S 0214 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PE MITNO.
BUILDING DIVISION APPLICATION/PRRMITPLUMBING-MECHANICAL 0214
BUILDING PROJECT 111E CATIIIN
UILDING ADDRF_SS: - SANITARY NO. - APPLICATION SUBMITTAL DAN
10 0 -TO-
:R'SNAMC: PHONE: CONTRACTOR'S NAME: LIC NO:
O NIC CON'IROLx
ARCHITF.C'1'/ENGINEER: LIC NO: AUUN&SS:
Ca
CONTACT: PHONE: _ BUILE NGPERMIT INFO
�hV�t v /'f/1 O aw tZ/x Consultant Fees Paid by Applicant(Initial) PLUMB MECH
LICENSED CONTRACTOR'S(DECLARATION r9 Q TY ELECTRIC PERMIT PEE
O a z 1 hereby abrin that I am licensed under provision s of Chapter 9 em unamic ng JOB DESCRIPTION
y)O with Section)00)o'Division3 fthe Flusinese.nd Probes sionx Code,and my license is R
E W_ in full force and effect. PERMIT ISSUANCE FCIDF�NT11
�ut License Class Ou.x ❑SFDWL ❑KITCHEN REMODEL
�<kd1 Dam Coarsenr APPLIANCES-RUSIE)CWIA ❑ADDITION ❑PLUMBING RE-PIPE.
py ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT El STRUCTURAL
Z O Z I underxuinJ my plana shall be used ser public rc<oNs
O Z� -. MODIFICATION
UP TO77 ❑INTERIOR ❑CHIMNEY REPAIR
�wal_1 Leensed Professtowl IMPROVEMENT SWIMMING POOLS
„I 201-IINX)AMPS
�y OWNER-BUILDER DECLARATION Contractors
ON ❑
y W�Q 1 hereby affirm that I am exempt from the Contractors Licenx Law for the OVER Ifx10 AMPS ❑BATH R- RIiPAIR N
x a L U following reason.(Section]t1JL5,Business and Prnfcxnions Cade:An cit t ❑OTHER � 1 f
LL7 F y y nr coon y SIGNS ELECTRICAL
F 4.C NQ which requires a permit to construct.alar,improve.demolish,or unfair any shucture liz
m.i prior to its insurance,also requite the applicant forsuch permit to file usigned stmemem SPECIAL CIRCUBUMISC.
} chat he is licensed pursuant to the prnvisid,of the Contractors License Law(Chapter 9
� OC, (commencing with Section 7")ofDivision 3ofthe Business and PrficomasCode)or TEMP,METER OR POLLINST. COMMERCIAL
ti o y that he is exempt themfmm and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
N Scam 7031.5 by any applicam for apenam,x.hjeadthc applicam loacivit penally of POWER DEVICES
not more than rive hundred dollars(5300). NANT ❑FOOD SERVICE
FSO ❑ I,as owner ofthe property,or my employees with wages us their sole compensation, SWIMMING POOL ELECTRIC I OVEMENT
F will do the work,and the structure is not intended oro med foreule(Sec.]04q Business ❑OTHER
ul �_ and Precisions Cale:The Cmerscmrs License Law dm nod apply m an awmer of OUTLETS-SWITCHES-FIXTUR
property who builds or improves lhemon,and who does such work himself or through
his own employees,provided that such improvements arc not intended or offered for NEW RESIDENTIAL ELECTR SQ FT.
sale.if,however.the building or improvement is sold within one year ofcampletion,the SQ.Ff.FLOOR &SQ.FT.
wnerh aleerwill have the burden o(fmving that he did not build or improve for put-
ale.).
ur-
soon �—
r of the propcnm y,aexclusively contracting with licensed cmmmcmrs m TOTAL:
Twho
the project(Seo.]n1A,Bmlmess and Profa'xions Code:)The Contractors hi. -
wdoesnetapplyinanownerofprferywhobuildsmimproo.thercon,mal TY PLUMBING PERMIT FEE
tracts for such projects with a comreelons)licensed pumumt to the Communes
Law. PERMIT ISSUANCE
exempt under SeeDate ALT.... DRAIN&VENT-WATER(EA)
VALUATION
WOR ER'S COMPENSATION DECLARATION BACK FLOW PROTECT.
