30288 APPLICANT TO FILL IN INFORMATION,WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO • - f BUILDING-ELECTRICAL •PERMIT NOr,,
BUILDING DIVISION r, APPLICATION/PERMIT'' PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
". BUILDINGADDRESS. 'SANITARY,NO. APPLICATION SUBMITTAL WM
W ER'S NAME: PHONE: TRACTOR'SAME: LIC NO,
NIC CONTROL#
r6
RC ECT/F.NGINEER: LIC NO: - ADDREPS - ❑ -
CONTACT: -PHONE: BUILDING PERMIT INFO
n _, .,�,,, '❑ Consultant Fees Paid by Applicant(Initial) ' ' BLDG ELECT PLUMB MECH
El El , H . ❑
LICENSED CONTRACTORS DECLARATION QTy. ELECTRIC PERMIT FEE
I hereby affom Nati licensed under pr tins of Chapter 9(commencing, JOB DESCRIPTION'
QWZ with Section 7000)ofDvision 3 of the Busiess and Professions� Cd,and my hearse is OW
- PERMIT ISSUANCE RESIDENTIAL:
m full force and effect.
Uf�L� License Class Lic:k. ❑SPDWL #ITCH REMODEL
Date Contractor APPLIANCES-RF.SIDENTIAC ❑ADDITION BING RE-PIPE
ARCHITECT'S DECLARATION , - ❑MULTI-UNIT., ❑STRUCTURAL
PANELS
Z p vv��� 1understandmy plan .k II b ed as pubhc records - �. � . � "' MODIFICATION -
OZ�4 - UPrTO 2M AMPS, f
r Licensed Prf. I '- - ❑INTERIOR [I CHIMNEY REPAIR
s 201-1
OWNERBUILDM DECLARATION 0(l0AMP5 IMPROVEMENT
ac I hereby affirm that I am exempt from the Commerce's License La for the OVER 1000 AMPS BATH REMODEIREPAIR ❑DEMOLITION.
iWG O a U following reason,(Section]031 5,Business and Pocifiessimen,Cadai CadA y air,or county SIGNS ELECTRICAL' ❑OTHER
W a LL y which requires a permit to compact,ober,improve,demolish,or repair any summer -
prior m its issuance,also requires the applicant for such permits fl gndstatement -
w SPECIAL'CIRCUIT/MiSC. 1
Gthat fees licensed pursuant 7 thep Division of rhe CommeeBusin ssL a ss (Chapter9
GGOO (commencing pttheref ]0nd easisor of the Burmese dor fel n.Cade)or 'TEMP.METER OR POLE INST. COMMERCIAL:
p� y' that he is exempt therefrom and the basis far the alleged exemption.n Any it penalty of - ❑NEW BLDG/ADDITION DEMOLITION
W m Sectio ]thaSanyapplicant for apenrit b) t rh appl'camto.c 'Ip rulry of POWER DEVICES []TENANT ❑FOODSERVICE
yyy tm t five huntiscry,ed r yempl - IMPROVEMENT .
Q ❑1 r ieed pe stra an army employees t age..the I pnssines SWIMMING POOL ELECTRIC
will do thework,and the o Coro inuer,Licause offe of r 1 (S 7044 Busmen. DOTHHR
and er ft who
a Coon:The over tend Cee L d t k himself
if owner of OUTLETS-SWITCHES FIXTURES t.
�' .. his own who buddy or unproven thereon,and who does such work himself or through --
sal own anaployhowever,
te,me building
that such mens is sold w ere not intended of ar offered for NEW R85IDHNTIAL L SQ PT.
sale.If.howev<e Ne M1uilding orimprovemem is sold within one year ofwmplerion,'te� r. $Q.FT FLOOR AREA .USQ.PI'.
xmer-bonder will have the burden of proving that he did not build or improve for pur- -
pose of sale.).
