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APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING -ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL
BUILDING PROJF.CTIDENTIFICATION
PERMIT N0. 2^ Q^ II
L 4J 4 -LJ 4
BUILDING ADDRESS:
f/
SANITARY NO.
APPLICATION SUBMITTAL DATE
-
#O�WjJE' AMC: PHONE:
COM'RA R'S NAME: LIC NO:
�N.NIC
CONTROL#
\RCNITECT/ NG R: - LIC NO:
ADDRESS; OO •�
!).
CONTACT., PHONE.
-
❑ Consultant Fees Paid by Applicant (Initial)
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
❑ ❑
LICENSED COcensed e, p DECLARATION
1 hereby M. that 1 am licensed under provisions of Chapter 9 (commencing
with Seadmi70(hom Division 3ofMa Busincssund Professions Cede,.nd my license is
in full force and effect.77�
License Class o
e onuacmr
Contractor
QTY ELECTRIC PERMIT FEE
JOB DESCRIPTION
RESIDENTIAL: '
❑SFDWL ❑ KITCHEN REMODEL
❑ADDfITON ❑PLUMBING RE -PIPE
❑MULTI -UNIT []STRUCTURAL
MODIFICATION
13 INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT
❑ BATH REMODEL -REPAIR ❑ DEMOLITION
❑ OTHER .a
1{
i{Z\/
PERMIT ISSUANCE
APPLIANCES -RESIDENTIAL
ARCHITECTS DECLARATION
I understand my plans shall be used as public tecnrds
PANELS
1 UPT0200AMPS
Licensed Professional
OWNER -BUILD I am exempt 1'r DECLARATION Contr ON
1 hereby affirm thm 1 am exempt from the Comrscmrs License law for the
following reason. (Section 7031.5, Business said Professions Cade: Any city or county
which requires a permit to conslruc, alter, improve, demolish, or repair any shacture
pnonoia issuance, also mquirtsthe applicant fnrsuchpermiwfileasigned sta¢ment
that he is licensed pursuant to the provisions of the Contractors License Law (Chapter 9
(commencing with Section 7000) of Division 3 of the Business and Professions Gale) or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicaas to a civil penalty of
not more than tout hundred dollars ($5110).
❑I, as owner of the prnpeny, oimy employees with wages as meirxnlc mmpenxation,
will do the work,and the somaltme loot intended.I.Mered forrile(Sec.]044, Business
.ad Professions Code: The Conaaomrs License law dtts ant apply to an owns of
property who builds or improves thereon, and who does such work himself or through
his own employees, provided that such improvements arc not intended or offered for
sale. If, however. Ne building or improvement is sold within one year of completion, Me
owneobuilder will have the burden of proving that he did not build or improve for pur.
pose of ale.), I
1, as owner of the property, am ve
exclusively contracting with licensed contractors m
convect the project (Sec. 70414, Business and Professiors Code:) The Connector's Li-
veru Law does not apply to an owner of property who hui Ids or improves thereon,and
who contracts for such projects with a contrector(s) licensed pursuant to Ne Contractor's
License w.
E] I am exempt under Sec. ,B& P C for this reason
201-1000AMPS
OVER IM) AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC.
TEMP. METER OR POLE INST._
COMMERCIAL:
❑ NEW BLDG/ADDITION ❑ DEMOLITION
TENANT El FOOD SERVICE
IMPROVEMENT
❑OTHER
POWER DEVICES
SWIMMING POOL ELECT
OUTLETS-SWIT FIXTURES
NEW RESIDENG E R SQ PI'.
,
5Q.FT.1T.00RwREA
d
AIA R •1
d �O(L[�
OO(J
Ulf,
i"UrCTF(TfkV
$/SQ. FT
'
- _
TO
QTY. PLUMBING PER FEE
("r
PERMIT ISSUANCE
ALTER - DRAIN & VENT- WATER (17
Owner Date
VALUATION
. WORKER'S COMPENSATION DECLARATION
I hereby offum under Penalty of perjury one of the following declarations:
I have and will maintain a Certificate ofConsetn to self -insure for Worker's Camper-
adaq as provided for by Section 37W of the Labor Cale, for the performance of me
work for which this permit is issued
❑ I have and will maintain Worker's Compensation Inverunea, as required by Salon.