1 hereby nlfirm under penalty of perjury one of the following declaralinne v
I have and will maintain a Certificate of Consent to self-insure for Workers Compen- DRAINS-17L R,ROOF.AREA,COND, STORIES TYPE CONSTRUCTION
section,a sb
provided for by Section 37M of the Inr Code,(a performa
the nce Of the
work for which this permit is issued. FIXTURES- ]'RAP
❑1 have and will maintain Worker's Compensation Insurance.to,required by Section
37M of the Labor Code,four the performance of the work for which this permit is issued. GAS-EA.S TE -l1NC.4sQLT'LETS OCC GROUP APN
My Workers Compensation Insurance carrier and Policy number arc'.
Cartier: Policy NO! GAS-EA.$ F.M� ENA EA
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFJINDD RI,W 'T :RCE R
(Thissectionncetl not be completed ifthe permitisforme hunJrcddollnafSlOq ED (DIVISION FEES
or less.) GREASE TRAP PLANCHECK
I eerily tam in the PaRmnancu oflhe walk for which this permit is issue d,I shall GRHASESANI'TANY-STOR 2
not employ any person in any manner so a to became subject to the Workers'COmpen- SEWER- ENERGY �•
Z O Applicant1111""
s of California Date WATER HEATER WNENT/ELECI'R GRADING
y NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should Wq'TER SYSTEM/TREATING
a ' become subject to the Workers Compensation provisions of the Labor Code,you must UPI,
W forthwith comply with such previsions or this permit shall he deemed revoked. WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMIi. SQ,FT.
U ZO l hereby arcthi thanhere is a co](Ses.nn lende.agenc,for the performance of a Ceipt x
Fthe work far which this permit is isaucJ(Sec.3097,Civ.C.)
O U LcnJer'sNmne TOTAL:
H.1lenders Address 'i'OTAL:
IL 1 certify that 1 have rad this application and suite that the abtwe information is BUILDIN FE
V) co eci.l agree to comply withal]city and county ordinances and smile laws relatingdo - y, MECHANICAL PERMIT FEE
U 7- buildingcomminum.and hcmbyauthorize representatives ofthiscilymenmOiNti.h. SP.M CP
above-mendinned property for inspection purposes. PERMIT ISSUANCE
(We)agree m save,indemnify end keep harmless the City Of Cupertino against ELIiCTRIC FEE
liabilities,judgments.comsandexpenses whichmay in any way name against said City ALTER OR ADD TO MECH.
in omotpic ren of the grading of this permit. PLUMBING FEF
APPLICANT UNDERSTANDS AND WILL COMPLY WIT T AIR HANDLING UNIT(TIO 10,M)CFM)
SOURCE REGULATIONS. MECHANICAL FT:E
sis AIR HANDLING UNIT(OVER 10.000CRM) CONSTRUCTION TAX
nature Of ApplicanVCOmmctor Date EXHAUST HOOD(WMUCT) HOUSING MITIGATIONF
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or hanme hazardous material HEATING UNIT(TO 100,000 BIU)
as derined by the Cupertino Municipal Cale,Chapter 9.12,and the Health and Safely
Cale,Section 25532601 HEATING UNIT K)VE R 1X1,0101 BTU)
❑Yes ❑No VENTILATION FAN(SINGLE RESID) PAID
Dale Receipt x
Will the applicant or furore building Occupant B use equipment or devices wwhichhen BOILER-COMP UHP OR 100,001 BTU)
I hazardous air contaminants a defined by the Pay Arca Air Quality Management
dJisltid? TOTAL:
C3 Yea []No BOILER-COMP(OVEN IIg1,gM1 N'I'U) _
I have read the hazardous materials requirements under Chapter 6.95o40he Cali- AIR CONDITIONER ISSUANCE,DATE
fomio Health&Safety Civic.Sections 25505,25533 and 255u.1 tutdco eland thm if the NEW RESIDENTIALMECH. SQ.FT.
building does not currently have a amount,that it is my responsibility to notify the necupand
of the requirements which mull he tact prior to issuance of a Ccerneate of Occupancy. _w
Owner or authorized ngem Dam TOTAL: ISSUED BY: Y
OFFICE
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