S 1688APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO - BUILDING - ELECTRICAL.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING- MECHANICAL
PESIT No, 16 8 8
BUILDING PROJECT IDENTIFICATION
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SANITARY NO.
APPLICATION SUBMITTAL DATE.
S-2c�-yds
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Consultant Fees Paid by Applicant (initial)
PERO
ILDING
MECH
RLUG ELECT PLUMB
-/
❑ El ❑ LJ/
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm thin I am licensed under provisions of Chapter 9 (commencing
with Section 7000 fDlvision 3 ofind Bushmxs ode, and my license in
in full force and a
Dam�_CnntDEC[ sou
License lax I-ia#
ARCHIfF.0 I"S DECLAR TI
lundersmnd my plans shall be used as public records
QTY. ELECTRIC PERMIT FEE
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JOB DESCRIPTION
RESIDENTIAL:
❑ SFDWL ❑ KITCHEN REMODEL
'
El ❑PLUMBING RE-PIPE
❑MULTFUNIT' El STRUCTURAL
MODIFICATION
El INTERIOR El CHIMNEY REPAIR
IMPROVEMENT SWIMMING POOLS
❑ BATH REMODEUREPAIR ❑ DEMOLITION
❑ OTHER
G
PERMIT ISSUANCE.
APPLIANCES - RESIDENTIAL
PANELS
_
UP TO 200AMPS
Licensed PTofexsional -
OWNER-BUILDER DECLARATION
I hereby affirm mat I am exempt from the Connector's License Law for the
following reason. (Second 70315, Business and Professions Cade: Any city or county
which requires a permit to construct, alter improve, demolish, or repair any structure
prior mit, kdoerce.nlso requires the applicemfc)revch peradea file. signed statement
that he i, licensed ponmen mda, pmenien,of the Contractors License Law (Chapter 9
(ermucrumg with Section 9000)af Division 3 mdue Bmaneasmd Professions Cade)m
thou he is exempt merm..in and the basis for the alleged exemption. Any violation of
Section 70315 by any applicant fora permit subjects the applicant to is civil penalty of
sol mofive re Ihaa hundred dollars ($500).
Fl Las owner ofthe property, or my employees with wages as their sole compensation,
will dothework,add mestrudurei,not immodialm.1ieredfarsa1e(Sec.7044, Business
and Professions Code: The Contractor's License Law does not apply to an owner of
property he build, rr improves thereon, and who does such work himself nr through
201-1000AMPS
OVER 1000AMPS
SIGNS ELECTRICAL
SPECIAL Cl RCU IT/M ISC.
-
TEMP. METER OR POLE INST.
COMMERCIAL:
❑ NEW BLDG/ADDITION ❑ DEMOLITION
❑ TENANT El FOOD SERVICE
IMPROVEMENT
COTHER
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS- SWITCHES - FIXTURES
his awn employees, provided that such improvements am not intended or offered no
NEW RESIDENTIAL ELECTR SQ
sale. If. however the building or improvement is sold within one year ofcompldion.Ihe
SQ. FT. FLOOR AREA
$/SQ. FT.
owner-hadder will have the burden of proving that be did not build or improve for par,
poseof sale). -
AL:
❑ 1, as owner of the property, am exclusively contracting with licensed contractors to
ansuud the sweet (Sec 9044, Business and Professions Code:) The Gmmudu's Li-
-
cense Law does not apply to an owner of property who builds or improves thenar, and
QTY. PLUMBING PERMIT
who contracts for such pmjects with a co ndmtor(s) licensed pursuant to the Contractor's
PERMIT ISSUANCE
License Law.
❑ I at. exempt under Sec , B & P C for this reason
ALTER -DRAIN&VENT-WATER (EA)
Owner Date
- VALUATION
JV
at
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
BACK FLOW PROTECT. DEVICE
DRAINS-FLOOR, ROOF, AREA, COND.
❑ I have and will maintain a Certificate of Consent to self-insure for Worker's Comped-
,anion, us provided for by Section 37M of the Labor Cede, far o perfoan
rmce of me
STORMSTYPE
CONSTRUCTION
FIXTURES - PERI RAP
work for which this permit is issued.
