S 1085APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICALI PERMn'NO.
APPLICATION/PERMIT PLUMBING.. MECHANICAL O 1085 O O C
BUILDING DIVISION I ann n.w rrwver-r mcurrsvrnnm S 1 85
NAME:
0
OFFICE
CONTACT: Gooses.:;
...............-...... I .— -
❑ Consultant Fees Paid by Applicant (Initial)
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LICENSED CONI'RACI'OR'S DECLARATION
1 herehy affirm hal 1 am licensed antler pmvisinns Of Chapter 9l commencing
with Section 7000) of Division 3 ofhe Business and Pndeslons Cole andnry license i.e.
L ease lass effect.
License Clan. LIC.k
Date Contractor
QTY ELECTRIC PERMIT FEE
.TOB ESCRIPTION
RESIDENTIAL:
❑SFTIWI. ❑KITCHCN RFMODEI.
❑ADDITION ❑PLUMPING RI PIPIT
❑MULTI -UNIT ❑STRUC'I'URAI.
MODIFICATION
El INTERIOR El CHIMNEY REPAIR
IMPROVEMENT OSWIMMING POOIS
El BATH RF,MODIiIl12EPAIR DEMOLITION
❑OTHER
PERMIT ISSUANCEW
APPLIANCES - RESIDENTIAL
ARCHITECTS DECLARATION
I undersand my pfun, anal) be used as public nce. ds
PANELS
UPI 0200 AMPS
Licensed Profseurel
1 hereby affirm hW Il am Rdmpt fromLDER EheCntractors License Law for the
following muton. ISeuinn ID3L5. Business and Profc..la., CWe:Anych,acounty
which requires a permit to construct, alter, improve demolish, or repair any structure
prior to it, issuance. aborequiresthe applicant fia,uch permit to lileasilind sammce,
hat he is licensed paramin.0e pmvisiansafhe Contraclor's License Law Chapter
(commencing with Section]Il0nor Division 3 of hcltuciness ons Professions Code)or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
no a civil penalty of
Section 7031.5 by any applicant for a gement subjects the andinu
olmom than Bve hundreddollat, 55001.
❑Loithewrnfhe pro pony.onnyotinhacee wile redfosalei(Sme comlwnsntlnn.
will Bo the work, and the no Core is not s Licenseded o w dku(or of p1 y to an, wour Of
iml apply s if owner of
and Professions Code The Contractors License Laws such
thereon, and wh nts am h work himself or through
progeny who boilsv provided
his own employccs, pmvidcJ hal such improvements arc not immnJul Or offcmJ for
that
sale.11',hnwevenhehuilJmprovih nethe
a.,1'),
201-I00IAMPS
OVER IUXIAMPS
SIGNS IiLI!CTRICAL
SPECIAL CIRCUITIMISC.
'TEMP. MET ER OR POLE INS'C
COMMERCIAL:
❑ NEW BLDGIAUDGHON ❑ DEMOLITION
❑TENANT El FOOD SERVICE
IMPROVEMENT
❑OTHER
POWER DEVICES
SWIMMING IKKIL ELECTRIC
OUTLETS -SWITCIfES- PI%'TURFS
NEW RESIDENTIAL ELECHi SQ FT.
SG. FI O9i FD
S/SQ. FI'
par
w h IJ will huv hcburdpowiri6 thanh did Milamimprove
ryas , 1 1.
❑ I f the p pony .Ins I) t ions w th Ib J tfncem set
construct n project is , 704aU Brounes and Professions C 1 ) I he Coutoauarr. 1.
tense Law does ..,applyt oflipent who buil), or indpoo,c,thmonmarl
29 'I� D��V
Ur
� .:
QTY. PLUMBING PERMIT F
who contracts for such projects with a contractors) Iicenwd pursmmnuo the Contractors
License Law.
❑lam esem tno c. .B&PCfor hisrc u
(Ur
�h��Np
"ERhfl'1' ISSUANCE
ner Uac
ALTER -DRAIN k VENT- WATER (EA)
VALUATION
BACK FLOW PROTECT. DEVICE,
WORKERS COMPS . ATION DECLARATION
IMrebyallinnunderpcnahyr perjury ane of the following Jeclarutionc.
❑ I have and will maintain a Cenilic te of Comenuo self -insure for Workers Compem
cation, as provided for by Sectio 9700 of the Lahr Crile, for he performance of the
DRAINS- FLOOR, ROOF. AR EA. GOND.
STORIES
'TYPE CONS' IR UCI'I0,
work for which this 1¢mah is musel.
