31119APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING -ELECTRICAL
PERMIT NO. J
"JI. l9A
BUILDING DIVISION APPLICATION/PERMIT, - PLUMBING - MECHANICAL. -
•I BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS:
SANITARY NO.
APPLICATION SUBMITTAL DATE
—�
OWNERS NAME, S, PHONE:
.I
„�O�_
CTRACTORME: LIC NO
/
X
N/C
CONTROLM�1
❑
A CHITECT/ENOINEERLIC NO
ADDSSS:
l ea 97. S alynz, brl t
CONTACT: - PHONE.
- 1
BUILDING PERMIT INFO
EI'Consultant Fees Paid by Applicant (Initial)
^ BLDG ELECT PLUMB MECH
❑ o❑
LICENSED CONTRACTOR'S DECLARATION
I hereby.M,. Net I am licensed under provnimm of Chapter 9 (commending
with Sectim70hr Division 3 of the Busiiessaad Professions Code,indmy license is
in full forceund effect.
QTY. ELECTRIC PERMIT FEE
W0Z
F+�
JOB DESCRIPTION
RESIDENTIAL'
❑SFDWL ❑KITCHEN REMODEL
'PERMITdSSUANCE
APPLIANCES - RESIDENTIAL -
�V
Da
Hm
r� 7�
License Class - Cmithmanr
Dataom,i
❑ ADDITION ❑PLUMBING RE -PIPE
❑MULTI -UNIT ❑STRUCTURAL
MODIFICATION
ARCHITECTS DECLARATION
1 understand my.pinns shell be used es public recortls
PANELS �
60
Z-
'?
i4 a
Licensed Professional -
OWNER -BUILDER DECLARATION
1 hereby affirm dmi I am exempt from the Contractors License Law for the
following reason (Section ]01IS, Business and Professions Code: Any city or county
UP TO 200 AMPS
I ❑INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT
[I BATH REMODEVRBPAIR 0 DEMOLITION
❑OTHER
201-I0OOAMPS
OVER IOOl1AMP5
SIGNS ELECTRICAL
O yt
.i --iii
a�,
which requires a permit to commoner, alter, improve, demolish: traction
repair, any stion
priormils issuance, also requires the applicam for such permitm lileasigned statement
di he is licensed pursuant to the provisions ofthe Contractor's License Law(Chapter9
SPECIAL CIRCUIT/MISC.
ail
TEMP. METER OR POLE INST.OF
-
COMMERCIAL:
❑ NEW BLDG/ADDITION ❑ DEMOLITION
❑TENANT ❑ FOOD SERVICE
IMPROVEMENT
❑O ER
00
Yyi$ o e'
W^m
iZ}
�C
a o
Lm
(commencing with Section 900) of Division 3 of Ne Business and Professions Code) or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil Penalty of
or an than five hundred dollars ($50%
❑I, as ownerof the propetty, or my employtts with wages as their sole compensation,
will do the work, and the structure is not im"dedmoffered forsulc(Site ]044, Business
and Professions Code: The Contractor's License Law does not apply to an owner of
-
POWER DEVICES
SWIMMING POOL ELECTRIC
-
OUTLETS - SWITCHES -FIXTURES
property who builds or improves thereon. and who does such work himself or through
his own employees, provided that such improvements an not intended or offend for
sale. If. however. the building or improvement is sold within one year of completion, the
NEW RESIDENTIAL ELECfR SQ FT. 10,
SQ. IT. FLOOR AREA
$/SQ. FT.
"
owner -builder will have the burden of Forcing that he did not build or improve for put-
Pose of sale.).
❑ I, as owner of the pmpeM, am exclusively contracting with licensed contractors to
"1
TOTAL:
construct the project (Sec. 7044, Business and Professions Coa eU The Contractor's Li.
n�
-
cense Law does not apply to un owner of property who builds or improves thereon, and
QTY. PLUMBING PERMIT FEE
who contracts for such projects with a eontmclood licensed pursuant to the Convenes
License Law.
❑ 1 am exempt under Sec: , B & P C for this revson
Ca/T
PERMIT ISSUANCE
ALTER - DRAIN & VENT - WATER (EA)
Owner Duce
ey//nn,�/� VALUATION '
WORKER'S COMPENSATION DECLARATION
BACK FLOW PROTECT. DEVICE
,Yx/
I hereby affirm under penalty of perjury one of the following declarations:
DRAINS- FLOOR, ROOF, AREA, COND.STORIES
I have and will maintain a Certificate of Consenuo self -insure for Worker's Compen-
sa0on, as provided for by Section 370 of the Labor Cade, for the performance df the
TY PE CONSTRUCTION
work for which this permit is issued.'
