S 1457APPLICANTTO FILL IN INFORMATION WITHIN RED LINES • USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL
PE18ITNO
BUILDING DIVISION APPLICATION/PE"IT PLUMBING -MECHANICAL
BUILDING PROJECT IDENT'IF'ICATION
1457
BUILDING ADDRESS:
SANITARY NO.
APPI.ICATION SUBMITTAL DM E
yGb C..QSfli/Q �
, 2
OWNER'S NAME: PHONE:
CON RACTOR'S NAME: LIC NO..
NIC
CONTROLN
❑
ARCHITECTIENOIN EER: LIC O:'
ADDRESS:
CONNFACTV r : Y,, g; _/ PHONE:L �/„ y
Nit
BUILDING PERMIT INFO
BLDG ELECT r PLUMB/ MUCH
VBG/ L—/J�/
❑ Consultant Fees Paid by Applicant (Initial)
LICENSED CON' TRACTOR'S DECLARATION
I hereby surra mal l am bRmaw ander pmvixidna nrenapter 9 ¢hnnmenahig
QTY ELECTRIC PERMIT FEE
JOB DESCRIPTION
with Section 700(bof Division 3 ofthe Business and Professions Code. antl my Icomse ix
in fill three and
License C4 ` Lic.ut
Dam Contractor
RESIDENTIAL' O
OSFDWL KITCHEN REMODEL
❑ADDITION ❑PLUMBING REPIPE
❑MULTI -UNIT El STRUCTURAL
MODIFICATION
PERMIT ISSUANCE
APPLIANCES -RESIDENTIAL
ARCHITECTS DECLA ATION
- 1 understand my plans shall he used as public reamds
PANELS
UP TO 200 AMPS
El INTERIOR OCH IMNEY REPAIR
IMPROVEMENT 0SWIMMING POOLS
El BATH RF,MODEWREPAIR El DEMOLITION
❑OTHER
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby a1Hrm that I am exempt from the ConlmeVrt'x license Low for the
following reason, (Section "1031.5, Broureoped Professions Cud, Any city or .)only
which requires a permit to construct, alter, improve, demolish; or repair any structure
201-1000AMPS
OVER IOIXIAMYS
SIGNSELECTRICAL
SPECIAL CIRCUFUMISC.
prior to its issuance, also acquires the applicant for such permit o file a signed andmhin
that he is licensed pursuant to the provisions ofthe Contmeror's License Low (Chapter 9
'1'EMp. METER OR DOLE INST..
COMMERCIAL:
(commencing with Section 9000) off) ...... n 3 dads Bmarrumsund Profession, Code)or
that he is exempt therefrom and the basis for the alleged exemption. Any vintend. of
❑ NEW BLDG/ADDITION O DEMOLITION
POWER DEVICES
Section 9031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not .,are than five hundred dollars ($500)
❑I,as owner ofthe property, or my employees with wenes.as their sole compensation,
will do the w.,k,.ad thescucmre is not intended melodist rot sold (So. 9044, Business
OTENANT ❑ FOOD SERVICE
IMPROVEMENT
OOTHER
SWIMMING POOL ELEC'I'RI'
-
and ProfeSions Code: the Coulmmor's License Low odea not apply to all owner of
OUTLETS -SWITCHES -FI U
property who builds or improves thereon, and who does such work himself or through
his own employees, provided that such improvements ore not intended or offered for
NEW RESIDENTIAL. ELE . QF
SQ. IT FLOOR AREA
$/SQ. FT.
stele. If, however. the building or improvement is sold within one year ofcompletion,the
owner -builder will have the burden of proving that he did not build or improve for pur-
pose id Salo ).
El 1, as owner of the property, vac exclusively honvooivg wire licereed amtmcmm m
oinlmol the project (See. 7044, Business antl Prolcssinms Code) The Commctor's Li-
nscLawdoesnotapplyinunnwnerofpropertywhobuildshrimprovesthereon,and
QTY. PLUMBING PERMIT FEE
who contracts Tor such projects with a eomrach000 licensed pursuam to the Connector
PERMIT ISSUANCE
License Law.
O l am exempt under Sec. , B A P C for this reason
Owner nate
ALTER - DRAIN @ VENT- WATER (EA)
VALUATION
WORKER'S COMPENSATION DECLARATION
BACK FLOW PROTECT. DEVICE
under of of the following dcdanations:
I hand
DRAINS -FLOOR, ROOF, AREA, OND.
