31312 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY ts'
CITY OF CUPERTINO - BDILdc'eLEcfkICAL 312
BUILDING DIVISION' APPLICATION/PERMIT "PIAMBI G-MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDINOADDRESS: SANITARY NO. APPLICATION SUBMTITALDATE
OWN R' NA E: P E' CONTRACTOR'S NAME: - LIC NO:
NIC CONTROL#
ARCHIWUMNGINEER: LIC NO: ADDRESS: _ ❑
Ff.�c.d
- .. + PHONE: - BUILDING PERMIT INFO
• Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB -MECH
LIC ENSEDCONTRACfORS DECLAwisher ATION
fChaptQTY ELECTRIC PERMIT FEEffnn this 1 I' seeu d p f Ch pr 9( mencmg JOB DESCRIPTION
C000)of Divsi n3 ofthe Busi es and Profession Code and mylcense is00effect PERMIT ISSUANCE.y ❑SFDWL ❑KITCHEN REMODEL
IOULioN APPLIANCES-RESIDENTIAL CADDITION [_1 PLUMBING RE-PIPE
ytil Date Contractor
F ARCHITECT'S DECLARATION
ElMULTI-UNITEl STRUCTURAL
y o cn F4 I understand my plans shall he used as public records PANELS MODIFICATION
024O _ UP10200 AMPS [I INTERIOR El CHIMNEY REPAIR
-+' Licensed Professional 201-1000AMPS IMPROVEMENT
"�'q`PPKCC OWNER-BUILDER DECLARATION OVER IOOO AMPS El BATH REMQDpj/REPAIR DEMOLITION'
Ill affirm that 1 am exempt from the Contractor's License Law for the M�rµl•
ui 3O y U following reason.(Section 9031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL . C OTHER
4,F which requires a permit to consumer,alter,improve,demolish,or repair any structure
prior m its issuance,also requires the applicant for such permit to file a signed statement SPECIAL CIRCUIT/MISC. Le
'*-
p., that he is licensed pursuant to the provisions ofthe Contractor's License Lw(Chapter 9'
W GC (commencing with Section 7000)of Division 3 ofthe Business and Professions Code)or TEMP.METER OR POLE MST. COMMERCIAL,
that he is exempt therefrom and the basis for the alleged exemption.Any violation of .C NEW BLDGIADDITION ❑DEMOLITION
^Y• Section 7031.5 bapplicant for a permit sucw the applicant to a civil penalty of POWER DEVICES y y any bje
OTENANT IMPROV El FOOD SERVICE
qyy not more than five hundred dollar ($empl IMPROVEMENT
as owner of the pro pent',rmyemntended with wagcsrtheir(Sec.compensation, SWIMMING POOL ELECTRIC
t'0 will Bothe Professions
and the structure is to intended Law ed does
of apply t oan Business ❑OTHER
3 and arty who
Code:The oyes thereon,
License Law does not apply to if owner of OUTLETS-SWITCHES-FIXTURES
a' property who builds or improves thereon;and who dcee such work himself or through - -
his own employees,provided that such improvements are not Intended or offered for NEW RESIDENTIAL ELECTR SQ FT. "
sale.If,however the building or improvement is sold within one year ofcomplaumi the t SQ.FT.FLOOR AREA $ISQ.FT.
owner-builder will have the burden of proving that he did not build or improve for pit, f D
pose of sale). -
❑ I,as owner of the property,am exclusively contracting with licensed contractors to
construct Ne project(Sec.7044,Business and Professions Code:)The Contractor's Li- "
cense Use does not apply to an owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT FEE OCT1,v a �(I��
who contracts for such projects with a conaacmis)licensed pursuant to the Contractors O W 1. Y7
License Law. PERMIT ISSUANCE
❑lam exempt under Sec. .B&P C for this reason
Owner Date ALTER-DRAIN&VENT-WATER IEA) A UA O
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE
I hereby affirm under penalty of perjury one ofthe following declarations: iF
❑I have and will maintain a Certificate of Consent to self-insure for Worker's Compen- DRAINS-FI.00R,ROOF AREA,COND, STORIES TYPE CONSTRUCTION
sation,as provided for by Section 3100 of the Labor Code,for Ne performance of the _
work for which this permit is issued. FIXTURES-PER TRAP 'I
❑I have and will maintain Workers Compensation Insurance,as required by Section
37M of the labor Code,for the performance of the work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP „ , APN '
My Worker's Compensation Insurance carrier and Policy number arc: - -
Cmner Policy Na: GAS-EA.SYSTEM-OVER4(EA) -
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEANDUSTRL WASTE INTERCEPTOR BUILDING[ ISION"FEES
(This section need not be completed ifthe permit is for hundred dollars 5100) GREASETRAP
m less.) PLANCHECK FEE
I cerify that in the performance lithe work for which this permit is issued,Ishall SEWER-SANITARY-STORM EA.200 FT. If
not employ any person in any manner so as to become subject to the Worker,Compen- ENERGY FEE
Z cation Laws ofCalifrria.Date WATERHEATERWNENT/ELECTR-
C Applicant GRADING
y NOTICE TO APPLICANT,IE after making this Certificate of Exemption,you should WATER SYSTENIG REATiNG SOUS FE
a become subject to the Woke,Compensaion provisions of te m
hLabor Code,you ust
W foMwith comply with such provisions nr this permit shall be deemed revoked. WATER SERVICE
Qz CONSTRUCTION LENDING AGENCY Y' NEW RESIDENTIAL PLMB. SQ.Ff. ' PAID
0 I hereby affirm that there is a construction lending agency for the performance of Dalt I Receipt#
hr the work for which this permit is issued(Sec,3097,Civ.C.)
