99120099APPLICANTTO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL PLUM NO.
BUILDING DIVISION APPLICATION/PERMIT nrara rsaPLUMBING rMMECHANICAL
- r utrawnNam
CON'IACI':
LIC NO'.
❑ Consultant Fees Paid by Applicant (Initial)
Owner Date
WORKER'S COMPENSATION DECLARATION
hueby affirm under penally A perjury nna of the fallowing de,lam arra:
J Ihav ..it will namania a Cenum,ntuof t1ar
Consent wIFm.e hob W...so'N Com
cation, as provided for by Section 3]30 of the Lahor Code, for the performance of
work for which this permit is issued.
1 have and will maintain Workers Compenxaion Insurance, as required by Sent
3730 of the Labor Code, for the perfommnce of the work for which this Permit is issue
My Workers CompP do Insurance artier and PolicyPumQy q�
Camey C �- MQ U Policy Neu: u% s4, f4, �3r� dal
7 RTIFlCATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need ex a be campeled Hthe permit is (Drone hundred dollars SIOn
r less.)
Lenity that in the performance of the work for which this permit is issued, I shall
not ctnploy any person in any manner so as to become subject to the Workers' Compcn-
O ,7. . dout Law, of Colifnmio. Date
7 C) Applican 1
G ry NOI'ICH 10 APPLICANT: If, after making this Cendiivaao of Exemption, you should
a , fiction, subject to the Worker's Compensation provisions of the Labor Code, you must
fonhwiah comply with such provasnms or permit shall b, deposed revoked.
0
U2 CONSTRUCTION LENDING AGENCY
UQ Ifar which do .it
is..construction 30lemling agency for the perfartnantt of
l2. F-' the work for which Nis permit is issued (Sec. JW]. Civ. C.)
O U Iwmders Name
Lt1 Lenders Address
1 certify on.,1 have read Nie application and ,e at Ne above inftnalion is
nFi Vat] smNmconincea. l agree to comply with all city and county ordinances and state laws relating it QTY.
V Z buildi its conumation, and hereby authorize repremnwtives of this city to enter upon the
aha f dIs proyI ctinsp rl :cs
(W) gcctoe indemnify fytndk p hurrat the City of Caricaturesagnan,
liubilitie.s.judgmenas, costs and expenses which may in any way accrue against said City
in n,equcnce of she granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-1'OIN'1'
11)
HAZARDOU TERIAI S DISCLOSURE
Will the applicant or future adding occupant score or handle hacvdons material
as deft red by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Cade, Senior 25532m)?
❑Yc. Fl No
Will the eppl leant or future build ung necupunt use equipment or devices which
In, hunudans sir crsuare taut, as dcfned by the Bay Are. Air Quality Management
❑Yes ON.
1 lave read die hacedous =tcnW% requirement under Chapter 6.95 of the Cali-
famia Health & Safely Code, Swoons 25505.25533 and 25534, 1 understand N„ if on,
building docs not currently have a tenant, that is is my atsMnotailoy to notify the ocapam
of are requirement which must Ic met prior m issuance of a Certificate of Company.
SQ FT
rA; KP v Sloy7dif I
Z
❑SFDWL
LICENSED CONTRACT'OR'S DECLARATION
QTY. ELECTRIC PERMIT
/
N/C
hereby affirm that I am licensed under provisions of Chapter 9 (commencing
AIR HANDLING UNIT (TO 10.0X) CFM)
CXZI
'th Section 701X) of Division 3 of the Business and Profepssio(�ns Code, and my licenu is
PE Rh11T ISSUANCE
11- =
C F-
n' full farce and eIf 901
Clxss 1,.r_ U i p D U
❑ BATH REMODEUREPAIR ❑ DEMOLITION
BLDG
❑
U
Q U
ZW
NQ6Dutc
Lteense
Conlmemr
APPLIANCES - RESIDENI'IAl.
