S0050 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPF.RTINO BUILDING-ELECTRICAL PERMIT NO.
RUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. ��
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
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OWNER'S NAME: PHONE: CONTRAC'TOR'S NAME: LIC NO:
15' Moj
n.�' N/C CONTROL k
ARCHITECVENGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT 1:1 1:1 PLUMB EJ LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby ntnrm then 1 nm licensed under provisions of Chapter 9(oo hands a, JOB'DESCRIPTION
WIZ with Section 7000)ocDivi,irn3of the Business and Professions Cole,and mylimoxis PERMIT ISSUANCE RESIDENTIAL
F4,W U in full forces effect. ❑SFDWI, ❑KITCHEN REMODEL
QUU Data Class _ Contractor
APPLIANCES-RESIDENTIAL
yxtul Onne Crntacmr 11 ADDITION LUMBING RE-PIPE
T.p r,, ARCHITECT'S DECLARATIONpgNELS ❑MULTI-UNIT []STRUCTURALrZ4� lunderstnnd my plans shall be used as public records UP T02IXIAMPS MODIFICATION
.4 H W Licensed Ponfessmnal L3 INTERIOR ❑CHIMNEY REPAIR
OWNER-BUILDER DECLARATION 201-1000AMPS IMPROVEMENT ElSWIMMING POOLS
'a OVER 1000 AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
Q 1 hereby,(Seth that I am exempt from the Contractor License Law for the WAC!nft.
4 U following reason(Section 70)1.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL. ❑OTHER
0 yyyF which requires v Permit to criminal,alter,improve,demolish,or reed,any swcmre
q�7yQ prior to its issuance,also requires the applicant for such permit to file a signed statement SPECIAL CIRCUIT/MIST.
i+ than be is licensed pursuant w the provisions of the Contractor'a License Law(Chapter 9
apmommenaingwith Sardia,7000)of Division 3 ofthe Birsiraw,md Profeisions Code)er TEMP.METER OR POLE INST. COMMERCIAL
4 4 c that he is exempt therefrom and the basis for the alleged exemption.Any vmlatian of El NEW BLDG/ADDITION El DEMOLITION
Wm Section 9031.5 by any applicant for a penult subject the applicant)a civil penalty of POWER DEVICES
not mom than five hundred dollar,($500). El TENANT El FOOD SERVICE
as owner ofthe norm bees with wi e"thiir sole cam conation, SWIMMING POOL[LECfRIC IMPROVEMENT
property, y employees g p
fri othe fework.Cand
e:the The structure is not
snaLintended
ense Law dx,doral apply to an,Boniness ❑OTHER
3 m mrd Preproperty
who
Cade:The Conoyes therco License Law tines not apply owner of OUTLF,TS-SWITCHES-PIXTU .S
property who build,or improves thereon,and who does such work tidohimself ffNmugh
his own owever,the provide)that such improvements are not intendedofm offered roe NEW RESIDENTIAL ELF.C'fR SQ PT
owns barldeventhe building or rden of
issoldhediwithin tbuild rimprovetfor the SQ,FT FLOOR AREA $/SQ.FT.
ner-builder will have the burden of proving niton he did not build or improve for part- '
puce of sale). -
❑I,as owner of the propene,am exclusively commding with licensed contractors to T AL'
it
construct the project(See.71144,Business and Professions Con&)His,Contractor a Li- Ali)e p
.e Law does not apply to an owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT Ht P i)
who commits mutual,projects with a ermra rrood licensed puramhnt to the CsonessnorS,
License Law.