❑Lhave will mai ofCour aone
Certificate insure
,,d,id1nmiinaimCi,,n37ateoflh,L.b o self Code, surefop Worker's Comped-
anti as provided for Section 3)00 0[ the Labor Code, Grt the performance df the
STORIES
TYPE CONSTRUCTION
FIXTURES -PER TRAP
wnrk h mi
If which this Demon is issued
v orkee Crone
O I have and will maintain n required Section
ce,which
he Performanceof the work d i
erf r for which this permit is issued.
h
3/W or the Lobster Cede, for the one carrier and Policy
My Werke{'y tppersonyn�Ins fn ca rand Policy nunp�r
Curries: di�l�,� LXX/Lea- carrierand
Net 4/oe
GAS - EA. SYS '1'EM-I INC 40UTLETS
OCC. GROUP
APN
GAS -BA.SYS'1'EM-OVC•R4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thisovetion need not he completed ifthe permit is(atone hundred dollars IS Its))
or less.)
GREASIINDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION ELI, S
GREASE TRAP
PLANCHECK FEF.
SEWER -SANITARY -STORM EA. 200 IO.
I certifying hire performancedithe warkfor which his permit isissued, l that
not employ any pemon in any manner so as to become subject o the Workers' Coupon-
ENERGY FEE
_
WA'fBR IfF.ATUR W/VENT/ELECfR
cation Laws of Califomia. Dom
Applicant
GRADING FEE
SOILS FEE
NOTICE 1'0 APPLICANT: If, after making this Certificate of Exemption, You should
become subject to the Worker's Compensation provisions of the Labor Code, you door
WATER SYS'I EMOREATING
thrihwith comply with such provisions or this permit shall be deemed revoked.
WATER SERVICE
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance or
PAID
Date Rexoip
NEWRESIDENTIALPLMN SQ. IT.
the work rear which his permit is issued (Sec 3099, Civ. C.)
,
Lender's NameTGTAL:
Lender's Address
T
BUILDING FEE
1 secify mm 1 arsenical this application and stain that the above information is
QTY. MECHANICAL PERMIT FEE
commit.I agree to comply who all dry one county curdannees and stair laws,wining w
building construction, and hereby authorize representatives of this city to enter upon the
SEISMIC NEE
above-mentioned prelacy for inspection purposes.
(We) agree to cove, indemnify and keep ha voles the City of Capsular against
PERMIT ISSUANCE
ELECTRIC F2E
ALTER OR ADD TO MUCH.
PLUMBING FEE
Iiabilitiesjudgmo
as,cosix and expenses which may in any way accrue against said City
in consequence ofthe graining of this permit.
AIR HANDLING UNIT(TO 10,000CFM)
M&''HANIGAL FEE D
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS.
AIR HANDLING UNG (OVER 10.000 CFM)
CONSTRUCTION TAX
Signature ofApplican/Contractor Dale
HAZARDOUS MATERIALS DISCLOSURE.
Will the applicant or future building compant store or handle hazardous material
EXHAUST HOOD (W/DUCT)SI
TGATIDN FEE
HEATING UNIT (TO 100,000 BTU)
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Saltily
Gude, Section 25532(a)?
- V
HEATING UNIT (OVER 100,000 BTU)
E] Yes 1 `7 No
Will the it licar I at orcontaminants
building bccameral theBu Area Atr nal mr Quality anawhich
moil hazardous air wmeminants as defined by the Bay Arca Air Quality Management
Diol n?
❑Yes ON. -
PAID -
paie Receif,M
VENTILATION FAN (SINGLE REMD)
BOILER- COME (THE OR 100,000 BTU)
TOcUk.
BOILER -COMP (OVER 100,000 BTU)
AIR CONDITIONER
I have read the hoeardous mmerials reyuirmments under Chapter 6.95 of the Cali-
firma Health & Safety Chde, Sections 25505, 25533 and 25534. 1 ondmswnd that if the
building does not virtually have a tenant, that it is my responsibility to notify the oecupam
ISSUANCE DATE�
✓✓✓ V
NEW RESIDENTIAL MECH. SQ. FT.
of lh qutrcmems which must be met prior to issaanee of a CeniEiane of acepancy.
ISSUED BY: / 9 A
Owncror emn
horized eg
TAL
OFFICE