S 1066 APPLICANTTO FILL IN INFORMATION WITHIN REO LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PE51T NO. 10 6 6
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL. J
BUILDING PROJECT IDENTIFICATION
SANITARY NO, APPLICATION SUBMITTAL DATE
BIDING ADDRESS:
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HER' AME HONE: CON I RACFOR'S NAMUi LIC NO: N/C CONTROL#
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CONTACT: fl N
BUILDING PERMIT INFO
Nanbq Pbe Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB
MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT F E JOB DESCRIPTION
I lamb nlfirm that I am licensed under provisions of Chapim 9(commencing
IYZ with nn] (Division 3 ofthe Business and Professions Code,and my hot is RESDENTIAL'
PERMIT ISSUANCE
F,,O in fnceandelFe t. 'Z" ❑SI'DWI. ❑KITCHEN REMODEL
lU se not Li 'A APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
77,. ate - actor
to RC IT 5 DF.CLA ATION ❑MULTI-UNIT ❑STRUCTURAL
Fro uM d used as public records
PANELS MODIFICATION
y ON UPT02MAMPS [I INTERIOR ❑CHIMNEYREPAIR
p:,ytW Profess n nn a 20I-I(XgtAMPS IMPROVEMENT [3 SWIMMING POOLS
S Y y O ER-BUI DECLARATION OVER 10RAMPS ❑BATH RiwoDEIIREPAIR ❑DEMOLITION
j OC a Illereby affirm than rapt from the Contractors License Law for the ❑OTHER
�6V following reason.ISedinn 7031.5,Business and Professions Code:Any citynecnunry SIGNS ELECTRICAL
3 LL F which requires a permit to commvet,alter,improve,demolish,or repair any structure
F LL+0 prior to its issuance,also requires the applicant for such permit to file a signed Immanent SPECIAL CIRCUIT/MISC.
�} that he is licensed pursuant to Ne provisions of the Contractor's License Law(Chapter 9 C.OMMERCIAI'
LL�GC (commencing with Section 7ll(Il)of Division 3 of the Business end Pmfessions Code)or TEMP.METERORPOLEIN
6 y m pE Nat he is exempt therefrom and the basis for Ne alleged exemption.Any cwho n,of ❑NEW BLDG/ADDITION E]DEMOLITION
b411 to Section 9031.5 by any applicant for a permit subjects Ne applicant to a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
son more Nan five handled dollars($500). IMPROVEMENT
C] SWIMMING as nwnensf the pmpeny,or myemplOyeeswiN wago ea Neirsole cnmpenmtinn, SWIMMING POOL ELECTRIC ❑OTHER
will do the work,and the, ocutr,is not intanded or olicted for sale ISec.7044.Business
W and professions Code:The Contractors License Law does not apply to an owns of OUTLC'TS—SWITCHES—FIXT'URFS
a 3 propmy who builds or improves Hereon,uad who does such work himself nr through
two n employees,provided that such improvements arc nm intended or offered for NEW RESIDENTIAL ELECI'R SQ
We.If,however.the building or improvement is sold within one year of completion,the SQ,FT.FLUOR ARE $ISQ.IT.
wneobuilder will have the burden of proving that he did not Wild.,improve far .pur. Q^/1
o
pose Of sola). (•�
Fl 1,as owner of the property,am exclusively contmcting with licensed contractors to
comuuctthe project(Sec.9004,Business and Professions Codec The ConlmcmrI Li-
cense Law does not apply to an owner of popery who builds or improves thereon,and QTY. PLUMBING PERMIT FEE
who contracts for such pmjmts with a commewr(a)h=msM purmanuo the Contractors
License Law, PERMIT ISSUANCE
1 um exempt under Sec. B Is P C for this..,an
ALTP.R—DRAIN&VENT—W ER(EA) VAWAf1ON
Owner Date
WORKER'S COMPENSATION DECLARATION BACK FLOW PR(TI'ECT.
