S 1004 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY _
CITY IOl..F CUPERTINO BUILDING-ELECTRICAL PF-J`�1IT NG.
." BUILUvNGDIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL �J 1004
BUILDING PROJECT IDENTIFICATION
UILDINO ADDRESS: - SANITARY NO. APPLICATION SUBMITTAL DATE
/O.U7 qR O E 1,b,
NEP.' HONE: CONTRACTOR'S NAME: LIC NO NIC CON 'ROL#
RCHITECDENGINEER: LIC NO: ADDRESS: ❑
CONT PHONE: BUILDING PERMIT INFO
Consultant Fees Paid by Applicant(Initial) BLDG LE UMB
Rbrlr❑ EC
16
LICENSED CONTRACTOR'S DECLARATIONQTY ELECTRIC PERMIT FEE
I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIM10N
OMZ with Seeded 7")of Division 3of,he Businessand Professions Cial,ind my license is RESIDENTIAL'
00 in full force end effect. PERMIT ISSUANCE
tO F, RESIDE El KITCHEN REMODEL
�U aClass Lie.
Date-
APPLIANCES-RESIDENT ❑
IAL ADDITION El PLUMBING RE-PIPE
a Dale Cammetm
Dy ARCHITECT'S DECLARATIONPANELS ❑MUI.TI-UNIT ❑STRUCTURAL
[[[8 n IK 1 understand my plans shall be used as public records MODIFICATION
pZ UPT02MAMPS ElINTERIOR El CHIMNEY REPAIR
Licensed Professional 201-1000AMPS IMPROVEMENT 0SWIMMING POOLS
$d 2, OWNER-BUILDER DECLARATIONOVER HITIPAMPS 0 BATH RE h�f� / AIR DEMOLIT
C OG I hereby affirm that 1 am exempt from the Contractor's
ffLicense Law for the 'J{{��.D
{TLS O y U following reason.(Section 7031.5,Buoress and Professions Code:Any city or county SIGNS ELECTRICAL OOTHER r�..q--
W 40.0 E' which requires a permit to conswct,alter,improve,demolish,or repair any structure
JR
pnonoin issuance,also requiresthe applicem for such permit to filen signed namme^t SPECIAL CIRCUIT/MISC.
W� that he is licensed pursuant to the provisions ofthe Contractors License Law(Chapter9
X00 (commencing with Section 7000)of Division 3 oftbe Bu,amas, nd Professions Code)., TEMP.MEFER OR POLE INST. COMMERCIAL:
4 a that he is exempt therefrom and the basis for the alleged exemption.Any violation of 0 NEW BLDGIADDITI N 0 DEMOLITION
G. Section]031.5 b
^, m y any applicant for n permit subjects the applicant to a civil Penalty of POWER DEVICES ICES 0 TENANT 0 FOOD SERVICE
Z,y not more then five hundred dollars($500). IMPROVEMENT
x6 01,as he,of me property,m my emfloyees with wages astheir sole compensation. SWIMMING POOL ELECTRIC
FO will do the work,and the structure is not intended proffered forsale(Sm.7044,Business. - DOTTER
Ivm vad Profession,Cafe:The Contractor's License Law does not apply m an owner of OUTLETS-SWITCHES-PI%TURES
property who builds or improves thereon,and who does such work himself or tbmugh
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ FT.
side.IL however the building or improvement is sold within one yearofcrmplamin,the SQ.FT.FLOOR AREA $/SQ.IT.
