B 0168 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMI .�0168
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 50001
F77777BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
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ARCHITECTMNGINEER: LIC NO: ADDRESS r {V\1{,X'11 V ❑
Z A AST , FALZALro
CONTACTT.:.� PHONE: BUILDING PERMIT INFO
o I '7 -1200 ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑ ly
LICENSED CONTRACTOR'S DECLARATION QTY, ELECTRIC PERMIT FEE
I hereby affirm that I.n licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
I�0OCy with Section 710X)of Division 3 ofthe Business and Professions Code,and my license is RESIDENTIAL,
0 can PERMIT ISSUANC2
0,C-5 Ltell fnree ands 1. ❑SFDWL ❑KITCHEN REMODEL
aUU Licen r�Cls Lic.# ob LG APPLIANCES—RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE
N4 Date Contract
ARCHITECTS DECLARATION PANELS EI MULTI-UNIT ❑STRUCTURAL
O Z 1 understand ary plans shell be used as public records
MODIFICATION
UP TO 20X1 AMPS
E� W Licensed Professional - ❑INTERIOR ❑SWIMMING
POOLS
we 201-1000 AMPS IMPROVEMENT SWIMMING POOLS
4 y OWNER-BUILDER DECLARATION OVER I"AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
N0 W 1 hereby affirm into I am exempt from the Contractor's License Law for the
?0qx5y O y U following reason.(Section 7031.5,Business and Professions Code.Any city or county SIGNS ELECTRICAL ❑OTHER
uI 'E- which requires a permit to construct,alter,improve,demolish,or repair any structure
pdonoits iseuantt,.lso squires the applicant for each peemluo Ele aslgned,tvtemenl SPECIAL CIRCUIT/MISC.
6 m that he is licensed pursuant the fthe Contractors Liputse Law Chat 9
b' pursuan provisions (Chapter COMMERIC1
that he is
(commencing withSection efro 9 and m basis for the al Business and Proon.Any vi Code)or TEMP.METER OR POLE INST _
At c y that io is exempt therefrom and the basis for the alleged exemption:Any lineation of E1 NEW BLDG/ADDITION ❑DEMOLITION
"^ Section 70JL5 twiny applicant fora permit subjects the applicannn.civil penalty of POWER DEVICES
On []TENANT ❑FOOD SERVICE
>> not morewthan e fof thundred pprtdollars
yempl IMPROVEMENT
SCO ❑Lashe work,the property,or myemployeesmia wage,as their sole compensation, SWIMMING POOL ELECTRIC
will do the work,and the sticture is not intended or offered s not.(Sec.7044,Business ❑OTHER
3 m and Professions Code;The Contractor's dome's License Law does not apply s if owner of OUTLETS—SWITCHES—FIXTUR
properly who builds or improves thereon,and who does such work himself or through
his own employment,e provided that such improvements are not intended or offered lite NEW RESIDENTIAL ELECTR
owner-builder
will
he burden
or prism issoldhewithin one ild orio.petfogtbe SQ.FT.FLOOR AREA $/SQ.FT
owner-builder will have the burden of proving that he did not build or improve for par,
El I,as owner of project
Sec.7property,stn exclusively contracting with:)The
contractors i- TOTAL:
construct the as not
(Sec.o an ownBuser
and ry who bpi Code:)The Contractor's nd
Li-
mil Luw does not apply m an owner of property who builds or improves thereon,and QTY PLUMBING PERMIT FE
who commas for such projects with acontramor(s)licensed pursuant to the Contractors
License Low. PERMIT ISSUANCE -
❑I am exempt under Sec. .B&P C for this reason
ALTER—DRAIN&VENT—WATER(EA)
Owner VALUATION
Date
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby M.under penalty of perjury one m rhe following declarations:
❑I have and will cremouina C,nifiraim.f Ccnsen to self-insure for Worker's Coarsen- DRAINS—FLOOR,ROOF.AREA.COND. STORIES TYPE CONSTRUCTION
sation,as provided for by Section 37M of the Labor Cade,for the performance of the
w rk for which this p.it is i...a& FIXTURES—PER TRAP
1 have and will maintain Worker's Camp arcouton Insurance,as implied by Section
4
ofthe Labor Code,for the performance ofthe work for which this permit is issued GAS—EA.SYSTEM-1 INC.4 OUTLETS OCC.GROUP APN
My Wo{� Cmpensamm Insar a cumerind Policy lJ lK�O�A�{�7 GAS—EA.SYSTEM-OVER4(EA7 ("
Carrier(-'��I I 1 {Policy O WOR
CER FIC OMPESIXEMPTIINSURAM WORKERS'
COMPENSATION INSURANCE GREASFJINDUSTRL WASTE INTERCEPTOR f^ ILUING DIVISION FEES
(Thisaectioa need not be completed ifthe Permit is for..hundred deltacs(S I W) GREASETRAP
or Isaac) IT KFEE
(certify that int mfithe as
for which this tthe W is rkesvedleba0 SEWER-SANITARY—STORM EA.200 Fr.
not employ any person in any manner so as m become subject the Workers'Compeo- NERGY FFQE(x
,z sation Lew,of California.Dam WATER HEATER z WNENT/ELECI'R'0 Applicant i - ,.FEE
WA4
l..t NOTICE TO APPLICANT:If,after making this Cenifrme of Exemption,you should WATER SYSTEMRREATING \\ -
hecome subject to the Workers Compensation provisions m the Labor Code,you most SOILS FEE
forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
� z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL FUND. SQ.FT. PAID Date Receipt#
LJ 0 I hereby alarm that there is a construction lending agency for the performance of
D. HNe work for which this permit is issued(Sea 3097,Civ.C.)
Lenders Name AL'
WLenders Address TOTAL:
97r I cenify that 1 have read this applicants and slam that the have mrorm timet w I BUILDING FEE
w+.
LO) I agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE '
U A building construction,and hereby authorize representatives ofthis city to enter upon the SEISMIC FEE
above-mentioned properly for inspection purposes. f_0 s.�
(We)agree m save.indemnify and keep hmmless the City of Cupertino against PERMIT ISSUANCE VV ELECTRIC GEE v
liabilities,judgments,casts and expenses which may in any way acerae against said City ALTER ORADD TO MECH.
in conan
sequence of the granting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CFM) 3 V
SOURCE REGULATIONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER Iff"CFM) CONSTRUCTION TA -
Signature of ApplicantlCortmehr Date EXHAUST HOOD CVMUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant.future huilding occopantwo,mhandlefamwelmornmend HEATING UNIT(TO 100.000 BTU)
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Heahh and Safety q
Code,Section 25532(.)7 HEATING UNIT(OVER 100,000 BTU)
Val IAB a PAID =
1u� VENTILATION PAN(SINGLE RESIO) Date Receipt#
Will the applicant or future building occupant use equipment or devices which BOILER—COMP(3HPOR 1 W,OW BTU)
mit hazardous air mmaminents as defined by the Bay Area Air Quality Management TOA,
District? BOILER—COMP(OVER 100,000 BTU)
❑Yes *a
IMM,read the hazardous..(anal,requirements under Chapter 6.95 of the Cali. AIR CONDITIONER ISSUANCE DATE
foci.Health&Safety Coda,Sections 25505,25533 and 25534.1 understand that tribe NEW RESIDENTIAL MUCH. SQ.FI'.
building duetemeollylmv. vent,thotp is my responvihility.notify the occupant C/O_�� In, _t
require anwhichmu be mpnQ[to issuance o(a Certificate of pn y.
Pq-
r enthonzed a ant D OT ISSUED BY: `—
OFFICE