S 1068APPLICANTTO 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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68
BUILDING ADDRESS: -
10555 DE�q /f/ f3L cu P eV_Tl//o
SANITARY NO.
APPLICATION SUBMITTAL HATE
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OWNER'S NAME: PHONE:
CON 'URACT R'S NAME: LIC NO:
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❑ Consultant Fees Paid by Applicant (Initial)
I BUILDING PERMIT INFO
BLDG EILEECtTT/PLUMB MECH
❑ Up ❑ ❑ '
LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm Not 1 am licensed under pmvisinns of Chapter 9 (commencing
with Section 7000) of Division 3 ofthe Btedres.k and Professions Code. an, my liccrse is
in full force and eH t
j License Is Lic.k 49,S;O--
>? Dam COmracaa_ya�-�_
u ARCHITECTS DECLARATIO
I understand my plans shall he used as public records
QTY ELECTRIC PERMIT FEE
JOB DESCRIPTION
RESIDENTIAL
❑SFDWL ❑ KITCHEN REMODEL.
[]ADDITIONElE PLUMBING RPIPE
❑MULTI -UNIT ❑STRUCTURAL
MODIFICATION
❑INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT SWIMMING POOLS
❑ BATH REMODEUREPAIR ❑ DEMOLITION
❑OTHER
J
PERMITISSUANCE
APPLIANCES—RESIDENTIAL -
PANELS
UP T021q AMPS
��l L¢ensed Pmfesmonnl
J OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Law for the
following teres. (Section Om la Business and Professions Cale: Any city or csunry
which acquiresng muca a permit m 031.5 ct, cher, improve, demolish de repair any r mcmre
prior wits issuance, also requires the applicant for such permit mtileesigned,moment
Nat he is licensed nothe
pursuan provisions Of the Com racmrsl-icenseiaw (Chirpier
(commencing with Seeds#](01 of Division)of the Boomssand Professions title) or
Y del he is exempt therchum it the basis for the alleged exemption. Any voted. of
n Section 7031.5 by any applicant finepertnit subjects he applicant aciA per.ltyof
not are than five hundred dollars D5W).
E] 1. as owner of the Property, Or my employees with wuges as their sole compensation,
dos not apply to an Business
will da the work, and c: The Core is not ces License
and Professions Cale: The improve,th refs License Low does not apply to if owner Of
y pmpcny who builds of improves thereon, end who does such work himself or through
his own employees, provided that such improvements ore not intended or offered for
sale. IL however, the building or improvement is sold avidin one yearorcompletion,the
owner -Wilder will have the buNen of proving that he did not build or improve for pur-
pose of sale.).
❑ 1, as Owner of the property, um exclusively contracting with licensed contractors m
construct de project (Sec. 7044, Business and Professions C dc) The Contracmrt Li.
cerise Law does not apply to an owner Ofpmpcny who builds or Improves thereon, and
who contracts for such projects with a contramor(s) licensed pursuant n hie Conwetor's
License Law.
❑ I am exempt under Sec. B& P C for his reason
201-1007AMPS
OVER HXMAMPS
SIGNS ELECD11CA1, - 2 0
SPECIAL CIRCUIT/MISC.
TEMP. METER OR POLE INSII
COMMERCIALc
[I NEW BLDG/ADDITION ❑DEMOLITION
❑TENANT ❑ FOOD SERVICE
IMPROVEMENT
❑ OTfiER
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS — SWITCHES — FIXTURES
NEW RESIDENTIAL CLEM SQ Far.
/C J
SQ. IT. FLOOR AREA
$/SQ, FT.
OTAL:
QTY. PLUMBING PERMIT FEE
PERMIT ISSUANCE
Owner Ume
ALTE R—DRAIN&V' '— ATER(EA)
VALUATION
WORKER'S COMPENSATION DECLARATION
1 herchy affirm under penalty Of perjury one Of the following declamtic ms:
❑ I have and will mainldn u Cerificate of Csna Mt Rivelf-insure for Workee, Co.,.-
action, as provided for by Section 37M of the letter Code, for the performance of the
work for which his permit is issued.
❑ I have and will maintain WonkMg Compensation Insurance, as required by Section
37M of he Labor Cade, for he performance of the work for which this permit is issued.