owner-builder will have the horde.of proving that he did not build yr improve forpur-
pnsemsale.). I D
1,as owner of the property,am exclusively contracting with licensed contractors to TOTAL: t
onsvuct the perfect(Sec.7004,Business and Professions Code:)The Contractor's Li-
nse Law does not apply m an owner of property who builds or improves thereon,and QTY, PLU IN ERMIT FEE OCT 0 7 REC,9
who contracts for such projects with a contractar(s)licensed pursuant the Contractor',
C
License law. PERMIT ISSUANCE /,
❑ lame to der Sec. B&P C for this reason 'T�I I Vr VUYt
011
:fl5wraF j7 ALTER-DRAIN&VENT-WA ER( ) VALUATION—
nal
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE, -
1 hereby illlmai under penalty of perjury me o the following declarations:
(have and will far by Se Certificate of Consent to sold,for the
Workers Critics- DRAINS-FLOOR,ROOF.AREA,GOND. STORIES TYPE CONSTRUCTION
alI..,r provided for mi Section 3700 of the Labor Code,for the performance of the
work far wbidM1 this gamut is issued. FIXTURES-PER TRAP
I of he swill maintain Worker',mance of
ftheowork for which
h required by Section
My of LaborCode,
nsatifor n Insurance cancer and Policyforwhich this permit is issue]. GAS-GA.SYSTEM-I INC.4OUTLETS OCC.GROUP APN
My Worker's Compensation Insurance carrier and Policy number are:
GAS-EA.SYSTEM-OVER 4(EA)
Carrier: Policy FROM
'
CERTIFICATEOFCOMPENSATION
NFROM WORKERS' GREASEANDUSTRI,WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION PEES
(This section need not he completed tribe permit is foronr hundred dollms($100) GREASF,TRAP
or lass,) PLANCHECK FEE
I certify that in the performance ofthe workmrwhich this permit is issued,l shall SEWER-SANITARY-STORM EA.200
peIT.
not employ any rson in any manner so as to become subject to the Worken.'ComNn- ENERGY FEE
O Z setion Laws of Cali omiv,Data WATER HEATER W/VENT/ELECTR
0 Applicant GRADING FEE
7 _
G f/� NOTICE TO APPLICANT:If,utter making this Ceri ficnte of E,emp kar you should WATER SYSTEM?HEATING SOILS FEE became subject to the Workers Compensation provisions of the Labor Come,you must
WIti forthwith comply with such provisions or permit shall be deemed revoked. WATER SERVICE
Q
Dz
CONSTRUCTION LENDING AGENCY NEW RESIUENTIALPLMB. SQ.IT PAID Date
V Q work
which
that ixsued(Sec.3097ndie.agency for tha performanw rl'
H the work for which this permit is issued(Sec.3f19],Civ.C.)
H" Landers Name TOTAL:
GUSI Lender's Address - TOTAL:
1 certify that I have read this application and smr,that the above information ix BUILDING P
C4-t V�1 correct.I agree to comply with all city and county ordinances and acme laws relating to QTY. MECHANICAL PERMIT FEE
U mantingwnx.uctiou,and hereby authorize representatives ofthis city to enter upon the SEISMIC FEEif
i dwe-mentioned property far inspection funguses. PERMIT ISSUANCE
(We)agree m save,indemnify and keep hmmless the City of Cupertino acorn ELECTRIC FEE
liabihties,judgmena.easts andexpenseswhich may in anywvyeccrue agalostsaid City ALTER OR ADD TO MECH.
I.comae"nay the grnting of this permit. PLUMBING FEE
APPLICA'f`, DERSuTANUS ANDWILL COMPLY ITH ALL NON-POINT AIR HANDLING UNIT(TO 10.0X10 CFM)
SOUMEL MECHANICALFE,
AIR HANDLING UNIT(OVER 10,"CFM)' CONSTRUCTION TAX
.4 a Date EXHAUST HOOD(WIDUCI') HOUSING MITIGATION FE
HAZARDOUS MATERIALS DISCLOSURE
Will theapplicant or future builiingoc....mature or handle hazaMon,material HEATING UNIT LTD 101,1100 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,end the Health and Safety
Code,Section 25532pd? HEATING UNIT(OVER 100,000 BTU)
❑Yes ON. VENTILATION FAN(SINGLE RESID) PAID
Data Receipt#
Will the applicant or future huilding occupant use equipment or device,which
haeardru.s air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(3HPDR 100,000 BTU)
TOTAL:7it
lnetl BOILER-COMP(OVER 100,000BTID
❑Yes ON.
I have read the hazardous materials requirements under Chapter 6.95 of the Culi- AIR CONDITIONER ISSUANCE DATE
rme Health&Safety Code,Sections 25505,2553]end 255]4.1 understand that if the NEW RESIDENTIAL MECH. SQ.ET.
lding does not currently haventenent.that it is my responsibilitymnotify the mcupamthe requirements which must be met prior to issuance of a Cenilicate of Occupancy.
ner or authorized agent Data TOTAL: ISSUED BY:
OFFICE