FEE
' ARCHITECPS D[CLA
NEW RESIDENTIAL PLM), SQ, FT.I
F D y
VENTILATION FAN (SINGLE RHSHH
PANELS
O o,,Z^
I understand my plans shall he..ed as public records
ZUP
AIR CONDITIONER
TO 200 AMPS
�.F..W
Licensed I-role—anal
201-IOWAMPS
.�...II
OWNER -BUILDER DECLARATION
OVER IOW AMPS
tY Q
1 hereby affirm that 1 am exempt bean the Contractor's License Law for the
OF
36 F
a
following reason (Section 70315. Business and Professions Code: Any city or county
which require, a permit m construct, altar, improve, demolish, or repair any structure
SIGNS ELECTRICAL
a y
�Q
prior as its issuance, also requires the applicantfor such permirto file a signedsaatemem
SPECIAL CIRCUIT/MING.
y"
that he is licensed pursuant in are provisions offle Contractors license law(Chapter 9
TEMP. METER OR POLE INST.
COO
(commencing with Section 70goofDivision 3 of the Business and Professions Code)or
Xc LL
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permitsubject% the applicant to a civil penalty of
POWER DEVICES
U�y
n mor, Nan Eve hundred dollvrs ($501).
=0
01, as owner of the property, or my employces with wages as their sale compensation,
SWIMM ING POOL F,LEC'FRIC
"CURES
p.
will dothework. and thestructum knot mendad proffered for sale (Sec. 9013, Business
al 3 m
and Professions Code: The Comneun's Lias., Law docs not apply m an owner of
OUTLETS- SWITCHES- FIX
el.prolveriy
who builds or improves thereon, are he does such work himeclfm through
his own employees, provided that each improvement, me not intended of off red lin
NEW RESIDEN'T'IAL ELEC'I'R
sale. If, however, the building or improvement is sold within one year of completinn, the
cr-builder will have the burden of proving that he did not build or improve for pub,
pow of suit.).
no .
1, as owner of the property, am exclusively contracting with licensed contmMO
Code:) e Co,.,',
umsoan the project (Sec. ]M0. Business and Professions Thnine
cense law does not apply to an owner of property who builds or improves thereon.
I
whit contracts forsuchp jests with a commands) licensed pursuant to the Contrast
Licenm law.
PERMITI N'
1 am exempt under Sec. . B & P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
hueby affirm under penally A perjury nna of the fallowing de,lam arra:
J Ihav ..it will namania a Cenum,ntuof t1ar
Consent wIFm.e hob W...so'N Com
cation, as provided for by Section 3]30 of the Lahor Code, for the performance of
work for which this permit is issued.
1 have and will maintain Workers Compenxaion Insurance, as required by Sent
3730 of the Labor Code, for the perfommnce of the work for which this Permit is issue
My Workers CompP do Insurance artier and PolicyPumQy q�
Camey C �- MQ U Policy Neu: u% s4, f4, �3r� dal
7 RTIFlCATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need ex a be campeled Hthe permit is (Drone hundred dollars SIOn
r less.)
Lenity that in the performance of the work for which this permit is issued, I shall
not ctnploy any person in any manner so as to become subject to the Workers' Compcn-
O ,7. . dout Law, of Colifnmio. Date
7 C) Applican 1
G ry NOI'ICH 10 APPLICANT: If, after making this Cendiivaao of Exemption, you should
a , fiction, subject to the Worker's Compensation provisions of the Labor Code, you must
fonhwiah comply with such provasnms or permit shall b, deposed revoked.
0
U2 CONSTRUCTION LENDING AGENCY
UQ Ifar which do .it
is..construction 30lemling agency for the perfartnantt of
l2. F-' the work for which Nis permit is issued (Sec. JW]. Civ. C.)
O U Iwmders Name
Lt1 Lenders Address
1 certify on.,1 have read Nie application and ,e at Ne above inftnalion is
nFi Vat] smNmconincea. l agree to comply with all city and county ordinances and state laws relating it QTY.
V Z buildi its conumation, and hereby authorize repremnwtives of this city to enter upon the
aha f dIs proyI ctinsp rl :cs
(W) gcctoe indemnify fytndk p hurrat the City of Caricaturesagnan,
liubilitie.s.judgmenas, costs and expenses which may in any way accrue against said City
in n,equcnce of she granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-1'OIN'1'
11)
HAZARDOU TERIAI S DISCLOSURE
Will the applicant or future adding occupant score or handle hacvdons material
as deft red by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Cade, Senior 25532m)?