(zreby affirm under penalty of perjury one of the fol lowing dcchrmans:
?and will maintain a Certificate of Consent to self-insure for Workers Camper- DRAINS—FLUOR,ROOF IMA,C STORIES 7YPE CONSTRUCTIOI
ation,as provided for by Section 37M of the Labor Cale,for the performance of the
work fur which this permit is issued. FIXTURES—PER TRAP
I have and will maintain Workers Compensation Insurance,as required by Section
3900 of the Latin,Coda,for Ne performanceof the work for which this permit is issued. GAS—FA.SYSTEM-1 INC_ OCC.GROUP APN
My Wnrk yQypp��yv I ar ee comer and Policy^ryaq?3'S 55'V GAS—EA.SYSTEMOVER
4(EA1
cortico�/TD3a �� Policy (p
CERTIFICATE OF EXCMPTION FROM WORKERS' GREASFANDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DMSION FRES
(Thlssectirn need not becompleted iftbepermil is foronehumbed dollars(SIO0) GRF.ASETRAP
or less.) PLANCHECK FEE � r
I certify that in the performance of the work for which this Perini(is issued,l shall SEWER—SANITARY—STONM F.A.21g1 IT.
no(employ any parson in any manner an uI to became subject Io the Workers'Counsel. ENERGY EEE I
cation Laws of Califomia.Date WATER HEATER WNF.NT/ELECTR GRADING FEE
O O Applicant
NOTICE TO APPLICANT.If,after making this Cerificlte of Exemption,you should WATER SYSTHMffREATING
F W5 become subject to Ne Workers Cooperation maidims m of Ne Ladr Code,you must SOILS FEF.
forthwith comply with such provisions Or this permit shall bn deemed invoked WATER SERVICE
0
a
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PCMB. SQ.FL PAID
Ihcrehyal nnin hat there iso comometion lending agency lis(he performance of Date Raeiptp
LLi F Ile work for which this permit is inucd IS" CNP,Civ.C.l TOTAL:
O U Lender's Name
Lk1 Lendlex Address BUILDING FEE
Os I cerify that 1 hove read this application end atom that Ne above information is
(A correct,l agree to comply with all city and county ordinances and state laws mating to QTY, MECHANICAL PERMIT FEE SEISM IC FEE
V buildingcensiuction,and hereby amhorim repmsenmtives of Nis city to enter upon the
above-me
' p yforimpectionpurynI PERMIT ISSUANCE ELECTRIC FEE
a)agree to Lave,indemnify and Is less Ise City of Cupertino against
liala ex,juhho nt. cos(sund expense mayin way awmeagainst,aid City ALTER OR ADD TO MMIC PLUMBING FEE
nssapin ce of c granting of t to . p
ICANTU ERSTAND L LY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) g' ECHANICAL FEE
OU FA , ATIONS.
AIR HANDLING UNIT-(OVER 10,000 CFM) RUCTION TAX
res pili OdCont Date EXHAUST HOOD(W/DUCD GMITIGATION ICE
HAZARD SM Al DISCLOSURE
Will Nc applicant or(marc mg ac at It..or handle harsrdom matmal HEATING ONIT(TO 100,00)BTU) - u11YkJ
as defined by the Cupertino Municipal Code,Chapter 9.12.and the Health and Safety HEATING UNIT(OVER 100,000 BTU)
Code.Section 25532fa1T
L]Yes VN. VENTILATION FAN RESIDI PAID
hs Dam ftettipt p
Will the applicant or future building occupant use equipment or devices which BOILER—COMP(311P OR 1(0.1,0!X1 HTO)
,yh171/2
allot m us a4 contaminant defined by the Bay Ama Air Quality Management TOTAL:
aa
4c ...fff BOILER—COMP(OVER 100,000 BT U) _
es g No
/ AIR CONDITIONER ISSUANCE DATE
1 have road, hazenlousmate' 'rale men Mer Charter 6.95 of the Call-
a Health&Su it Code,See i 5505 S and 25534.1 umdcomnd that il'the NEW RESIDENTIAL.MECH.
h Ifdeta trot rrenLLy ave 'nt, smymapmsibility to notify the occu nt
the ' tie Iwhle met p' i....nceofaCmistatorlkcu
ISI thrrirdagem i \ ISSUED BY:
OFFICE