S 1341- - APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
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CITY OF CUPERTINO BUILDING - ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL
BUILDING PROJECT IDENTIFICATION
PliIT NO.
1341
BUILDING AUURIS
-
SANITARY NO.
APPLICATION SUBMITTAL DATE
WNER'S E: PHONE:
CONT R'S NAME'. LIC NO:
L
NIC
CONTROL#
ARCHITEC'UE GINEER: LIC NO:
DDDR SSS: �<.
EJ
CONTACT: PHONE:
BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant (Initial)
pLD _ ELECT PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARA'DON
1 hereby affirm that I am licensed order pmvisions of chapter 9 (commcaring
QTY. ELECTRIC PERMIT FEE
JOB DESCRIPTION
PERMIT ISSUANCE
with Section 70100) of Division 3 of the Business and Professions Gude, and toyliceme is
it Full force and effect.
RESIDENTIAL
❑ SI'UWI. ❑KITCHEN REMODEL
APPLIANCES-RESIDENTIAL
Dieters Clues Co
Date- Contractor
[I ADDITION El PLUMBING RE -PIPE
El MULTI -UNIT ❑STRUCTURAL
MODIFICATION
❑INTERIOR HIMNEY REPAIR
IMPROVEMENT 0 S IMMING POOLS
ARgtlDECLARATION DECLARATION
1unMrswnd my plans shall be used as public records
PANELS
UP TO 200 AMPS
Licensed Professional
201-1000AMPS
OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Law for the
fallowing reason. (Section "1031.5, Business and Professions Code: Any city or county
E] BATH REMOUEL/REPAIR DEMOLITION
OOTHER
OVER I(1W AMPS
SIGNS ELECTRICAL
which requlms a pemtit m c.wwc6 alter, improve, demolish, or repair any swcwre
SPECIAL CIRCUIT/M)SC.
-
pantomitsi"emae,.L,n reyuiresthe apgliwm fnr such puminn (ileuxigned ntawncmt
them he is licensed purmant the p ... kirnsofthe Contractor's License Lino (Chapter 9
TEMP. METER OR POLE INST
COMMERCIAL:
(commencing with Section VWl) of Division 3 ofthe Business and Professions Code)or
that he is exempt therefrom and the basis matte alleged exemption. Any violation of
0 NEW BLDG/ADDITION 0 DEMOLITION
-
POWER DEVICES
Section 703 LS by any applicant for a pcnnit subjects the applicant o a civil penally of
rat more than Eve Imndreddtllies O50(p.
❑has owner of the property, or my employees with wages as their sole compensation,
will do the work, and the structure is not intended or offered for sale (Sec. ]044, Business
El TENANT ❑ FOOD SERVICE
IMPROVEMENT -
❑OTHER
SWIMMING POOL ELECTRIC
and Professions Code: Tire Contramors License Law does not apply to an owner of
OUTLETS - swiTci IES -FIXTURES
progeny who build.. or improves thereon, and who does such work himself or through
his own employees, provided that such improvements are not intended or offered Far
sele.If, hewever, the buildi he or improvement is sold within one year of completion, the
NEW RESIDENTIAL ELEC3'R SQ ET.
SQ. IT. FLOOR AREA
$/SQ. Cr
nowner-builder will have the burden of proving that he did not build or improve for par-
,,aofsaleJ.
0 1, as owner of the progeny, am exclusively contracting with licensed contract to
P q
/1
TOTAL'
contract the project (Sea 7044, Business and Professions Code) The Coal toils Li-
cense Law does not apply to an owner of pmpeny who baildsm improves thereon.and
who umbacu for such projects with nconmmun(s)licetued pursuannr the Contractor's
License Law.
