S 0670 APPLICANTTO FILL IN.INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY 7
CI TY OF CUPERTINO BUILDING-ELECTRICAL PEI�MII'NO. 0670
Q 1 D
BUILDINGI VISION APPLICATION/PERMIT PLUMBING.MECHANICAL S v
BUILDING PROJECT IDENTIFICATION
DING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL HATE
� avGG B RH£ A*r CUPERTWO eA
O NER'S NAME: PHONE: y CONTRACTOR'S NAME: LIC NO:
11A�lGI LE£ 46- q79 / N/c CONTROL#
ARCHITECOENGINEER: LIC NO: ADDRESS: ❑
CONTACT. PHONE: - BUILDING PERMIT INFO
❑ CRnsUltant Fees Paidby Applicant(Initial) BLDG ECT PLUMB MECH
❑ ❑ ❑
.
1 hereby union that 1 am licensed under provisions of Chapter 9(commencing
LICENSED CONTRACTOR'S DECLARATION QTYELECTRIC PERMIT FEE JOB DESCRIPTION
{OylOZO with Section 7")of Division 3 oftbe Business and Pofessions Code,and my l memse is PERMIT ISSUANCE RESIDENTIAL,
F ly— in full force and effect.
U V License Class Lic.# 0 SFDWL ❑KITCHEN REMODEL
Z APPLIANCES-RESIDENTIAL
y<L Dme Conmannr El ADDITION [I PLUMBING RE-PIPE
ARCHITECCS DECLARATION PANELS
[.7 m> - ❑MULTI-UNIT ❑STRUCTURAL
,Z O m❑ I understood my plans shall h used as public records MODIFICATION
024' UPT02MAMPS ❑INTERIOR ❑CHIMNEY REPAIR
sr7 Licensed Professional 201-100VAMPS IMPROVEMENT SWIMMING POOLS
OWNER-BUILDER m Ce Comm ON *'
yy LLW I hereby affirm that I am exempt from the Cnnlmotmrs License Law for the OVER IUIIO AMPS ❑BATH REMODEI,(JtEPA1Jt�DEMOLITION
w 3 L F following reason(Section]031.5,Rosiness and professions Cade:Any city nr county SIGNS ELECTRICAL ❑OTHER -'T�/1�•bAX
uF WOya which requires a permit to conswct,alter,improve,demolish,or repair any structure
yaN.]
prior to issuance,also requires the applicant for such permit to file asigned statement SPECIAL CIRCUIT/MISC.
aa� that he it licensed
00
(commencing with
0)the)of Daysiioxmnno3f urine BusinessaaLntlicPennsefeLvsaiwon(s Code)ro9r
TEMP.METER OR POLE(NST. COMMERCIAL
L fy o N that he is exempt therefrom and the hosts for the alleged exemption.Any violation of 4 ❑NEW BLDG/ADDITION ❑DEMOLITION
iWC r�r L� Section 7031.5 by any applicant for o permit subjects the applicant to a civil penally of POWER DEVICES
ry
yyyyzC not more than five hundred dollars($500). ❑TENANT ❑FOOD SERVICE
� O ❑ Lmowner ofine property,or my em to ers with wa es as their sole cont IMPROVEMENT
p y g pemation, SWIMMING POOL ELECTRIC
will do the work,and the structure Is not intended oro fared for sale(See.7044,Business ❑OTHER
and Professions Code:The Comracons License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
.. property who builds or improves thereon,and who does such work himself or through
his awn employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECfR SQ ET.
sure.If.huweser,the building or improvement is sold within one year of completion,the SQ ,&AREA $/SQ.FT
owner-builder will have me burden of proving that he did not build or improve for pur- �� ti/
pose of selene ` ego❑I,as owner of the property,um exclusively concocting with licensed Crinolines
i- T i 18-D
consortia the project(Sec.7!144,Business and Prnfessinne Code:)The Cnmmarrs Li- //ttI ii
cense Law does not apply to an owner of properly who builds or improves thereon,and QTY PLUMBING PERMIT FEE 1+g
who contracts for such projects with a cnnrmads)licensed pursuant m the Contractor's y
License Law.
