99110098 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION -
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ERLDINGAUDYESS: SANITARYN APPLICATION SUBMITTAL DATE
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OWNER'S AME: t� PHONE: C RAC OR' NAME: LIC NO:
V%N ^ O _ 2f dQ NIC CONTROL k
CHITECTMNGINEER: Q LIC NO: F ADDRESS: f` ❑
CONTACT: PHONE: 'BUILDING kERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATIONQTY ELECTRIC PERMIT FEE
1 hereby affirm that 1 am licensed under previsions of Chapter 9(commencing I JOB DESCRIPTION
Poo with Section7XIOUfDivision Softhe Bronres,tnd Professions Code,and my license is RESIDENTIAL;
1�
Fooin full force and effec. PERMIT ISSUANCE
W F [ISFDWL El KITCHEN REMODEL
�UU License Class-Lim, APPLIANCES-RESIDENT'IAL [I ADDITION El PLUMBING RE-PIPE
lirG 4 Data Chairman,
ARCHITECTS DECLARATION ElMULTI-UNITElSTRUCTURAL
z OD.in z i understand my plans shall be used as public recoNs PANELS MODIFICATION
pz„- UPT02MAMPS [I INTERIOR ❑CHIMNEY REPAIR
(... W Licensed Professional 2111-1000AMPS IMPROVEMENT I]SWIMMING POOLS
OWNER-BUILDER DECLARATION
.4 OVER 1000 AMPS ❑RATE REMODFUREPAIR ❑DEMOLITION
Q 1 hereby affirm tM1a.I am exempt from the Contractors License Law for the []OTHER
ip5,O.U following reason,(Serio 7031.5,Business and Professions Cade:Any city or only SIGNS ELECTRICAL
I++'3 Fv¢r which requires a permit to construct,alter,improve,demolish,or repair any sham c
F'yO.i prior wits issuance,also requires the applicant for such pennillofileasi,iodstmcmenl SPECIAL CIRCUIT/MISC. 41 Lyr! AA
that he is licensed pursuant m the provisions of the Contractors License Law(Chapter 9
aJQC> (commencing with Section 700()of Division 3 of the Business and professions Code) TEMP.METER OR POLE INST. '
d o qEMIAE
Tq that he is exempt therefrom and the basis Por the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
W"o N Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of FEWER DEVICES ❑TENANT ❑FOOD SERVICE
-F.S6not more than five hundred dollars SSW). IMPROVEMENT
p I,as owner utile property,or my employees with wages astheiambe compensation, SWIMMING POOL ELECI'EIC /
tsQ will do No work and the stmcture is not intended oroHeted for sale(Sec.7044,Business []OTHER
aase and Professions Code:The Contractors License Law does not apply no an owner of OUTLETS-SWITCHES-FIXTURES
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 offered for NEW RESIDENTIAL ELECTR SQ PT.
sale.If,however,the building or improvement is sold within one year of completion,the SQ.FT.FLOORARRA.__, $ISQ.FT.
owner-builder will have the burden of Forcing that he did nut build or improve for put-
0 of salf.) '
1,as owner of the property,am exclusively contructing with licensed contractors to
wTOTAL: 1 D
et the project(Sec.7044,Business and Prnfessions Cade:)The Convectors Li.
cense Law does not appy to an owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT FEE NOV
1 1 7
who contracts for such projects with a contmaogs)licensed pursaam to the Conlrudor's gg
License PERMIT ISSUANCE
exemp ;"
❑1 pro. r .B&P C for this reason r
AL9'ER-DRAIN&VENT-WATER TA) VALUATION
7M37MER'S COMPENSATION DECLARATION BACK PLOW PROTECT.DEVICE
thereby under Penalty of perjury one of the following declarations: !�
odIhaveard will maintana CenificateofCcament roself-insure forWmker's Compen- DRAINS-FLOOR,ROOF,AREA,COND. STORI S TYPE CONSTRUCTION
rie ,as proided for by Section 37M of the Labor Code,for the performunce of the
ork for which tsuis permit is ised. FIXTURES-PER TRAP
I have and will maintain Workers Compensation Insurance,as required by Section
of the Labor Ce,fonhe perfmmanceof the weak for which this permitis issued. GAS-EA.SYSTEM-I INC 4OUTLEfS OCC.GROUP ^ AP>
y Worker's Compensation Insurance carrier and Policy number are: - 7
Carrier Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' Q
COMPENSATION INSURANCE GREASEIINDUSTRL WASTE INTERCEPTOR ,$ ;$ UUILbING:bI I$IpNtF'NliS. M$+
(Tis.section reed net becompleted ifthe nermh is boron,hundred dollars($100) GREASETRAP
or Icss.7 PLANCHECK FEE
I certify that in the penbmianccofthe work for which this permit is issued,Lsbdl SEWER-SANITARY-STORM EA.200 FL
not employ any person in any manner so as to become subject w the Workeri Compen- ENERGY FEE
Q Z spoon Laws of California.Date WATER HEATER WNENT/ELECTR GRADING FEE
Q Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption.you should WATER SYSTEMITREATING
F ; hcome subject m the Workers Compensation provisions of the Labor Code,you must SOILS HE
Wforthwith comply with such previsions or this permit shall be deemed revoked. WATER SERVICE
Q
� z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLML SQ.ET. PAID Data ReceiptN
L.1 O (hereby affirm that is a construction lending agency for the peffrtmeneeof ,
(~ the work for which(his Fermn is issued(Sec.3097,Co.C.)
W Lender's Name TOTAL:
0. Lender's Address TOTAL BUILDING FEE
fe'^" 1 wniy that 1 have read this application and state that the above information Is
N correct.I agree to empty with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
VZ building construction,and hereby au.honze representatives of this city to enter upon the SEISMIC FEE
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)ngrea to save,normal y end keep harmless the City of Cupertino again.. BLHCTRIC PEE
liabilities,judgmen.s,costs and expenses which may in any way accrue against said City ALTER ORADDTO MUCH.
e of the g(�z 'Tl mndn ofihis permit. PLUMBING FEE
APPLICANT NDE US A "D WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
MECHANICAL FEE
SOURC 'C iL NS.
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
utureofA i Comraetor Dara EXHAUST HOOD(W/DUCT) HOUSING MITIGATION HE
HAZARDOUS MATERIALS DISCLOSURE
Willtleapplicamoc future building temporal store a,handle hazanlous material HEATING UNIT(TO 100,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safely
Code,Section 25532(a)? HEATING UNIT(OVER 100,000 BTU)
11 Yea ❑No VENTILATION FAN(SINGER RESID) PAID "-
Dam Receipta
Will the applicant or future building occupant use equipment or devices which _
mit hazardous air contaminants as defined by the Bay Arca Air Quality Management BOILER-COMP(3HP OR I(q,OW BTU)
T L:
Di#da? BOILER-COMP(OVER 1 o"WrU)
C]Yes ❑No
1 lave read the hazundma materialsrequirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
to Suba Code,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.FT.
uildinIdeas of ave mart,that i.is my responsibility to notify the occupant /�
oftbe req ' ahmustbe et prior w issuance of a Certificate of Occupancy.
c,oramhon gent Data TOTAL: ISSUED BY:
OFFICE