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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL
PERMITNO.
BUILDING DIVISION APPLICATION/PERMITPLUMBING. MECHANICAL.
-29327
BUILDING PROJECT IDRNTIFICATION
BUILOINGADDRESS:�_
SANITARY NO.
APPLICATION SUBMITTAL DATE
�
o zo b; I \ c rekS Kill cr_1-+al�•J
O ER'SNAME: C B� N 14L
CONTRACTOR'S NA LIC NO:
NIC
❑
CONTROLp
RCHITEC /ENGINEER: LIC NO:
ADDRESS:
CONTACT. PHONE
BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant (Initial)
1@LD2 LECI , PLUMB MECH
���`"•' �Ll(`s`�
LICENSED CONTRACTOR'S DECLARATION
I haffirm that I am liceereby amul under pm novas of Chapmr 9 (commencing
with Section 700ho.lLvisom 34the Business and Professions CudA-dmylicenseis
Licenfall eClassorce elect.
License Class Lic. p
pant Commmor
QTY.
ELECTRIC PERMIT FEE
JOB DESCRIPTION
RESIDENTfAf�
❑SFDWL ❑ KITCHEN REMODEL
DITION (]PLUMBING RE -PIPE
MULTI -UNIT ❑STRUCTURAL
MODIFICATION
PERMIT ISSUANCE
APPLIANCES -RESIDENTIAL
ARCHITECT'S DECLARATION
I understand my plans shall he used as public records
PANELS
UPTO200AMPS
❑INTERIOR' C] CHIMNEY REPAIR
IMPROVEMENT
C1 BATH REMODEUREPAIR C1 DEMOLITION
11 OTHER
Licensed Pmfessiunal
OWNER -BUILDER DECLARATION
I hereby affirm ohm 1 am asernp emmpr from the Cannanore, cense Law for the
following reason. A Permi(Sectt Code: Any city mcoume
which requires a permit re amsweL alter, improve, demolish, Ar repair
7ono auslnesauprove, demolish, swment
201.I(Nq AMPS
OVER UgX)AMPS
SIGNS ELECfRICAI.
SPECIAL CIRCUIT/MISC.
prom ed
prionoiB issuance, also requires the Applicant (m such PermitCimma,we Law( statement
Out he is licensed ....... he provisions of the Commnor a License Law (Chapter 9
Lamas
TEMP. METER OR POLE INST.
COMMERCIAL'
(commencingwithSection 7U W) ofbasisan3ofthe Code? or
,bar he eged vanndPo Any violation of
that he is exempt therefrom anJ the basis far the alleged exemption. Any
❑ NEW BLDG/ADDITION ❑ DEMOLITION
POWER DEVICES
l
Section 7031.5 by any hundred domfor a ra($50nnit subjects the applicant toacivil penalty of
not mom than five hundred dollen ($SW).
❑ I. As owner of the property, m my employees with wages as their sole compensation,
will do the work, and Ne xtromurc fs not intended nroffercd foraale (Sea 7N4, Business
[]TENANT ❑FOODSERVICE
IMPROVEMENT
❑ OTHER
SWIMMING POOL ELECTRIC
and Professions Code: The Cmuracmfs'License Law does not apply to an owner of
OUTLETS -SWITCHES -FIXTURES
property who builds or impmvcs thereon, and who does such work himself or through
his own employees, provided that such improvements we not intended or offered for
NEW RESIDENTIAL ELECTR SQ FT.
Ff.&COR AREA $/SQ. FT.
2a
sale. If. however, the building or improvement issuld withinone year ofcompletion,the
own builder will have d th Ad of proving that he did not build or improve for purr-
of sale.).
�SQ.
TOTAL.
I, us owner of the property, am exclusively contracting with licensed contractors to
n the project (Sec. 7N4. Business and Profcssfuns Code:) The Comment's Li-
QTY. PLUMBING PERMIT FEE.
censeLaw dors not apply to an owner of property who builds or impmva thereon.and.
who contracts for such pmjeas with a omamxor(a) licensed pursuanno the Contractor's
x01
' s,V I' h
PERMIT ISSUANCE
License low..
