISSUANCE DATE
forma Healg does&Safety Code,Sections 25505,25533 and 255]4.1 i understand that if the NEW RNSIDENTIAL MECH. SQ.fT. �-I �
building m how not currently have mete tont o is ua responsibility to notify the pony. f
of the mquirememe which must be met prior to issuance of a Cmificme of Occupancy.
Owner or anthout ed agent Date TOTAL:
ISSUED BY:-
OFFICE