FIXTURES - PER TRAP
❑ I have and will maintain Worker's Compensation Insurance, as required by Section
370 ofthe Luber Cade, for the performance ofthe work for which this permit is issued.
GAS -EA. SYSTEM -1 INC. 4 OUTLETS
. OCC. GROUP
APN
-
My Wor 6C xmylyYvs `c d Policy t)rpij U%W-?Xi
Carriee�_f. R T PalIcy �YRK
t '
GAS -EA. SYSTEM -OVER 4(EA)
O
RTIFICCO OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
1
GREASFJINDUSTRL WASTE INTERCEPTOR •
BUILDING DIVISION FE IS
(This section need not becompletW iftha permitisfor one hundred dallare ($ 100)
or loss.)
GREASETRAP
PLANCHECK FEE _
Z
WQ
Cw
U O
I certify that in the perfmoremoeofthe work far which this Permit is issued,Ishan
not employ any person in any manner so as to become subject o the Workers' Compen-
action Laws of California. Date
Applicent -
SEWER -SANITARY -STORM PA. 20 PT.
ENERGY FEE
WATER HEATER WIVENT/ELECIR
'GRADING FEE
NOTICE TO APPLICANT If, after making this Certificate of Exemption, you xhould
become subject to the Worker's Compensation provisions of the Labor Cade, you most
forthwith comply with such provisions (it this permit shall be deemed revoked
CONSTRUCTION LENDING AGENCYESTDENTIAL
Ihereby affirm that there is a construction lending agency fill he latmmance of
ER S T qvb BEATING
WATERS VICE
SOILS FEE
PAID
Date Receipt is
PLMB. SQ: FT.
�+
0
WLender's
Ln
U%.
the work for which this permit is issued (Sec 3097, Civ. C.)
Lenders Name
-
TOTAL'
TOTAL:
Address
I certify that I have read this application and state that the above information is
correct I agree to comply with all city and county ordinances and state laws relating to
building construction, and hereby authorize representatives of Nis city to enter upon the
above-memmindproperty for inspection puiposes.
(We) agree to save, indemnify and keep hormless the City of Cupertino against
liabilities,judgments, costs and expenses which may in any way tri against said City
inconsequence of the gra ting of Nis per 't.
-CO
BUILDING FEE
QTY. MECHANICAL PERMIT FEE
SEISMIC FEE
PERMIT ISSUANCE 1.
ELECTRIC FEE
-
PLUMBING FEE
ALTER OR ADDTO MECH.
AIR HANDLING UNIT (TO 10,000 CFM)
MECHANICAL FEE
APPLICANT ANDSA L PLY WITH ALL NON -POINT
SOURCE S.
AIR HANDLING UNIT (OVER 10,000 CFM)
CONSTRUCTIONTAX
�$
Sign reaf Ap cam/Contmc Date
HAZARDOUS MATERIALS DISCLOSURE
EXHAUST HOOD (W/DUCT)..
HOUSING MITIGATION FEE
HEATING UNIT (TO 100,01 BTU)
-
Will the applicant or future building occupant stare or handle loozmdous material.
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Cud, Section 25532my?
HEATING UNIT (OVER 100,000 BTU)
.DYesF-INo
Will d... applicant or future building by the D use equipment or devices which
emit hazadoos air contaminants as defined by the Bay Area Air Quality Management
District?
�ElYes EJ No
PAID
Dem Receiptk
VENTILATION FAN (SINGLE RESID)
BOILER -COMP (3HP OR I00,000 BTU)
TOTAL. .h V
YSSd
BOILER- COMP (OVER 100,000 BTU)
-
AIR CONDITIONER
I have read the hazardous materials requirements under Chapter 6,95 of the Cali-
ISSUANCE DATE
NEW RESIDENTIAL MECH. i SQ. Fr
f rmin Health At Safety Code, Sections 25505, 25533 and 25534. 1 understand Nat if the
building does not currently have a tenant that it is my responsibility to notify the occupant
of Ne requirements which must be met prior to issuance of a Certificate of Occupancy.
TOTAL:
ISSUED BY: • _
Owner or authorized agent .. - Date
OFFICE