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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL P61NT PEN ONLY
CITY OF CUPERTINO IBUILDING -ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING -MECHANICAL
_ BUILDING PROJECT IDENTIFICATION
PERMIT NO. r 0
5'5
BUILDINGADDRFS
�r
SANITARY NO.
APPLICATION SUBMITTAL DATE
OWNERNA7R, - ^=HO
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WNTR ORSNAMFy , �CNQ
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CONTROL#
ARC E /ENGINEER: - LIC NO:
A DRESS:
11)5S5, LL' LKc,
CONTACE' PHONE:
BUILDING PERMIT INFO
'
❑ Consultant Fees Paid by Applicant (Initial)PLUMB
MECH "
fILyX( ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm that I am licensed trader provision, of Chapter 9 (commencing
QTY ELECTRIC PERMIT FEE
- JOB DESCRIPTION
with Section 7") of DD smm 3 ofthe Business an ofewions Code,andmylicenseis
in full force and effec . 3
LicenseC LIC.M
Date s Convector
PERMIT ISSUANCE'
W L El KITCHEN REMODEL
❑ ADDITION ❑PLUMBING RE -PIPE .
❑MULTI -UNIT ❑STRUCTURAL
MODIFICATION
ppPLIANCES— RESIDENTIAL
ARCHITECT'S DECLARATION
I understand my plans shall be used as public methods
PANELS -
UPTO 200 AMPS
El INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT • -
Licensed Professional
201-1000AMP$'
OWNER-BUILDER
OWNER -BUILDER DECLARATION Contractors
1 hereby affirm Um 1 from the Contractor's License Law for the
❑ BATH QjIR GI�1Eh{QL¢�N
OVER B)00 AMPS
SIGNS ELECTRICAL ^
following mown. (Section 7031.5, Business and Professions Code: Any city or county
OTHEREMQ�E
El OTHER
f
which requires a permit to construct, alter, improve, demolish, or repair any structure
prior to its issuance, also acquires theapplicent for such permit o file a signed statement
SPECIAL CIRCUIT/MISC.
that he is licensed pursuant o the provisions of the Contractors License Law (Chapter 9
TEMP, METER OR POLE INST.OMCOMCMERCIAL:
(commencing with Section7")'of Division 3.f the Businwawd Professions Code) or
that he is exempt therefrom and the basis for he alleged exemption. Any violation of
0 NEW BLDG/ADDITION, 0 DEMOLITION
Section 7031.5 by any applicant for a Pmanotsuhjixta the opplicantto a civil penalty of
not more Oran five hundred dollars ($500),
O Las owner of Ne property, or my employees with wages as their sole compensation,
will do Ne ..,it, and the structure isnot intended or offered for sale (sec.7nobt1 Business
POWER DEVICES
El TENANT '1 MOD SERVICE
IMPROVEMENT '
[]OTHER
SWIMMING POOL ELECTRIC
OUTLETS—SWITCHES—FIXTURES
and Professions Code: The Contractor's License Law does not apply to w owner of
property who builds or improves thereon, and who does such work himself or through
his own employees, provided that such improvements are not intended or o➢ered for
sale. If, however, the building or improvement is sold within one year ofcompletion,the
NEW RESIDENTIAL ELECTR SQ FT
SQ. FT. FLOOR AREA
'$/SQ. FT.
caner -builder will have the burden of proving that he did not build or improve for For,
pose of sale ).
0 I, as owner of the property, am exclusively commons with licenud conuacmrs m
^
pp ee D
A 1
'.1
TOTAL Q
construct the project (Sec. 7044, Business and Professions Code:) The Con ns mrs Li-
cense Law does not apply to an owner of property who builds or improves thereon, and
'DEC
•.
QTY, PLUMBING PERMIT FEE
who contracts for such projects with a owumemr(s) licensed ptamam r.,he Contractors
199
PERMIT ISSUANCE -
License Lo,
0 l we exempt under Sec. , B & P C for this rca n
C11 yr UUrc,-iY
Owner Date
ALTER — GRAIN & VENT — WATER (PAT
VALUATION
� %.fi w� .
