S 0304APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO RIIILDING- ELECTRICAL - _ _ FFITN(l.
BUILDING DrvINION APPLICA'1'ION/PF,RMIT PLUMBING-MliCHAm1:A1. • J
0304
BUILDING PRON C'I' IDRNF PICATION
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ARCHLY /ENGINEFi N: IC NO:9RCtiS
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�CONTACT, A PHONE:
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❑Consultant Fees Paid 6y Applicant (initial)
BUILDING PERMIT INFO
BO ELECT, PLUMB MI•❑Cfl
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LICENSED CON'TRACTOR'S DECLARATION
I hourly aMrm that I em licensed under provisions of Chapter 9 (commencing
with Section NlIXB of Division J of he Business and Professions Cole, and my license is
in fail forceand effect .P X10 '!-r41
License Class 11Lisp 1
Dam Conaccu
QTy ELL'CTRIC PERMIT FEE
JOB DESCRIPTION
RESIDENTIA L'
❑SFDWI. [IKITCHEN REMODEL
❑ADDITION E) PLUMBING RE -PIPE
[I MULTI -UNIT ❑STRUCTURAL.
MODIFICATION
❑INTERIOR CHIMNEY REPAIR
IMPROVEMENT E] SWIMMING POOLS
PERMIT ISSUANCE S
APPLIANCES-RCSIDENI'IAl.
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ARCHfrECTS DECLARATION
1 uadersmnd my plans shall he used ac public mcmds
PANELS
UP TO 200 AMPS
4 t:W
Licensed Pm(emional
201-1000AMPS
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4 O F
OWNER.RGILDER DECLARATION
1 hereby affirm that 1 am exurpt from the Contractor's License Law for the
following reason. (Section 70)1 s, Bosireas and Professions Coda Any city or county
which requires a permit to com un, almr, improve, demolish, or repair any structure
prior to itsusuounce, alsomporish ppl' nt Eursuch Permit in Ilcu signed statement
BATH REMODELEPAIR ❑D'1GLI'I[ON
El/R
❑ OTHER
OVIiN 10(s) AMPS
SIGNS ELECTRICAL,
SPECIAL CIRCUI I-IMISC.
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p.
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that he is ficonstalI ds nt the provisions at 'h Contractor s License Law (Chapter 9
(ci gwllhSecti 17111X1)fDlvis n9 f(l B:mcs all I sion,Cnde)nr
That he Is exelnPt Ihercfrom rand Thu heals far the alleged mournion. Any violation of
Section 71115 hynny npplicnnt to a permit suhlcrl, thenpplicam m.acivil penalty of
TIMI' METER OR POLE INSII
CO R I
❑ NEW BLDG/ADDITION 0 D17M01,1'I'ION
❑'I'F.NANT ❑ FOOD SERVICE
POWHR DEVICES
FZT}
not lnommon live hundred Jnllars($5(0).
Liermacrofthcprnpeny,or mycntpinyeu with wages usihcirxulcoompensmiom
is intended for (See. 7040 Business
IMPROVEMENT "
[]OTHER
-
SWIMMING POOL. ELECTRIC
OUTLETS - SWITCHES -FIX'I'1JR17S
L�El
3
will Jo the work, laud the swcwrc not or oll'mN sale
and Professions Cade: The Comraclars Licen.m Law Joe, not apply an an owner of
property who builds or improves themor, and who docs such work himself or through
his awn employees, provided that such improvements am not intended or offered for
auto. If, he..,. the building or improvement is sold within one year ofcompletion.the
NEW RESIDENTIAL FLEC'I'R SQ FI'.
SQ. Irl", FLOOR AREA
$/SQ. FI',
-
twaerbuilder will hove the harden of proving that he did not hrildor Improve for pur-
is-
TOT
peaeOfsile.).
❑ 1, as owner of the Property, am exclusively contracting with licensed contenders to
QTY: PI,IIMBINC ITS FEE
construct the project (Sec. 1014, Business and Professions Cont The Coaurctmrs Li -
i-censeLawJensnotapplymwownerofpd)pedy who builds or improves thereon.and
crone Law does nor apply it) par owner of pTt)pmy
who comm l,forsuch pnjecm with acontracums) licensed pram uantmthe Contracmre
PF.KMIT ISSUANCE'
License law.