1 aPERMIT ISSUANCE. Durtff 1JI�U
m exempt under Sm. ,B&P C for this reason
ALTER DRAIN&VENT
Ower. - -WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARAT CblT r r BACK FLOW PROTECT.DEVICE
I hereby affirm under penalty ofpejury one ofthe following declarations:
❑ Iha .
have andwill maintain aCertificateofConsem I.wOf-insurefm Worker's Camper- DRAINS-FLOOR,ROOEAREA, STORIES TYPECONSTRUCTION
salirn,as provided for by Section 37M of the Labor Code,for the performance of the
work for which this permit is issued. FIXTURES-PF.R TRAP
❑I have and will maintain Workers Compensation Insurance,as required by Section -
370)of the Labor Code,for the performance ofthe work for which this permit is issued. GAS-EA.SYSTEM-1 INC.4 OUTLETS OCC.CRUUP APN
My Workera Compensation Insurance carrier and Policy number am: ,
Carrier: Policy No.: GAS-EA.SYSTEM-OVER 4(BA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASMNDUSTRL WASTE INTERCEPTOR BUILDING DIVISION PEES
(nis,edionnwdnoth cmmpletedifthepenniti foronehundreddollafs($100) GREASETRAP or leas)
- PLANCHECK PEG
Icenify that in in Perany mmaoce arofthe
astoficomewhichthis the and WrkeraompaE SEWER-SANITARY-STORM EA.20)FT.
not employ any person in any mmrner xn as to become subject m the Workers'Compem ENERGY FEE -
Z cation Laws of CaliPornia.Dam
O O
Applicant 1 WATER HEATER W/VENT/ELECfR GRADING FEE
NOTICE TO APPLICANT If,aper making this Ccmfic,m of Exemption,you should WATER SYSTEM/I'REATING
F-t become subject to the Worker's Compensation provisions of the Lubar Code,you must SOILS FEE
4ai1� forthwith comply with such provisions or this permit shall he deemed revoked. WATER SERVICE
z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.ET. PAID
UO -
Iherebyaffirm that them is a construction lending agency for the perhimrrnceof Dat Receipt#.
4& the work for which this Permit is issued(Sec.31197,Cls.C.)
Q Lenders Name NOTAL:
Lenders Address TOTAL:
Rt I certify that 1 have mad this application and state that the above information is BUILDING FVJ
V) correct.I agree to comply with all city and county ordinances end state laws relating to QTY, MECHANICAL PERMIT FEE
7A
U G building concoction,a ad hereby authorize representatives ofthis city to enter upon the SEISMIC FEE
amve-mentioned property for inspection purposes. PERMIT ISSUANCE.
(We)agree m save,indemnify and keep harmless the City of Cupertino against ELECTRIC
iabilities,jul,ments,costsaml expenses whiehmay many woyaceroe againsts2id City ALTF.RORADDTOMECIL pLI1MBING
in consequence of the grunting of this permit.
Mq
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
SOURCER ULATIONS. it MECHANICA EE
AIR HANDLING UNIT(OVER 10,(100 CPM)
s R 9 CONSTRUCT NTA%
Signature fAWlicamt/Conoomor Date EXHAUST HOOD(W/DUCT) HOUSING MI GATION FEE
HAZARDOUS MAT IALS DISCLOSURP.
Willtheapplicanlorfmurebuildin occupantsmre ar handle hamrdoua material HEATING UNIT(TO IBgWO BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12.and the Health and Safety
Coda Section 25532ND HEATING UNIT(OVER 10O"BTU) -
❑Yes F7 No VENTILATION FAN(SINGLE RESID) PAID '
Date Receipt#
Will the applicant or furore building occupant ace equipment or devices which card hi
hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP CHP OR 100,003 BTU)
so District? TOTAL:
FI Die., - ❑No BOILER-COMP(OVER l00,W0 BTU)
1 have read the hazuder s materials is under Chapter fi 95 of the Cali- AIR CONDITIONER
requiremen ISS NCE DATE
fomia Health&Safely Code,Sections 25505,25533 umd 25534.I understand that if me NEW RESIDENTIAL MECH. SQ.FT.
building dues not currently have a tenant,that it is my responsibility to notify the occupant
of the mquirements which must be into prior m issuance of a Certificate of Occupancy.
Owner or authorized agent Date TOTAL ISSUED BY:
OFFICE