❑ In. e tumdcr ,B& PC for this reason
ALTER - DRAIN & VENT - WATER UA)
rter.16M
Q 17VON
BACK FLOW PROTECT. DEVICE
"ORKeRrgCOMPI3NSATON DECLARATION
I hereby affirm under penalty of pc jry declarations:
one of the following declaration
❑Ihaveandwill maintain aCeniftwmof Conaenuoself-insure for Worker's Compem-
sation, as provided for by Section 37W of the Labor Code, for the performance of the
r V 1gf•T—'—
♦.
DRAINS - FLOOR, ROOF, AREA, GOND.
gTQRI •'s//$V
TYPE CONSTRUCTION
work for which Nis permit is issued, -
FIXTURES - PER TRAP
❑ 1 have and will maintain Workers Compensation Insurance, so required by Section
37M of the labor Cafe, for the performance of the work for which this permit is issued.
My Workers Compensation Insurance carrier and Policy number am:
GAS - EA. SYSTEM- I INC. 4 OUTLETS
OCC. GROUP
,
APN
Cartier: Policy No:
GAS - EA. SYSTEM -OVER 4 (EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not he completed if the permit is Intone hundreddollam ($1 AA
or lust
GREASEIINDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
GREASETRAP
PIANCHECK FEE
I canny that in the performance Arrive work for which this permit is issued, l shall
remounts not employ any pon an
in y owm become warmer so as m subject the Workers' Compem
SEWER - SANITARY - STORM EA. 200 FT.
ENERGY FEE jam+
WATER HEATER WNENT/ELEC R
cation Laws of Califnmia. Date
Applicant
GRADING FEE
NOTICE TO APPLICANT" If, after making this Certificate of Eaempdon, you should
hccmme subject to the Worker's CAmpensmicm prawkium of the labor Code, you must
WATER SYSTEMRREATING
SOILS FEE
forthwith comply with such Provisions m this Permit shall be deemed invoked.
WATER SERVICE
NEW RESIDENTIAL PLMIL SQ. FT.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
PAID
Data Receipt# _
the work fur which this pemut is issued (Sec. 3897, Civ, C.)
Lenchea Nem.
TOTAL:
Lender's Address
L:
BUILDING FEE
1 certify that 1 have read this application and state thin the above infmmati n is
corrtchlag�ee mcomply with all city and munry oNinancea and sum laws rclatingm
building construction, and hereby authorim representatives of this city to enter upon the,
QTY, MECHANICAL PERMIT FEE
SEISMIC FEE
PERMIT ISSUANCE
above-mentioned maperty for inspection proposes.
Wed agree to save, indemnify and keep harmless the City of Cupertino against
ELECTRIC FEE
ALTER OR ADDTO MECH.
liabdities.judgmeau, costs and expenses which may in Any way accme against said City
in consequence of fl a grunting of this permit.
PLUMBING FEE
AIR HANDLING UNIT TO 10,000 CFM)
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON POINT
SOURCE REGULATIONS.
-
MECHANICAL ME
AIR HANDLING UNIT (OVER W." CFM)
CONSTRUCTIONTAX,
Signature of Applicumt/Centmctor - Dow
HAZARDOUS MATERIALS DISCLOSURE
EXHAUST HOOD(WIDUCD r
HOUSING MITIGATION FEE
HEATING UNIT (TO 100.000 BTU)
Will theapplicant or future building occupnmstwem handle harnrdous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Cede, Section 25532(x)?
HEATING UNIT(OVER 100,03) BTU)
Year LIN.
Will the applicant or future building occupant use equipment an- devices which
emit loodadoos air contaminants as defined by the Bay Area Air Quality Management
District?
❑Yes, _ F7 No
PAID
Data - Rccaqu #
VENTILATION FAN( SINGLE RESID)
BOILER -COMP IMP OR 100,000 BTU)
TOTAL:
BOILER- COMP (OVER I W,000 BTU)
AIR CONDITIONER
I lave read the hazardous materials res, i¢ments under Chapter 6.95 of the Cali-
ISSU E DATE
NEW RESIDENTIAL MECH. SQ, IT.
fordo Health & Safety Code, Sections 25505, 25533 and 25534, 1 understood that if the
building does nor currently havea mount, that it is my responsibility to ratify the occupant
of the requimmen¢ which must he met prior to issuance of a Certificate of Occupancy.
ISSUED
Owner mnuthoriaed agent Date
A
OFFICE IA v N