99100017 pLPPUCANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
-- CITY OF CUPERTINO BUILDING-ELECTRICAL
MIT BUILDING DIVISION APPLICATIONTERMIT v1.UMBING-MF,CIIANICAL SOOOl
RUILDING'PROJECT IDENTIFICATION
]WILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE'
Z
OWNER'S NAME: PHONE: CONTRACT 'S NAME: LIC NO:
VIZ Ufa 1 N/C CON TROL#
ARCHITUCT/ENGIN fl R: UCNO', ADDRES��� ❑
CONTACT': PHONE: 'BUILDING PERMIT INFO
❑ Consultant F¢¢B Paid by Applicant(Initial) BLDG ELECT PLUME MUCH
LICENSED CONTRACTORS DECLARATION
I herebyaffirm thin I am licensed d admirer ler 9 QTY ELECTRIC PP.RM7F FEE
p p (commencing . . JOB DESCRIPTION
AWSwith Seehmn 9000)ofD vsmn3 nrthe Bou an Prufesxions Cade,andmy l'ense's PERMIT ISSUANCE '
in full fared and c L � //�����sTm»�� i}' ` ❑KITCHEN REMODEL
aVV LicensO Class (a.CCL"'tm.# APPLIANCES-RESIDENTIAL FFION C1 PLUMBING RE-PIPF.
m Dale Contractor _
ARCHITECT'S DECLARATION El MULTI-UNIT ❑STRUCTURAL
Fah Ivndcmtandm 1 hllhused as puhlicrecnNs PANELS MODIFICATION
aO j� plans
1
UP'0200 AMPS E]INTERIOR ❑GIIIMNEY REPAIR,
fir. W Liern.ed Pmfessinnal 201.1000 AMPS- IMPROVEMENT E]SWIMMING POOLS
CCG Cyu,l OWNER-BUILDER DECLARATION OVER IIXN]AMPS BATH REMOUEIJREPAIR ❑DEMOLITION
p� W
a 1 hereby affirm that I am exempt from the Commences License Law for the _
W O Ps V following Tenssan.Permit
,91131.5.Business and Professions Gde:Any oily or ..mySIGNS ELECTRICAL ❑OTHER
F Orn which q eertdl l .,aid t alto p a oli h p an,howroore
6� pro t t Issuance,al. qui th ppl tf hp roto fl signed sm,emwt SPECIAL CIRCUITIMISG.
!!!!j{js thinh
d ad pc oCG (commencing rtwith
pSection
,Sl ath))ofDavi,on 3forthe
C t Business
Lnd'Professions Code)
)or
TEMP METER OR YOL T. COMMERCIAL'
El NEW BLDG/ADD
ITION L1 DEMOLITION he Is evanpl Therefrom and the Basis for the alleged exemption.Any violation of
WN Section 7031.5 by any applicant for a permit subjects the applicant o a civil penalty of POWER DEVICES ❑TENANT - ❑FOOD SERVICE
F
not more than five hundred dollars($500). IMPROVEMENT O ❑ I,as owner of the properly,or my employees with wages vx lheirsolecompearchun, SWIMMING POOL'
p.i wit[dothe w.rk,and deswemre is nor intended mothered for sale(See 9B44,Busiuess El OTHER -
W end Professions Code:The Contractor's License Law does not apply To ea owner of OUTLETS-SWITCIII?S
G .. property who builds Or improves thereon,and who does such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR
sale.IL however,the building Or i mprovement is sold within ane year of completion,the SQ.1,1 FLOOR AREA $/SQ.FIF
nemerTmilder will have the burden of proving that he did int build or improve fin To,
posy of sale.).
❑L as owner of the property,am exclusively contracting with licensed contractors,to -TOTAL:
construct the pn9ect(Sec.9(D4,Business and Professions Cmde:)The Contractors Li-
cense Law does not apply to an owner of property who builds or improves thereon,and QTYPLUMBING PERMIT' FEE
who contracts for such project with a compactor(s)licensed pursuant to the Cmntracmr's
License Law. PERM I'F ISSUANCE
Iamexemptunder Sea ,B&PCfoilsreason
ALTER-DRAIN&VENT-WATER(UA) VALUATION
Owner Data
WORKER'S COMPENSATION DECLARATION, BACK FLOW PROTECT DEVICE /T"./sr-�.