❑1,as ow er of the property,am exclusively comrdcdng wit licensed conascto.,. TOTAL:
construct the ro'eet(Sec. Business and S
' ( Prolamines or The Contractor's and
PJ ) Q
cense Law does not apply to an owner of property who builds or improves thereon,end QTY. PLUMBING PEf�II 'FEE A0
who contracts for such projects with.coovacmr(s)licensed pursuant to the Contractor's
License Law. ,fs
❑'I am exempt under Sec. - - ,B&P C for this reason PERMIT ISSUANCE • a 1 1\��
,. 'V ..ve''t'.1 t4R ql)
Owner - - Dam ALTER-DRAIN.&VENT-WATER(EA,)' v VALUATION
WORKER'S COMPENSATION DECLARATION BACKFLOW PROTECT.DEVICE'• -
Iherebyaffinuunder Penalty ofperjury one ofthe following declarations
I have and will maintain a Cedfificatp of Consent to self-imare far Warker's Convince- DRAINS-FLOOR,ROOF AREA,COND. J STORIES ' r TYPE CONSTRUCTION
sari..,as provided far by Section 3700 of the Labor Code,for to performance of the _ a '
work for which this permit is issued. ' Zi- FIXTURES-PER TRAP i
❑I have and will maintain Workers Compensation Insurance,as required M1y Section
37M of the Labor Code,for the performance of the work for which thio permit is issued. 'CAS-EA.SYSTEM-1 WC.4OUTLETS
OCC.GROUP DPN,
My Wo r in 6 In. tie and Policy number a, `7 y y a
Cartier _Policy N., ! 7 GAS-EA.SYSTEM-OVER4(EA), '
CCERTIFICA E OF EXEMPTION FROM WORKERS' .t
COMPENSATION INSURANCE ' GREASPIINDUSTR,WASTE INTERCEPTOR
r •Cnassecdormad nm be completed if the permit is fortune hundred dollars($100) - BUILDING DIVISION FEES
crlessJ GREASETRAP PLANCHECK FEEnot `
(certify Norinthe anynomanceof the work for which Nis per Wiisissued,lshall SEWER-SANITARY-STORM EA.200 Pf anion
any person in any manner so as m become subject to the Workei%Compen ENERGY FEE s
Z nationanws of California.Dare _
z O Applicant �" ' - WATER HEATER WNENT/ELECTR GRADING FEE 4'
rv) NOTICE TO'APPLICANT:If,after making this Carnfieme of Exemption,you should WATER SYSTBMITREATING '
a [' become subject to the Worker's Compensation provisions of to Labor Code,you must - SOILS FEE
Giary
forthwith comply wit such pravisions or Usteatitic,
p peed adeemed revoked. WATER SERVICE -
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT PAID
V 0 Ihreby affirm thee' constructionlending agency forms,performance of Data
m tiptA
La, I••, theworkfof which this permit is issued(Sec.3119],Ci¢CJ
Q L.l Lender's Name _ t.
Lender's Address TOTAL: TAC:
1 certify that I have read this application and store Nat the above information is BUILDING FEE /
N correct,l agree,.comply with all city and county ordinances and state laws relating to QTY, MECHANICAL PERMIT FEE
building consumption,and herebyauthorne representativesof tis city to ental open the SEIShiICF ..1
ab,ive-mentioned property for inspection purposes.- PERMIT ISSUANCE'i -
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC -
liabilitiee,judgments,costs and expenses which may in any wayaccrue against said City ALTER OR ADD TO MECH. PLUMBINGFEE ;'I -
in nsequenes of the granting ofthis pe
APPLICANT UND R. ANDS.AN CO PLY WITH ALL NON-POINT
)' S0 RCER 5.; AIR HANDLING UNIT(TO 10,000 CFM) MECHANICAL FEE
'XJ 9li AIR HANDLING UNIT(OVER 10,0)0 CFM)
,t � � CONSTRUCTION TAX=
Signeru - ppli nUConaffairDole EXHAUST HOOD(W/DUC),
HAZARD 5 MATERIALS DISCLOSORE. HOUSING MITIGATION FEE
Will the applicant or future building occupant store or handle hicaudoes material HEATING UNIT(TO 100,000 BTU) ,
as defined by the Cupertino Municipal Code,Chapter 9,12,and to Health and Safety
Code,Section 25532(a)? _ - - HEATING UNIT(OVER 100,000 BTU)
❑Yes - - F1 No - PAID 1:
VENTILATION FAN(SINGLE RESID) Data Receipt#
Will to applicant or future building occupant use cociparmal or devices which r
mit hazardous air contaminants as defined by the Bay Area Air Quality Management' BOILER-COMP(SHP OR 100,000 BTU)
Dian? TOTAL -
'rYes ' " 7 N BOILER-COMP(OVER 100,000 BTU)
I have read to hazardous materials requirements under Chapter 6.95 of the Cali AIR CONDITIONER ISSUANCE DATE
fomir Health&Safety Code,Sections 25505,25533 and 25534 I understand that if the NEW RESIDENTIAL MECH. SQ.FT.
building flows not currently have a tenant that it is my responsibility to notify to occupant
of to requirements which must be and prior to issuance of a Cerificate ofOrcupaaey. '•
Owner or sutorized agent Date ) TOTAL: ISSUED BY:'
OFFICE