❑Yc. Fl No
Will the eppl leant or future build ung necupunt use equipment or devices which
In, hunudans sir crsuare taut, as dcfned by the Bay Are. Air Quality Management
❑Yes ON.
1 lave read die hacedous =tcnW% requirement under Chapter 6.95 of the Cali-
famia Health & Safely Code, Swoons 25505.25533 and 25534, 1 understand N„ if on,
building docs not currently have a tenant, that is is my atsMnotailoy to notify the ocapam
of are requirement which must Ic met prior m issuance of a Certificate of Company.
SQ FT
JOB DESCRIPT ION
RESIDENTIAL:
Z
❑SFDWL
❑ KITCHEN REMODEL
❑ADDITION
/
N/C
CONROLN
AIR HANDLING UNIT (TO 10.0X) CFM)
MODIFICATION
❑ INTERIOR
BUILDING
PE'RMI'T' INFO
❑SWIMMING POOLS
❑ BATH REMODEUREPAIR ❑ DEMOLITION
BLDG
❑
ELECT PLUMB
❑ ❑
MEECCHH/
A C
FEE
JOB DESCRIPT ION
RESIDENTIAL:
Z
❑SFDWL
❑ KITCHEN REMODEL
❑ADDITION
❑PLUMBING RE -PIPE
❑ MULTI -UNI T
El STRUCTURAL
AIR HANDLING UNIT (TO 10.0X) CFM)
MODIFICATION
❑ INTERIOR
C Cl IIMNHY REPAIR
IMPROVEMENT
❑SWIMMING POOLS
❑ BATH REMODEUREPAIR ❑ DEMOLITION
❑ OTHER
SOILS FEE
—
A C
COMMERCIAL:
[3 NEW BLDG/ADDITION ❑DEMOLITION
❑TENANT ❑ FOOD SERVICE
IMPROVEMENT
❑OTHER
VALUATION
OAS - EA. SYSTEM -1 INC. J OUTLETS
OCC. GROUP
Z
GAS - EA. SYSTEM -OVER 4 GGO
GREASEBNDUSTRI, WASTE INTERCEPTOR
BUILDING DIVISION
PGES
GREASETRAP
I'LANCHECK FEE
AIR HANDLING UNIT (TO 10.0X) CFM)
SEWER - SANITARY - S'TORM EA, 230 FT
ENERGY FEE
AIR HANDLING UNIT(OViiR 10.030 CFA)
WAl'EE HEAlER WIVIiN'1'/IiLECIR
GRADING FEE
EXHAUST HOOD (WMUCD
WATER SYSTF,MITREAfING
SOILS FEE
HEATING UNIT (TO 100.001 BTU)
WATER SERVICE
PAIDr
HEATING UNIT (OVER 101.0X0 BTU)
NEW RESIDENTIAL PLM), SQ, FT.I
$/SQ. FP.
MECHANICAL PERMIT FEE
S9C FEE
L_/Msl.
PERMIT ISSUANCE
I.I.&PRICd FEE
ALTER OR ADD TO MECH,
YLUMBINC FEE
AIR HANDLING UNIT (TO 10.0X) CFM)
MECHANICAL FEE
AIR HANDLING UNIT(OViiR 10.030 CFA)
CONSTRUCTION TAX
EXHAUST HOOD (WMUCD
HOUSING MITIGATION PEE
HEATING UNIT (TO 100.001 BTU)
HEATING UNIT (OVER 101.0X0 BTU)
PAID
-
VENTILATION FAN (SINGLE RHSHH
Dam Ron,"a N
TOTAL
BOILER - COMP (3HPOR I00.IXX)B'IU)
BOILER -COMP (OVER II1f1.IXX) BTU)
AIR CONDITIONER
ISSUANCE DATE
I ^I ^ i/ -7 -`e
T
NEV RESIDENTIAL MECH. SQ. ET.
JU1AL:1 IISSUED BY.
OFFICE