S 0428 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITYOF CUPERTINO BUILDING-ELECTRICAL. PE 1T NO. O
_ BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL, I v`
BUILDING PROJECT IDENTIFICATION L�
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
OWNER'S NAME:5F% PHONE: CONTRACTOR'S NAME: LICN
� LDLC [ , �
QQG NFC CONTROL#
)S RCHITECTMNGINEER: LIC NO: ADDRESS:
{� vI.^
CEe'rn I PHONE:
BUILDING f ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT
NFO
PLUMB MECH
DD LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that 1 am licensed under previsions of Chapter 9(commencing JOB DESCRIPTION
with Section of Division 3 ofthe Businessand Professions Cade,and my license is PERMIT ISSUANCE 00 - RESIDENTIAL:
n full mole and dfecc
�UyV License Close Lia# ❑SFDWh ❑KITCHEN RE-PIEI.
ti60. Date Contractor APPLIANCES—RESIUF,NTIAL ❑ApDIT10N � ❑PLUMBING RE-PIPE.
ARCHITECT'S DECLARATION - 0 MULTI-UNIT ❑STRUC URAL
Z O'/+Z 1 understand my plans shall be used as public ramrds PANELS MODIFICATION
Oxo'O UP TO 200 AMPS
El INTERIOR CHIMNEY REPAIR
F�J Licensed Professional 201-10WAMPS IMPROVEMENT O IMMING POOLS
pa��y' OWNER-BUILDER DECLARATION OVER 1000 AMPS
`C 1 hereby affirm that I am exempt from the Contractors License Law for the ❑BATH REMODEL/REPAIR DEMOLITION
3 O y U following reason(Section 7031.5,Business and Professions Code:Any any or county SIGNS ELECTRICAL ❑OTHER
W F which requires a permit m relation,alter,improve,demolish,or repair any xosaure
0printto its issuance,also requires theappl want fmsuch pen tet fleasignedemtemenl SPECIAL CIRCUITIMISC.
C. that he is licensed pursuant to the provislnnsofthe Contractor's License Law(Chaplerl)
DO (commencingwith Section 7000)of Division 3 ofthe Businessand Professions Code)or TFMR.METER OR POLE INST. COMMERCIAL
0.p,M e' that he is exempt therefrom and the basis for the alleged exemption.Any violation of El NEW BLDG/ADDITION [IDEMOLITION
W M m Section 7031.5 by any applicant for a permit subjects the applicant ro a civil Penalty of FEWER DEVICES ❑ El FOOD SERVICE
ZZ tmtre than five hundreddullms($500). []TENANT TENANTEMBNT
O ❑1,os owner of the properly,army employees with wages ac theirwlecompemation, SWIMMING POOL ELECTRIC
will do the work,and the structure is not Intended mothered for svle(See 7M4,Business ❑OTHER
til and Professions Code:The Contmetrr's License Law does not apply to an owner of OUTLETS—$WITC E —F ORES
property who builds or improves thereon,and who does such work himself or through
his awn employees,provided that such improvement,are not intended or offered for NEW RESIDENTIA T SQ FT.
sale.If,however.the building or improvement is sold within one yearofcompletion,the SQ.FT.FLOOR AREA $/SQ.E..
convolailder will have the burden of proving that he did not build or improve for par- ,
pose of sale.). h
❑ I,as owner of the Employ,am exclusively contracting with licensed contmctnrc to TAL: V
construct he pac t(See.](154,Business and Professions Code;)The Contractor's Li-
corm
i- 4S
wac m Law does not apply to an owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT FEE y 1 Fn�F...n
s counters for such pajeew with a contractors)licensed Pursuant to the Contmcmrs ��11 •t�4sD
License Law. PERMIT ISSUANCE C/ {/
❑1 nm exempt under Sec. ,B&P C for this reason 1!
ALTER—DRAIN&VENT—WATER LEA)
u�,
Date
Owner
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirmunder penalty of perjury one of the following declarations:
I hove and will maintain a Certificate of Conant to self-insure for Workens Compen- DRAINS—FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
cation,as provided for by Section 37(X1 of the Labor Code,for the Performance of the
work for which this permit is issued. FIXTURES—PLR TRAP ,
E]I have and will maintain Worker's Compensation Insurance,as requires!by Section
37ffliahe Labo Cnde,for the penormance of the work for which this permit is issued. GAS—EA.SYSTEM-I INC,4OUT'LETS OCCLGROUP AFV
_ My WorkersC penesaon Insurance carrier and Policy number are: GAS Policy No.: OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GRFASFJINDUSTRL WASTE INTERCEPTOR
(This section need not Ise completed duepermit is nature hundred dollars($(BIB BUIL IV1. NFEE.S
orlessJIvaGREASETRAP
PLANCHECK FEErtify that in the performance of the work forwhich this permit is issued,I shall
not employ any person in any manner co as to become subject to the Wurkers'Cnn- SEWER—SANITARY—STORM EA.200 FT.
z cation Laws of California.Dace ENERGY FEE
zO Applicata l WATER HEATER WNF.NT/ELECI'R GRADING FEE
y NOTICE TO APPLICANT:If,aper making this Craiftcme of Exemption,you should WATER SYSTEM)TREATING
became subject to the Workers Clon,r olon provisions of the Labor Code,you must SOILS FEE
ISJ forthwith comply with such powisians or this permit shall be deemed revoked. WATER SERVICE
Q
CONSTRUCTION LENDINGAGENCY NEW RESIDENTIAL PLMB. SQ.IT. PAID
L) l far
rwhich that Noun,
isace (Stm.30 leading agency for the Performance of Date ReceiplM
0F, the Lenders for whichthis pennit is issuW(Sec.3f19],Cie.C.)
Lendels Name TOTAL
r {U Lenders Address TOTAL:
I certify that 1 have mad this application and state that the above information is BUILDING FEE.
o-Fi fa/J correct.)agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE 77
V building construction,and hereby authorize representatives of this city to enter upon the SEISMIC PEE
uhrwamcationed Property for inspection purposes. PERMIT ISSUANCE
'(We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
liabilities,judgments,costs and expenses which may in any way wane against said City ALTER OR ADO TO MECH.
in consequence of the gtamin of this permit. PLUMBING FEE
APPLICANT UNDERSTANIS ND WII COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IQWOCFM)
SOURCE ULATIONS. MECHANICAL FE
fl"X /I AIR HANDLING UNIT(OVER 14IXMt CFM) CONSTRUCTION TAX
Signature pplicanUContre r V 1 Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZAR US ERIALS DISCLOSURE
Will the applicant or future h ding Occupant store or handle hazardous material HEATING UNIT(TO 100,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health mud Safety
Gde.Section 25532(x)1 HEATING UNIT(OVER 100,00d,BTU)
❑Yea ❑No VENTILATION CAN(SINGLE RESID) PAID Data Recevp
- Will the applitaminants a building by the Bay Ana Air Quality Management BOILER—COMP QHP OR IOg0110BTU)
St.
hazardous air contaminants as defined by the Bay Arca Air Quality Management TOTAL:
Jrstrlat?
71 yes 7 N BOILER—COMP(OVER IOO,f1W BTU)
I have read the hazardous materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
heads Health&Safety Code,Sections 25505,25533 and 25534.I understand that if the NEW RESIDENTIAL MECH. SQ.FT.
building does macurrantly have a cewnt,that it is my responsibility to notify the occupant
of the rw{r.imauntc which must Ise mel pit arto issuance of a Certificate of Occupancy.
Owner or authorized agent Date TOTAL: ISSUED BY:
OFFICE