B 0202 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO�
PLUMBINGI � O L 02
BUILDING DIVISION APPLICATION/PERMIT BUILDING PROJECTIDENTIFICATION
SANITARY NO. APPLICATION SUBMITTAL DATE
BUILDING ADDRESS
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OWNER'S NAME: PHONE: CONTRACTOR'S NAME: LIC NO'. -NIC CON'TROLM
ARCHITECTANGINEER: LIC NO: ADDRG95: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
C S / C ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB h1Ef�CH/!
❑ ❑ ❑ LJ
LICENSE[)CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE JOB DESCRIPTION
1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing
C8Z with Section 7")mfDivision 3,fnc Business add Professions Code.and my license is RESIDENTIAL;
{sl O PERMIT ISSUANCE
F O in full farce Lind effect ❑SFDWL ❑KITCHEN REMODEL
Q V UPU License Class Lie.p APPLIANCES-RESIDENTIAL. ❑ADDITION ❑PLUMBING RE-PIPE
F•Z W Date Contractor
rn6y ❑MULTI-UNIT ❑STRUCTURAL.
Oh ARCHITECTS DECLARATION PANELS MODIFICATION
w Z 1 understand my plans shall be used as public records
UP TO 21p AMPS
❑INTERIOR [I CHIMNEY REPAIR
yOj Licensed Professional 2111-I(NN)AMPS - IMPROVEMENT ElSWIMMING POOLS
�Yf OWNER-BUILDER DECLARATION OVERT AMPS ❑BATH RBMODEUREPAIR C1 DEMOLITION
SS C I hereby efOnn that 1 am exempt from the Commcmi s License Law for the ❑OTHER
pd 3 a v following rcoson.(Seedon 7031.5,Business and Profession,Code:Any city or county SIGNS F.1 (CAL
llilil W O which inquires a Imnit m conswd are,improve,dere.00,or reliability swctme 1
prime,it issmnce,Lilsorcquires the...heum ILL pe,.iu,Elea signed smtemem SPECIA IT/MISC.
y�M} that he is licensed pursuamto Ne provisions offer Convector's License Law(ChaP¢r9
6W"t7 (commencing with Section 7001 Union.3°frhe Business it Profession Code)or TEMP.METER . LE INST. COMMERCIAL
F y M a that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
tIX1 I+N• Section 7031.5 by any applicant for a permit subjects the applicant a civil penalty of POWER DEVICES [I TENANT ❑FOOD SERVICE
t tome Nan five hundred dollars(5500). IMPROVEMENT.
Q �1,as owner of the propcng or my employees with wages as their sole compensation, SWIMMING POOL ELECTR
will do the work.and Ne swctore is not intended m uffeded for sale(Soc. Business ❑OTHER
Lae and Professions Code:The Contracting License Law docs not apply m an owner of OUTLETS-SWITCHES-FE TURES
-. property be builds or improves thriven,and who does such work himself or through
his awn employees,provided Nat such impmvemen4 are nor intended or offered for NEW RESIDENTIAL ELECTR SQ PT.
sale.If.however,the building or improvement is sold within,neywrofcnmpletion,Ne SQ.Ff.FLOOR AREA SISQ.FT.
owner-huilder will have the burden of paving that he did nal buil]or improve fur pur-
pose of sole.).
TOTAL'
I,as owner of the property,am exclusively contracting with licensed contractors m
construct the project(Sec.7044.Business and Professions Core;)'I he Contractor's Li-
cameLaw does not apply toanowner ofproperty who builds or improves thereon.and QTY PLUMBING PERMIT FEE
who contract(,.such projects with a,ommetod(,<)licensed pursuunuo the Contractor's -
License Law. PERMIT ISSUANCE
1 am exempt under Sec. .B&P C for this reason
Owner
0�Q
ALTER-GRAIN&VENT-WATER 0A) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby allirtn under penalty of perjury one of Ne following dection ions:
❑I have and will maintain a Certificate mf Conant t°self-insure furworkees Cnmpen- DRAINS-FLOOR,RODE AREA,COND. STOR1&S TYPE CONS I KUCTIO!