Leaders Name _ - TOTAL:
U Lender's Address TOTAL:
s�" W I ramify that 1 have read this application and state that.the above information is BUILDING F
br f�yA comet.I agree m comply with all city and county ordinances and state laws relating to QTY MECHANICAL PERMIT FEE SEISMIC FE
V F7 buildingconumetion,and hereby immorii,amnescraideesofthls cityto entarupon the
aMva-memlomed propeny for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
habililies,judgments,costsand as,moss which may in any way accrue against said City ALTER ORADDTO MECH. PLUMBING PEE
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLYWITH ALL ANON-POINT AIR HANDLING UNIT(TO 10,000 CFM) MECHANICAL FEE _
SOURCE REGULATIONS.
''AIR HANDLING UNIT(OVER Might CFM) CONSTRUCTION TAX '
Signature of ApplicantsContrenor Data EXHAUST HOOD(WMUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
- Will the applicant or future building occupant store or handle hamrdous muternal HEATING UNIT TO 100,000 BTU) '
a defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety -
Code.Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU) -
❑Yes nNn PAID
VENTILATION FAN(SINGLE RESID) - Dam Receipt#
Will the applicant or future building occupant dse equipment or devices which -
analhatmodousair contamir t a defined by the Bay Arco Ail Quality Management BOILER-COMP(3HPOR 100,000BTU)
TOTAL:
DislnuEl - BOILER-COMP(OVER 100,000 BTU) '
❑Year s]No
I have read the haznrd`ous mstenuls reyuirements under Chapter 6.95 of Ne Cali- AIR CONDITIONER ISSUANCE DATE
fomia Health&Safety Code,Sections 25505,25533 and 25534,1 understand that if the NEW RESIDENTIAL:MECH. SQ.Fr.'
building does not contently haves reason,that it is my responsibility in notify the occupant
of the requirements which must be into prior to issuance of a Cenific rte of Occupancy.
Owner or authonzW agent Data TOTAL: ISSUED BY:
OFFICE
ADDITIONAL PERMIT.FEES
BUILDING PROJECT IDENTIFICATION VALUATION
.L11.1
aoDRE
1101 Cgju—,ick P
DNNER3
01 I /1 kV ( vHONE .).rj I FEE SUMMARY
CONT ((��QQ
I4A.E rags BUILDING
C
V�V L C� "C.NO. PLAN CHECK
CONTRACTOR'S FEE
ADDRESS
vNoxE SEISMIC FEE
OTV. ELECTRIC PERMIT FEE
UTLETS-SWITCHES-RECEP ELECTRIC 22A
LIGHTING FIXTURES PLUMBING
APPLIANCES-RESIDENTIAL
PANELS ECHANICAL
SIGNS
SIGNS TRANS. TOT L 22•�
SPECIALCIRCUIT 1 v
EMP.METER OR POLE INS. PERMIT VA
LIDATION
MOTORS SEE FEE SCH. AN 14 III.0 I
SERVICE CHANGE
Z z Cfi Ur IurcNlfNO
T TOTAL
ISSUANCE DATE
Lu R! QTY. PLUMBING PERMIT FEE BIOG. I Ejj PEG. MED".
M z ALTER-DRAIN&VENT-WATER(EA.) ❑ ❑ ❑
U O BACK FLOW PROTECT.DEVICE
O w DRAWS-FLOOR,ROOF,AREA,COND.
} y FIXTURES-PER TRAP (//y
F z GAS-EA.SYSTEM-l1NC.4OUTLETS
() GAS-EA.SYSTEM-OVER 4 IEA.)
INDUSTRIALWASTE INTER.
LAWN SPRINKLERS-1 INC 5 V.B.
LAWN SPRINKLERS-OVER 5(EA.)
SEWER-SANITARY-STORM EA.200ft/
WATER HEATER W/VENT
WATER SYSTEM
WATER TREATING EQUIP. y
TOTAL
GTV. MECHANICAL PERMIT FEE .A
ALTER OR ADD TO MECH. .
APPLIANCE
AIR HANDLING UNIT(TO I&=CF.M.)
AIR HANDLING UNIT IOVFA 10000CEM.)
EXHAUST HOOD(WITH DUCT)
HEATING UNIT(TO 100.000 B.T.U.)
HEATI NG UNIT 10 V ER 100,000 B.T.U.)
VENTILATION FAN(SINGLE)
BOILER-COM1P(3 H.P.or 100,000 B.T.U.)
BOILER-COMP low~.IODUDD BTUI SEE FEESC
TOTAL