My Workma COmpcnsatiom Insurance nsunce carrier and Policy mumlx�r ore :
Cosier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not he completed if he permit is for one hundred dollars (Slip)
or lcssJ
thework beemor subjectch this perthe ait Wisarx'Copen.
Loy any batonthe pay Manner
net employ of pcwn in any manner so as to bunme subject the Workers' COmpch-
sobs# Laws of Califnmia. UseAppli
not
BACK FLOW PROTE D
DRAINS — FLOOR. ROOF, EA,
STORIES
,
(ICC. GROUP
TYPE CONSTRUCTION
AI'N
FIXTURES —PER THAI'
GAS—EA. SYSTEM -I INC, 4 OUTLETS
GAS — EA. SYSTEM -OVER 4 (EA)
GREASIVINDUS URL WASTE INTERCEPTOR
GREASE TRAP
BUILDING DIVISION FEES
PLANCHECK FEE
SEWER—SANITARY—STORM EA. 200 Fr.
ENERGY FEF.
WATER HEATER W/VEFIDELECfR
GRADING
GRADING FEE
NOTICE
becomeTO APPLICANT. If. ftm Compensation rCertificate of Exemption.de, you uild
become auhject y the Worker's Compensation pmvisinns of the lad. Code, yon most
forthwith comply with each provisions or his permit xhell be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for he perfomn of
he work for which this Permit is issued (Sec. 31197. Civ. C.)
Lender's Name
WATER
SOILS FEE
WATER SERVICE
PAID
Data •ce
NEW RESIDENTIAL PLMB. SQ. FT.
TOTAL:
Lenders Address
TOTAL_
1 eerefy that I have real his application and .amu that the above information is
correct. I agree to comply with all city unit county ordinances and state lows reining to
building construction, end hereby outhoriee representatives of this city to enter upon the
above-mentioned property for inspection purposes.
(We)a to wve, indemnil' p City pe y
gree ram whit harmless the Cit arca rtstsid City
in liabilities,judgmentsepointing of this eswhich mayinany way uceme against said City
consequence of the painting of hu permit
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS.
�jk7 /
BUILDING FEE
QTY. MECI{ANICAL PERMIT FEF -
SEISMIC FEE
PERMIT ISSUANCE
ELECTRIC FE O
ALTER OR ADD TO MECH.
PLUMBING FE
AIR HANDLING UNIT(PD Eta16 CFM)
MECHANICAL TE
AIR HANDLING UNIT(OVER III,INI(I CFM)
CONSTRUCTIO TAX
Signature O(Alp�pbc�anVjCGo(mrvrno to
gUrG[��
HAZAR US MATERIALS DISCLO HE
Will the applicant or furore building Occupant store or handle Wandmxmmmad
sw defined by the Coltman. Municipal Code, Chapter 9.12, and the Health and Safety
Calc, Section 25532(x)? /
E] Yes
Will the air comm or furore building occupant use ea Air Qu or devices Management
emit harardnus sir enmaminanm azdefined by the Bay Area Air Quality Managsmenl
Dlslrlcl?
]yes �
I have read the havvdpus materials p
re, 25533 an under Cha ter 6.95 of he Cali -
Health & Safety Code, Sections 25505, 2551) esp 25941 uorimily d tom if due
ofydeoecupant
of thengdceenot currentlyentswhich have o am[phrrhis uace afe Certificate
of the mSuiren¢ms which must he rent prior m issuance of a Certificate ofOccupancy.
EXHAUST HOOD ted/DUCT)
HOUSING MITIGATION FEE
HEATING UNIT TO 1011,pBo BTU)
HEATING UNIT (OVER IIXI,M) BTU)
PAID -
Date Receipt #
VENTILATION FAN (SINGLE RE.SID)
BOILER — COMP(JHP UK 103,000 BTU)
-
TOTAL:
—
BOILER — COM P(OVER 100.000 BTU)
AIR CONDITIONER
ISSUANCE DATE
D^�j ^��
/�)� ?-- �/—
ISSUED BY: e�D9 A �7 �O s
NEW RESIDENTIAL MECH. SQ. FI'.
a 0&
Owners tualmr,oxi a
TOTAL]
OFFICE