I hereby affirm under penalty of perjury one of the following declarations: ( zry
❑I have and will maintain a Certificate of Consent to self-insure for Worker's Compen- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
sation,as provided for by Section 3900 or the Labor Code,for the performance mine
w rk for whichthis permit is issued. FIXTURES-PER'1'RAP `,v
1 h d will maintain Workers Compensation fie,ran w reached by Section
-
3 fth Labor Codefor the performance of the work for whichth',permit is mood, GAS EASY ' v IN LoYy W c.ORQUP l l APN(D3
MyEXEMPTION
ha
y numb
CarW -r IyNn CAS 9 (EA)
CERTIFICATE IONFROM
TORKERV
COMPENSATION INSURANCE GREASWI LWAST G'M s
(This section need not be completed Ifthepermit is Loon hundred dollars($100) DING DIVISION PEES
or,less) CREAS9'TRAP UCK FEE
Icertify that in the perfnrmaneeOfthe work hnwhich,his permit is isercal,Isbell SEWER-SANITARY EA.21
nor employ any person in any manna sn as to f ocnme subject subjeco the Workers'Crampon- ENERGY PEP.
,7., sation Laws of Callfomla.Date WATER HEATER I
O Applicant to - GRADING FEE
tzr 0NOTICE TO APPLICANE If,after making this Certificate of Escordiew you shm W WATER SYSTEM
abecome subject to the Wodu's Compensmion pmvi,was of the Labor Code,you most SOILS FEE
L1a forthwith comply with such provisions or this permit shall be deemed revoked. WATERSERVICE
aA
CONSTRUCTION LENDING
ng.'aO NF.W RESIDENTIAL PLMB. SQ.FF. PAID
V p Ihurishwhrmthat
Periodthere isaconsteeli30 len ding agency for the perfonnvnecof Tx �ceipCM„
the wink fm which this permit is Icrved(Sec.3119],Civ.C.)
OULender's Name
V Lender's Address 'TOTAL: .
w 1 can fy that I have cud thisropplication and nam that the above infuriation is BUILDING FE i
h correct I agree to comply with all city and county ordinances and stale laws relating to QTY - MFCHANICAL PERMIT - NEB. ^ T
V� bnlld ng crnsTmet inn and hereby authorise representatives mi this any mcumr uponlio1. SBISMICP A1C 1 V
above-memioned property for instiwtinn puHxases. PERMI L ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino agairnt ELECTRIC EESS
Ilabilairs,judgmems,costs and expenses which tory in any way acme agaimisaid City ALTER OR ADD TO MECH. PLUMBING 1
f the gran ng fthia peanut.
APPLY NTeUNDERSA SA WILL COMPLY WITH ALL NON-POINT AIRHANDLINGUNI'1'(TO10,000CFM) 11
.-r--
SOUR RGGULATI
MF.CHANICAI.FF:H,» ::
(/ AIR HANDLING UNIT(OVER 10,000CPM) CONSTRUCTION TAX
r AA
- no pre opdicrd/Cmntmcmr Dtae EXHAUST I IOOD(W/DUCT)
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Will the applicant or future building occupant store or handle haznowus material HEATING ONIT(TO 101.000 E'TU)
defrned by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
ode,Section 25532(x)? HEATING UNIT(OVER 100,000 BTU)
❑Vas ❑No PAID
VENTILATION FAN(SINGLE.RESID) Date Receipt
Will the applicant or firth¢building occurred use equipment or devices which
'100not hr ardour air cnmaminants as defined by the Bay AreaAir Quality Management BOLER-COMP(3HPOR 100,000 BTT)
District? IOF '
❑Yds EJ No BOILER-C(1MP(OVER IW,11(NI E'fU)
Heave rand the hazallou meriale rvyuiremema'under Chapter695 of the Coli- AIR CONDITIONER ISSUANCE DATE
fmmla Health Safely ff e lions 2 5,2, end 25534.1 vndcrstvnd that if the NEW RESIDENTIAL MECH. SQ.FP. / d ��
building dces ncurte it] v awn. ,t o It is my responsibility ni notify the vexation, /'
of the paper ,cots uRir pit to issmmce ofx Cenifievteof Oceup_may/y
Owner or orized again - �' Data TOTAL: ISSUED BY
OFFICE