laPERMIT ISSUANCE AY 29
❑ m exemptunderce B&PCT,this,anon
Owns Data ALTER-DRAIN&VENT-WATER(EA) iryy I L VALUATION
lORKER'S COMPENSATION DECLARATION BACKFLOW PROTECT DEVICE. - I �r vUI'frwHrlw
Thereby of ten under penalty of pejury one of the following declarations: "- V
❑ I have and will maintain a Certificate of Consent to self-insure for Worker's Compen- DRAINS-FLOOR,ROOF,AREA,COND. - TYPE CONS'BUCTION
sation,as provided for by Section 37M of the Labor Cade,for the performance of the STORIES
work for which this permit is issued. FIXTURES-PER TRAP
❑I have and will maintain Worker's Compensation Insurance,as required by Section
37M ofthe Labor Code,for the performance ofthe work for which this permit is issued GAS-EA.SYSTEM-1 INC.4 OUTLETS OCC.GROUP' APN
My Worker's Compensmion Insurance chair,and Policy nonfat,an:
Cartier Policy Nn: GAS-EA.SYSTEM-OVER 4 TA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASE/INDUSTRI.WASTE INTERCEPTOR
(This section need not be completed ifthe permit is fornne hundred dollars($100) BUILDING DIVISION FEES
or
Tax,.) GREASE TRAP PLANCUECK FEE
(certify hot in peafterromanymannro theas
work for subject
bjech tto perthe it Wlslss'Ci Ishan SEWER-SANITARY-STORM EA.200 FT.
not employ any person in Any manner so as m become nubjea to the Workers Compen- ENERGY FEE
,Z nation Laws of Califnmia.Date
O
Applicant I WATER HEATER WNENT/ELECfR
GRADING FEE
`zs ti NOTICE TO APPLICANT:IL after making this Cations of of Exemption,you should WATER SYS'TEM/TREATING
a +
become suoJml In the Worth Pr Compensation pmvisions of the Labor Coke you roust SOILS PHH
forthwith comply with such Provisions or this permit shall be Jcemed revoked. WATER SERVICE
ZD
z CONSTRUCT]ON LENDING AGENCY NEW RF.SIDENTIALPLMB. $Q.FL PAID
L) 0 Ilmreby affirm theuherc is ecnnswdion lending agency forthe performance of Du I Receipt If
the work for which this permit is issued(Sce.3097,Civ.C.)
Q (~ Leadm's Nam, TOTAL:
L) Lenders Address TAL:
y1 certify that L have mad this application institute that the above information is BUILDIN
H
V) corach,l agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT PEE
V building
memminsctit)n,and herfor by asphalt..
To,axas. tives of this city to enter upon the SEISMIC
above-mentioned propene for emnifyian purposes.
(We)agree m nave,indemnify and keep harmless the City r Cupertino against PERMIT ISSUANCE. ELECTS] E
liabilities judgments,granting ex this permit.
may in any why name against said City ALTER OR ADD TO MECH.
in consequence of the granting of thin permit PLUMBING FE
AP�UNDENU WIL COMPLY WITH ALL NON-POINT pIR HANDLING UNIT(TO 10,00)CFM)/ MF.CHANICA FF.E
Z,A *1T AIR HANDLING UNIT(OVER IBM)CFM) CONSTRUCTION TAX
Signature of Appl imucholeacm, /VN `D�aIteLL���� EXHAUST HOOD(W/DUCT) HOUSING MI ATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building overipant store or handle hamodous material HEATING UNIT(TO 100.00)BTU)
as defined by the Cupertino Municipal Cale,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)7 HEATING UNIT(OVER 100.000 BTU)
El Yea ❑Nr
VENTILATION FAN(SINGLE RESID) PAID _
Will the applicant or futuro building occupant use equipment or devices which Date Receipt N
emit hu>arJous air conwminhnu as deflneJ by the Hay Areo Ah Quality Mvnagemeat BOILER-COMP DHP OR 1011,0011 BTU) -
Ili,wrict? TOTAL:
❑Yes F-1 No BOILER-COMIC(OVER 100,000 BT U)
I have read the ho>nothus materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER 141
ISSUANCE E
hands Health&Safely Code,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.ET.
building does not currently have a tenant,that it is my responsibility to notify the occupant
of the requirements which must be met prior to Issuance of a Certificate of Occupancy.
Owner or authonceJ agent Date TOTAL ISSUED BY:
OFFICE