`RI have and will mammon Workers Compensation Insurance, as required by Section
10 0i aUI or c, Ends,u-no inane teff, doomY(or fvlychsl�iylrenji'i
�`anl}1�L,( rUr1V-•1
.I
J—Al
GAS- EA. SYSTEM-I INC. 4 OUTLETS
OCCGROUP
APN
Camoc+„
CL TIFICATE OF EXEMPT ON ROM WORKERS'
GAS -EA. SYSTEM -OVER 4(EA)
CC
J Frplx,L
'
COMPENSATION 1 RANCE
section need not be completed ifthe Permit is farone hundred dollars SEXE
or lesx.)
GREASE/INDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES(This
GREASE TRAP
PLANCHECK FEE
SEWER-SANITARY-STORM EA. 2(X1 UP
OZ
Q
Ieerufy met In the perfnnnence oflhe work(orwhich obis permit is issued, l shall
not employ any person In any manner sin as m become subject to the Workers'Cnmpem
ration Lawsnf Cmmmaia. Dare
Applicant
ENERGY FEE
WATER HEATER WNENT/ELECTR
GRADING FEE
NOTICE TO APPLICANT: if, after making this Cenificate of Exemption, you should
become subject m the Workers Compensation provisions of the Labor Gde, you must
WATER SYSTEM/IREATING
rjI
�^
-
SOILS FEE
W Iti
a
C) 0
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LF.NDINCAGENCY
l for whichmi,pedthere issued( (See 30lending agency fnnhe perG+rmunce of
the work far which this punnil le issued (Sec.309], Civ. CJ
WATER SERVICE
PAID
Dote Receipt#
NEW RESIDENTIAL PLMR. S
U
{ki
�. �A"il
V 4
Lender's Name
Lender', Addf
TOTAL:
ANS'Det
I certifyythat I have read this application and stem m(be above information is
correct, Iagreemcomply wimad city add eruntyordinancex and wine laws renting to
building concoction, and hereby authorize represedifivex (if this city to enter upon the
QTY. MECHANICAL PERMIT FEE
BUILDING FEE
SEISMIC HE
above-mentioned property for inspection purposes,
(We) agree to'ave, inand keap harmless me Cily of Cupertino against
PERMIT ISSUANCE �^
J 'J�
ELECTRIC FEE
ALTER OR ADD TO MECH.
-
PLUMBING FEE
IiuNll e,judgments,cosiwandexpenxes which may in anyway mane andel .said City
Iu eons tenting oM mit
AIR HANDLING UNIT (TO 18000 CFM)
MECHANICAL FEE P4 310
WUNDI
APPLISTANDWill :1^IP LY WITH ALL NON-POINT
.OUR 1705
[[l�
AIR HANDLINGUNIT(OVER 10,000 CPM) �—IsLd 0
CONSTRUCTION TAX
EXHAUST HOOD(W/DUCT)
-
HOUSING MITIGATION FEE '
Signature ofApplicftCe man Dmc
ZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (TO 100,000 RT U)
Williheappl at orfumed buddmgocenpanl,mmminddlehavmmin urserisl
as defined by Ibe Cu enino Municipal Code, Chapter 9.12, and the Health and Safety
CMB Section 25532(a)?
E] Yee, ❑No
Will thea licide or fm ed btiilJin t use a mem or devices which
pp gbytheB qup
mit hazardous air contaminants as defined by the Boy Area Air Quality Management
Dismicn?
7Ycx I]No
HEATING UNI 'I(OVER 10X1,000 BTU)
PAID
Date Receya #
VENTILATION FAN (SINGLE RESID)
BOILER- COME(3HP OR 100,000 BTU)
TOTAL:
BOILER- COMP(OVER IW,IIfXI BTI])
AIR CONDITIONER [r�
I V
I have mad the hazardous Se materials 5, 2553 an under Chapter 695 d that it the
fomia Health & Safety mm Coda. ed'eare rdel 25533 and 25534.1 understand nd that it
is
buildingdremmts
mopoce Ce irymnmifymeacepam
'ISSUANCE DATE ZS .
Gy//
,
NEW RESIDENTIAL MECH, SQ. FT.
uainy
of me requirements which mu the met prior to isvuvnce araC nificme of Occupancy.
whicynum be met Farrar ofa
ISSUED BY Oe�ti%a(.i.cC,r—ti7`7(.L.CC'r'
Ownerstr authorized agent Dam
(�
TOTAL: ut�0_
OFFICE