FIXTURES - P12R TRAP
O 1 have and will maintain Workds Comlmensainn Inwonese, as inquire l by Section
3700oflhe Luh -Cole, forthe perliammoceofthe work forwhich this pemail n issued.
GAS - EA. SYS TEM -I INC. i OU'TLCFS
OCC. GROUT'
APN
My WOfker's Compensation Inramnce carrier and Policy mainframe
Cartier: Policy No.:
GAS - HA. SYSTEM -OVER i (EA)
C12RI'IFICA'I'E OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This seetiun nth not hammpfried if he permit is fnronc huodreJ Jnllnrs ($IW)
or Ices.)
GREASE IINDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FENS
GREASETRAP
PLANCBECK FEE
SEWER - SANITARY -STORM EA. 2N)FT
Iccnifylhai.heperformencc ofthe x.,k fawhich lhi.pemat i.e. µcued, I µball
not employ any person in any manner so as to become subject to the Workers' Compen-
ENERGY Ilia
WATERIEATEiRW/VENT/ELECTR
OX
Z O
>
0
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a.he. Laws of California. Date
Applicant
GRADING FEE
NOTICE TO APPLICAN I': If, after making This Cerlilicale of Exemption, you should
become subject m the Workers Compensation provisions of the Labor Cade, you mint
forthwith comply with such por,Wornorda, perean Snell be Jeen¢Jrevoked.
CONSTRUCTION LENDING AGENCY
l agency for he performance of
that issued(See NE7.
WATER SYSTEM I REATING
WATER SERVICE
SOILS FEE
PAID
Date Receiptp
NEW RGSN17N'1'IAL I'LMB. SG. IT
—
t+
for hiaffirm Cing
the wnfk for which this pump is issued (Scc.9tn]. Civ. C.)
"I 111AL:
0
O U
>1
F y
U X
beadce,Name
fcndcrn Arltlresn
TOTAL:
1 rtify Ih d I have read This applieminn and some tem the above ofnnnaion u
ceanmct.I agrte to mmplYwih allcityand coory oNmanccc and.anm Wws ml;ning t"
building construction, and herebyemhmim repocamenivesofhis citymemv,.,u. he
QTY. MECHANICAL PERMIT FEE
BUILDING 17EE
SEISMIC PER
PEkMI'1' ISSUANCE
HLECI'RIC FEE
above-mentioned pmpedy fur inspection puryoses.
(We) agree to _cave. Indemnify and keep Stainless the City of Cupertino against
ALTER OR ADD TO MECH.
Iiabrilies,judgmen ,costs and cxpcnse.e which may in any way accrue against said City
in nxqucnce of be senting of his permi.
PLUMBING FEF,
AIH HANDLING UNIT '(TO 10.00(i CFM)
MECHANICAL PEE
APPLICANT 'ND 11TANDS A LL COMPLY WITH ALL NON -POINT
SOURCE / I "IONS. a�
/
AIR HANDLING ON[[ (OVER 0.0(KCFM)
CONSTRUCTION TAX
�,X
//// j
Signaldf, of cmnUC nmor )ate
HAZARDOUS ERIALS DISCLOSURE
EXHAUST HOODOVIDUCT)
HOUSING MITIGATION FEE
1 IEA'I'ING UNIT TO 1110,000 BTU)
Will he applicant or fmure b 1ingoccupmm.tom or handle hrzanloas material
as Jefinea by he Cupertino Municipal Cotte. Chapter 9.12, and the Health and Safety
Cale. Section 25532(a)]
HEATING UNIT (OVER IS).000 BTU)
❑Yes ❑No
Will the applicant nr name bolding occupant uoc agwpmem ser devices which
emit hamrdnus air contnminann me defined by the flay Arca Air Quality Management
Distinct!
❑Yes ONO
PAID
Late Receipt M
VENTILATION I-AN(SINGLE RESAT)
BOILER -COME (311P OR 00.00h PTU)
TOTAL:
BOILER- COMP (OVER I OP000 BT U)
AIR CONDITIONER
I have read the hazardous macrials a uimmems a.&, Chapter 6 95 of he Cali-
4
ISSUANCE DATE
NIiW RIiSIDENTIALMliCll. SQ.IT.
that it the
NameHealthSoftly Cass, Sections 25505. 255JJand2SSlit1 to many
building does not currently have n mnnnt, that it is my responsibility m notify the «cupam
the
of the regaimmenm which masa be nim pour In issuance of a Cerlilicam of Occupancy.
ISSUED BY: _
Oscermentharoad agent Irate
TOTAL:
OFFICE