Clam exempt under Sm. ,R&PCf.nhis reason
'
IIS
A� {/
Cary
QTY. P�IJMBING PERMIT FEE
PERMIT ANCE
Owner Date
ALTB DRAT ENT- WATER (EA)
RACK Fli PROTE EVICE
WORKERS COMPENSATION DECLARATION
I herebyaffirm under penally rf perjury ane of the fallowing declovd.ns:
DRAINS -PI. RROOF. ,COND,
❑ I have and will maintain a Cenificvte of Consenttoself-insure for Worker's Compen-
often, as provided tor by Section 37(A or the Lvhor Code, for the performance of the
STORIES
TYPE CONSTRUCTION
work far whi,h,hi, germitis i ... ed,
FIXTURES - PER P
❑ I have and will moi tain Workers Compensation Insurance, as required by Section
"'mofihe Labor for the rf.rmance of the work far which this tis is. d
pe pett�pi
AS-b:A. SYSTEM- N .4 TLETS
OCC GROUP
APN
My Worker '.n lnsumnce Cartier and Pnlicyl�
Cartier: Policy Na, �KK
GAS -GA. SYSTEM -OVER (EA)
CRF.ASFlINU1JS'fRL WASTE INTERCEPTOR
RTIFIC OMPE EXEMPTION FRO WORKERS'
COMPENSATION INSURANCE
BUILDING DIVISION pF.ES
(Thls section need not be completed if lite permit is e, dollars (81 W)
or loss.) (I
GREASE TRAP
_
FEE
I remit, that inthe perfoomarrofthe work for whichthis permit is issued, Ideal
not employ any person In any manner so a to become subject to the Workers' Compen
SEWER -SANITARY- STORM EA. 21X) FT. ,
ENERGY PEE '
..tion Laws of California. Dam
Applicant
WATER ((EATER WNENT/ELF.CTR
GRADING PEE
NOTICE TO APPLICANT: If, after making dais CeniBcae of Exemption, you should
became subject as the Worker's Compensation pmvisions of the Labor Code; you mast
WATER SYSTEMOEEATINO
-
SOILS FEE
forthwith comply whibsuchprovi,i.ram,his pcunit shall bedeemedeevoked.
WATER SERVICE
CONSTRUCT ION LENDING AGENCY
I hereby affirm that them is acotammiot lendingagcncy for the performance of
NEW RESIDENTIAL PLMR. SQ. IT
PAID
Dam yberialir
the work for which this permit Is issued (Sec. 3097, Civ. C.)
Name
TOTAL
Lender, Ackhow,
TOTAL:
BUILDING F
1 rectify that 1 have card this application and swte that the vh.ve information is
QTY. MECHANICAL PERMIT FEE
SEISMIC FEEL r
correct, l agree to comply with all city and county ordinances and state lawsrelating to
building construction, and hereby authorize representatives ofthivclty to emorup.o the
PERMIT ISSUANCE
ELECTRIC PEE
ahavo-mentioned propany for dnspicaum purposes.
(We) agree to save, Indemnify and keep harmless the City of Cupertino against
ALTER OR ADD TO MECIL
PLUMBING FEE
I imbilities, judgments,costs and expenses which may in any way acerae against said City
in a grunting of this permit.
AIR HANDLING UNIT (TO IB,IXX) CFM)
MECHANICAL FEE
EXPANDS AND WILL CO h p(,. NON -POINT
SOURIONS.
AIR HANDLING UNIT (OVER 10.000 CFM)
CONSTRUCTION TAX
r
WWiB
EXHAUST HOOD(W/DUCT)
HOUSING MITIGATION FEE
ociatracmr Date
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (TO 00.000 BTU)
_
icatnor fuwmbuilding occupantsmrear hurullehazanom material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Gale, Section 25532(.)7
HEATING UNIT (OVER 100.0110 BTU)
❑Yes ONa
PAID -
Date Receipt#
VEN'TILA'HON FAN (SINGLE RESID)
BOILER -COMP (9iP OR 100,0071 RTU)
Will the applicant or future building niche E use equipment or devices which
it hvnair contaminant., a, defined cry ills Bay Arca Air Quality Munngement
emzaNus
District Y Yes CNn
❑
- T
BOILER -COMP (OVER I ftmarI BTU)
AIR CONDITIONER
l have read the hmaminus materials requirements under Chapter 6.95 ofthe Cali-
ISSUANCE DATE
NEW RESIDENTIAL MECH. SQ. PT.
forma Health & Safety Code, Sections 25505, 25533 and 25534. 1 understand that if the
building it.,.., ontend, have a term, that it is my responsibility ...,try the occupant
.fine requirement, which moa be met fl I,) i,werese ar. Cendwele of c,cupuncy.
ISSUED BY:
TOTAL:
Owner or authorized vKent Data
OFFICE