ardor,as provided for by Section 37W of the Labor Cody for the performance of the
work for which this permit is issued. FIXTURES-PER TRAP
1 have and will maintain Wm els Compensation Insurance,as declared by Section
3700 of the Labor Code,for the performance of the work far which this permit is issued. GAS
-FiA.SYSfEM-I INC.40I1TLLT5 OCC GROUP APN
My Wmkers Compenmtimn Imurance artier and Policy number tae:
Cartier: Policy No.: GAS-EA.SYSTEM OVER 41EA)
CERTIFICATE.OF EXEMPTION FROM WORKERS' GREASELINDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE HUILUING DTVI SION FEES _
(This section=it not h,completed lithe permit is forms,hundred dollars(51110) GREASE TRAP
PLANCHECK FEE
to less.)
I certify that in the performance ofdhe work for which this From is issued,)shut SEWER-SANITARY-STORM EA.200 FT.
not employ say person in any mummer so es to become subject to the Workers'Co.,.- ENERGINY FEE
Ztadien Laws of California.Data WATER HEATER WNENVELECTR GRADG FEE
Q Applicant I
NOTICE TO APPLICANT If,afar making this Certif¢nm of Exemption,you should WATER SYSTEM/I'REATING
FN-O5011.5 FEE
abecome subject to Lou Worker's Compensation provisions of the Labor Csde,you must
Lkl f,nhwith comply with such previsions or this permit shall be deemed revoked. WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. D ReceiptM
I hereby affirm that there is a construction lending agency for the performance of
W the work for which this pannit Is Issued(gee.3097.Co.C.) J 'TOTAL:
Q V Lender's Name
Lembe,Address TOTAL.
0. 1 earl fy Nm I have read this application end than that the°hove information is )LNG
tF. N storm.I sato to comply with all city add county ordinances and state laws relating t QTY, MECHANICA P�.11T FEE SEI. IC FEE
(,) building conduction,and hereby authorize representatives ofthis city to enter uptto Lie
above.mentioned property for inspecdios pudpores. PERMIT ISSUANCE r RICE
1 We)agree to save,indemnify and keep hadmless the City of Cupenino against
liabilidiw,judgments,costs and expenses which may in any way seem,against said City ALTER OR ADD TO MECH. PLUMBING FEE
in consequence mf the granting of Nis pemdt.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,00)CFM) MECHANICAL FE
SOURCE REGULATIONS,
AIR HANDLING UNIT(OVER lO,IXNI CFM) CONSTRUCf10N TAX
Sigvamre,f Applierad Conuecmr Data EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
'HAZARDOUS MATERIALS DISCLOSURE.
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(TO Hn000 BTU)
as defined by the Cupenis0 Municipal Cdde;Chapter 9.12,and the Heald end Safety HEATING UNIT(OVER 100,1100 BTU)
Cede,Sectiou 25532(x)?
❑Yes f7 No WHO
AN(SINGLE RESID) PAID Dare Receipt#
Will the applicant or future building°ccepam use equipment or devices which COMP OR 1011,000 BTU)
emit handers air contaminants as defined by the Bay Arca Air Quality Management TOTAL.
. District? P(OVER 100.000 BTU)
E]Yes ❑Na
I have read the hazardous materials mquitnments oder Chapter 6.95 of the Cali- NER ISSUANCE DATE
fnmia 11ca1N&Safety Code,Sections 25505,25533 and 25534.1 understand Nm if theIAL.MECH. SQ.FT.
building does nal currently have a tenant that it is my responsibility to notify Ne occupantlv
of this,requirement which mum be met Frim to issuance of a Certificate of Occupancy. �f
OwnermeuNnrized agent Da¢ AL ISSUED HY:�Q� R �� O
OFFICE