3200.1' Me labor Cala, fee the perfemard,eof the work for which this permit is ismed.
My Work tpe9Eb)Ast�tce carrier and Policy �Mfticr !NN//�T �I Jr' Policy No,
CERTIFICATE OF EXEMPTION FROM ORKHRS'
COMPENSATION INSURANCE
IT section need nm he completed if the permit is for one hundred dollars CS 100)
or less)
I vanity thus in the performanceuf me work forwhich this permit is issued,) shall
not employ any person in any manner so as to become abject to the Workeri Compen-
cation Laws of California Dam -
Applicant
BACK FLOW PROTECT. DEVICE
DRAINS- FLOOR, ROOF, AREA, COND.
STORIES
TYPECONSTRUCTION
FIXTURES- T
GAS - EA. SY . lINCA OIITLEI'S
OCC. GROUP
APN
GAS- EA. SYSTEM -OVER 4(G)
GREASMNDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
GREASE TRAP
PLANCHECK FEE
SEWER -SANITARY -STORM FA . 200 FT.
ENERGY FEE
WATER HEATER W/VENT/ELECTR
GRADING FEE
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Cale, you must
forthwith comply with such provisions or this permit shall he deemedrevnked
CONSTRUCTION LENDING AGENCY
I hereby affror that is a construction lending agency for the performance of
the work f.r which this permit is issued (Sec. 3097, Civ. C.)
Lender's None
WATER SYSTEM?REAGNG
WATER SERVICE
SOILS FEE
PAID part Receipt
NEW RESIDENTIAL PLMB. SQ. FL
s
TOTAL:
Lender's Address
TOTAL:
BUILDING FEE
I candy that 1 have rad this application and state that the above information is
correct l agree to comply with all city and county ordinances and sate laws relining to
building cementation, and hereby aumnrize rcpmsentatives of this city to enter upon the
uhove-mentioned prnpeny for inspection purposes.
Wo) agree to ave, indemnify and keep harmless the City of Cupertino against
lmbilities,judgments, costssad expenses which may in any way accrue against said City
in onsequenca of the granting of this permit
APPI.I \NT UN ERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOU +REGI' TIONS. `
`� V�
VVVV
-
QTY. MECHANICAL PERMIT FEE
SEISMIC FEE
PERMIT ISSUANCE
ELECTRIC FEE
ALTER OR ADD TO MECH.
PLUMBING FEE
ALR HANDLING UNIT (TO W." CFM)
MECHANICAL FEE
AIR HANDLING UNIT (OVER to." CFM)
CONSTRUCTION TAX
Si amrc pplicmt/ naador '. Dine
H ROODS MATERIALS DISCLOSURE
ell he applican or future building occupant store or handle hazardous material
M defin b the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Coda, Sat 25533(a)F
❑Yes ❑No
Will me applicant or fmure M1ufiling Meupam use equipment or devices
mit hazudaa air commutations as defined b the Ba Arca Air QualityMates eaten
IsWn2
E] yes ❑Nri
1 have read the haurdous armenals requirements under Chapter 6.95 of the Cali-
famio Health & Safety Calc, Sections 25505, 25533 and 25534. 1 understand thin if me
building dossnot curtatI, more. tenant stat it is my respnnsibility mummify the acumen,
of me requirements which muss be met prior to issuance of a Cmificam of Occupancy.
EXHAUST Hppp (W/DUCE)
HOUSING MITIGATION FEE
HEATING UNIT 1(10.X01) BT'U)
HEATING UNIT (OVER 100,01) BTI!)
'7
PAID
Data Receipt#
VENTILATION PAN (SINGLERCSID)
BOILER-COMP(IHP OR 1011,000 BTU)
TOTAL:
BOILER -COMP (OVER 100,000 BTU)
AIR CONDITIONER
- ISSUANCE DATE
ISSUED BY. - • a
NEW RESIDENTIAL. MECH. SQ. Un
Owneroiridensedagent Data
- TOTAL I
OFFICE