99090138 APPLIeANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDINGELECTRICALPERMITN,
. I
BUILDING DIVISION APPLICATION/PERMIT PLUMBING MECHANICAL
BUILDING PROJECT IDEN'TIF'ICATION vaiiiimlw
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
J- - q �s DQ — . 3
WNER'S NAME:,.t. PHONE: CONTRACTOR'S NAME, LIC NO:
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RCHITECTANGINEERi LICNO: ADDRESS: ❑
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ONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT' PLUMP MECH
LICENSED CONT'RACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE fLyJ{
1 hereby dfiem atm 1 am Eeensed mnaer prmvisimns or cnapmr 9¢mmmendng JOB DESCRIPTION
censZ with e clastion h)) cDivixiwn}uf iheBmine2v mdlhfcxviaac Cade,and my lice2se isPERMIT ISSUANCE RESIDENTIALfull force and eBeca. Lie ❑SFUWL ❑KITCHENREMOUF.L
Or
am Contractor
APPLIANCES-BfSIDFNTIAL []ADDITION ❑PLUMBING RE-PIPE
pcin ARCHDECTS DECLARATION [I MULTI-UNIT ❑STRUCTURAL
Z C).Zl undentnnd my plane shall he uncd res pabllc reworks PANELS MODIFICATION
OZ- +C UP T0200 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
F`:F'4: Licensed Pmfesnionol 201-1(XX)AMPS IMPROVEMENT
OWNER-BUILDER DECLARATION C]S SWIMMING POOLS
5 C Y, 1 hereby affirm Ihan I am exempt from the Contractor's License Law for the OVER 1000 AMPS '�BATH REMODEUREPAIR ❑DEMOLITION
K 3 6 U following reason.($action 7031.5,bovines,and Professions Code:Any city nr county SIGNS ELECTRICAL � El OTHER
F. t y which mNdms a permit to mnanna.alter,improve,demolish e,repair any structure
F.
prior to its issuance.also requites the applicant for such permit to rile a signed statement SPECIAL CIRCUIT'/MISC.
ly yJ that he is liremed,all. d to the pmvisimnof the Contractor's License Law(Chapter Y
(commencing with Section 7000)of Division 3 of the Business and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL
a X e y that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
N Section 7031.5 by any applicant for a permit subjects the applicant to a civil Penalty of POWER DEVICES
F Z} not more than five hundred dollars(S500). ❑TENANT ❑FOOD SERVICE
[ owner nfthe property.army employees w lth wages as tnciradecompenotem. SWIMMING POOL ELECT RIC IMPROVEMENT
= will do the work.and the structure e.not mtendedarolfened for sale(Sec.701 Business ❑OTHER
F_
L3 m and Professions Code:The Conforms,Iceenm Law docs oat apply m.aa owner of "i OUTLETS-SWITCHES-FIXTURES
prnpaty who builds or nalmoes themon,and who dors such work himself or though
his own employees,provided that such impmventerb are not intended or oRered for NEW RFSIEWNTIAL ELECTR SQ FT.
sale.IL honvcvc,the building or i al,owenmm k o,ld wiahmonc ycurd'mmpdenion.the afrl':F000RARIC 11$/SQ.PT'. I
owner-builder will have the bumn of proving that he did not build or improve for per- pIi I � 1i F.