WORKER'S COMPENSATION DECLARATION
BACK FLOW PROTECT. DEVICE
-
olnrm under penalty of perjury one of the following
Ie
Co
�jC/'i/
DRAINS—FLOOR, ROOF. AREA, COND.
and w Welles
Olbave and will main tains Certificate of the LaborCode, for Performance
Section 3]00 of the Labor Code, for the performanre of the
section, as provided for of the
STORIES
TYPE CONSTRUCTION
work for which mi is issued.
FIXTURES —PER TRAP
-
ill rimrmit
❑ 1 have and will maimain Workers Compensation required Section
3]00 of the La or Code, for the performance of the work for which this Pertnis is ismcd.
work hi h t i
'GAS — EA. SYSTEM -1 INC. 4OUTLETS
- OCC. GROUP
APN
My Worker n or rnr lnsu Policy
,latl
�carrierand
Gamer Policy Nm.:
GAS—EA. SYSTEM -OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
/
GREASIVINDUSTRL WASTE INTERCEPTOR G
BUILDING DIVISION FEES
(This section road nolbe wmplmWlftho permit is for onehuvdred dollars($100)
or less.)
I certify That in the performance of the work for which this permit is issued,) shall
not employ any Not.. in any manner so os w beer. subject m the Workwa' Compen-
GREASE TRAP
PLANCHECK FEE
SEWER—SANITARY—STORM EA. 2'k, FT
ENERGY FEE
. IQ
WATER HEATER WNENTMLECfR
sation Laws of California. Date
Applicant -
GRADING FEE
NOTICE TO APPLICANT. If, after making this Certificate of Exemption, you should
become subject to the Workers Compensation provisions of the Labor Code, you must
WATER SYSTEM/TREATING
SOBS FEE
,
forthwith comply with such provisions or this Permit shall be deemed revoked.
WATER SERVICE
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a coretruction lending agency for the performance of
NEW RESIDENTIAL PUSH. SQ. FT.
PAID
Date ReceiptM
the work for which this Permit is issued (Sec: 3097, Civ. C.)
Leoders Name
- TOTAL:
Leader's Address -
TOTAL:
BUILDING FEE
1 certify that I have read this application and state that he abenve information is
QTY, MECHANICAL PERMIT FEE
SEISMIC FEE
correct. I agree to comply with all city and century ordinances and state laws relating to
building construction, and hereby authorize representatives of his city m enter upon the
PERMIT ISSUANCE
BLBCTRIC ME
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino againat
PLUMBING FEE
liabilities,judgments, costs and expenses which may in any way name against said City
in sequence of he granting of this permit.
ALTER OR ADDTO MECH.
AIR HANDLING UNIT (TO 10,000 CFM)
MECHANICALFEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS.
AIR HANDLING UNIT (OVER 10,000 CFM)
CONSTRUCTION TAX
Signature of ApplicarmCommcmr Date -
HAZARDOUS MATERIALS DISCLOSURE
EXHAUST HOOD(WMUCT)
HOUSING MITIGATION FEE
HEATING UNIT (T0100,000 BTU) '
Will the applicant or future building occupant store crowds, hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and he Health and Safety
Code, Section 25532(0)]
HEATING UNIT (OVER 100,000 BTU)
�. []Yes ON. _
PAID
Dam Receipt k
VENTILATION FAN (SINGLE MST D)
_
BOILER— COME LIFE OR 100.000 BTU)
Will the applicant or future building occupant use equipment or devices which
pp g p nAir n
emit hazardous air contaminants as defined by the Bey Aree Air Quality Management
Di sWciT ,'
DYes ONo
TOTAL:
BOILER — COME(OVER 100," BTU)
1
AIR CONDITIONER
1 have read he niumos us materials nx,ohminews under Chapter 6.95 of the Cali-
ISSUANCE DATE
NEW RESIDENTIAL MECH. SQ, hT.
forma Health & Safety Cade, Sections 25505, 25533. and 25534. I understand hat if the
building was net currently have m mount, that it is my responsibility m notify the,ccupam
'
of the requirements which most be met prior no issuance of a Certificate of Occupancy.
-
ISSUED BY: -
TOTAL
Owner or authorized agent - - Date
OFFICE