of sale,. 1 I l '
❑ 1,as owner of the propary,am csolasioiy cmu'ucting with licenced emmrachnv a0 TOTAL: SEP 2 3 J
construct the project(Sec.'l0LI,Business and Professions Code:)The Contractor's Li- IE 1 n
cense law dues not apply m an owner of properly who builds or improves thereon,and QTY. PLUMBING PERMIT FEE 'J F+f ��� Ilf,.r�
whocommets E'oroachp jests with acmnhactor(s)IiceasN pursuant to the Commences L
License Law. PERMIT ISSUANCE a
Iamc, mpt under Sec ,B&P C for this reason
-Jif r
mer
Da¢ ALTER—DRAIN&VENT—WATER(EA) VALUATIOhT�""��—
WOR K 17R COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm under Penalty of perjury one of me following declarations:
1]I have and will maintains Cenificao of Current o self-insure for Worker s Compen- DRAINS—FLOOR,ROOK AREA,COND, SORIES TYPE CONSTRUCTION
sminnd4,as provided for by Section 3910 of the Labor Cofor the Performance at the
work for which this permit n issued, FIXTURES—PER TRAP
1 have and will maintain Worker's Compensoion Insurance,as required by Section
3700of the Labor Code,forthe peHormanceof the work for which this permit is issued. GAS—EA.SYSTEM-]INC.d OUTLETS OCC.GROUP
My Workerss Compensation lnsumnce caricrand l•olicy number are: Y L
Carrier: Policy Nov GAS-EA.SYSTEM-OVER d(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GRF,ASE/INDUSTRI.WASTE INTIIRCEPTOR
(Chis,scion need not be mmpletN it the .hit is franc hundred dollars(E I W) BUILDING DIVISION FEES
or less.) GREASE TRAP PLANCHECK FEE
Iccnilyflera Iscro the-1roumew,1.ah1.teomrwhich phis permit isisonod.r,'C. ,n-0nall SEWER-SANITARY-STORM EA.200 Fr.
not employ any person in any manneno a,no become suhjm to nhc workcri Compen- ENERGY FEE
2 maion laws of California.Doc
O WATER I1EADiR WNENT/131.ECTR GRADING FEE
z o Applicata
N NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should WATER SYSTEMTREATING
a ? become subject to the Worker's Compensation provisions of she Labor Co c,you must SOBS FEF.
fimhwith comply with such provisions or this permit shall he deemed revoked. WATER SERVICE
aQ
CONS'TRUCI'(ON LENDING AGENCY
U Z NEW RESIDENTIAL PL,Me. SQ.ET. PAID
U lherebyaffirm ahemat I isacol Som.3n len ding agency for the performantt of Dem RecciplN
� F the work for which this permit is issued(Sec.}09].Civ.C.)
pU Ecri Name TOTAL:
1 lender's Andrea TOTAL:
I certify that 1 have read this applieuaien rend state that nM1e above infumnmion is BUILDING FEE
En correct.l agree to comply with all city and county ordinances and state laws relatingm QTY MECHANICAL PERMIT FEE
V z building construction.and hereby authorize representatives of this city to enter upon the SEISMIC FEE
abuvanemioned property for la"eCticn purposes, PERMIT ISSUANCE(We)agree to.rave,indemnify and keep frames,the City of Cupertino agnivn ELECTRIC FEE
lhunhis-,judgments,costs and cspeu,es which may in any wayarrac against said City ANTER OR ADD FO SUCH,to mequence of am gramih,of this pertain. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IO,Wo CPM)
SOURCE REGULATIONS, MECHANICAL FEE
4 Aw AIR HANDLING UNIT(OVER 10,000 CFM)
/Q�/ a 7�G'C CONSTRUCTION TAX
Stgn ore ufApplicud/ConpD0 Uute EXHAUST HOOD(\V/DUCT)
f1A"LARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Will the applicant or future building occupant store or handle haeaNnus material HEATING UNI'RTO 100,000 BTU)
as defined by the Cupertino Municipal Cade Chapter 9.12,and the Health and Safety
Code.Section 25532(a)Y HEATING UNIT(OVER 100,000 BTU)
MYcs Nor
VENTILATION FAN(SINGLE BESIDE PAID
Will the applicant or future building occupant use equipment tar devices whichDate Receipn Is
ni m hazardous air contu :m
nninants as defined by the Bay Area Air Quality Magement BOILER—COMP(3HP OR Ifth BEER BTU)
l
DisancR TOT �./
❑Yes ON. BOILER—COMP(OVER 100,M)B'TO)
I have read she hmaadous mamnaH rproarim,under Chapter 6.95 of Ne Cali- AIRCONOITIONF.R ISSUANCE DATE
btmia Itches&Safety Cuda,Sections 25505,25533 mW 25534.1 uedc..fym that if that NEW RESIDENTIAL MECH. SQ.ET. ''') C1
building docs a ,winml}'lurcatcnanh that it is my res'IfRCiliaymnmifythcmccupant G 7
oI rhe rw M1i p nuance ora Ccnificam m[(ksvpancy.
%h... i,
Ow thort�agena Date TOTAL:
:ISSUED BY:
OFFICE