❑ 1 em esernm i ndu Sec. . R & P C (onbis reason
ALTTiR - DRAIN & VENT- WAITiR I
VALUATION
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one older following declarations:
LOW
BACK FI'ROT[CT. DEVICE
STORIES
TYPE CONST RUCTION
I have and will maintain a Cordillera, ofComentto self -insure for Worker's Comped-
DRAINS- FLOOR, ROOK AREA, COND s.
sation, as provided for by Section 8710 of the Labor Cade, for the performance of the
w 'nr which this permit k it"to d.
FIXTURES - PER TRAP
and will maintain Worker's Compensation Insurance, as required by Section
-- 700 of the labor forrf"orlmaannce of the workfor which this permit is issued
GAS-EA.SYSTEAI.I INC.401f1'LIirS
'
OCG GROUP
APN
GAS - EA. SYSTEM -OVER 4ORA)
CCode,yforftthe
My Work I�1✓Is'�r1 �"`-c^ nugbvpry IC2�,�
CENTIFIC O PHNSAPTON GN FRAN WORKERS'
GDMPI?NSA'fIONINSURANCF.
GREASEIINDUSTRL WASTE INTERCEPTOR
BUILDING DIVEE'AN F17ES
(This section need not he completed if the permit is for one hundred dollars.($107)
or less.)
GREASETRAP
PLANCHBCK FEE
- SANITARY -STORM EA. NO FL
ENERGY FEE
I cenh'y Main lhcperfnnnunco nfthe work liar which this mut is lssueJ,IshallSEWER
not employ any person in may m. der sons le leanne subject In the Workers' Comped-
WATER IIEAI'I7K WIVENDF/1].IiCI'H
GRADING PHB
z radon Laws o1' Culliond.. Date
Q 12 Applicant ) -
WATER SYS'ITNUTREAI'I NO
SOILS FEE
NOTICE TO APPLICANT, If, alio looking this Certificate of Exemption, you should
[" become subject to the Wnrka's Conrpeosmien previsions of the Labor Code, you must
PAIDse Receipt#
forthwith comply with such pduvisionsor this permit shall be deemed revoked.
Uj Q
G CONSTRIICTION LENDING AGENCY
7D z Ihereby affirm that is a construction lending agency for the perfmmance of
W P the work for which this perout is issued (Sec. 30cri. Civ. CJ
QU louder', Name
WATER SERVICH
NEW RESIDENTIAL 111.1013 SQ. F..
TOTAL:
TOTAL:
BUILDING FE
W Lendoeu Address,
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aF. co)
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1 codify that I have read this application end ,all that the above information is
correct.I agre,mcomply with all cityaulcouniyoMinancesand.,totelawsrelatingta
buildingmnatuNogiad herchy author immior,entmives of shin city mora, upon Ne
QTY. MECHANICAL PERMIT FEE
_
SEISMIC FEE
PERMIT ISSUANCE
ELECTRIC FEE
`
mlove.meationed property for inspection pugroscs.
(We) agree to save, indemnify and keep hrnnle,, the City of Cupertino against
PLUMBING FEE
Iiahiliuc,.fulfillments costs and espersea whichomy in my way acc,ueagainst said City
sryuence of the genmin6 sif this permit.
n PPI CANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
'O ERE ULATIOIdS. � j0
ALTER OR ADD TO MECIL
AIR HANDLING UNIT LTO 10,gk1 CFM)
MECHANICAL FEE
AIR HANDLING UNIT (OVEN 10.0011, CFM)
CONSTRUCTION TAX
tili
igna reef ApplicanJConfactor Dae
HA7ARDOUS MA'I'ERIAIS DISCLOSURE
OWEWE1
EXHAUST HOOD IW/DUCI}
HOUSING MITIGATION FEE
If1iAI'[NO UNIT (1'0 100,00 BIO)
the applicant or future building emulate store or handle hvallous material
as defined by the Cupertino Municipal Cede, Chapter 9.12, and the Health and Safety
Code, Section 2553201?
HEATING UNIT (OVER 1101100 BTID
VENTILATION FAN(SINGLERESID)
❑Yca ❑Nn
PAN
Dale Receipt p
'emit
Will the applicant o, future building occupant use equipment or denwa which
hazardous air cmmdminants a, JeEned by the Buy Area Air Quality Management
ROLLER -COMP OHI' ON I(O,fNX) BTU)
�-T01'AI;
Dietnefl
❑Yca ❑Nn
BOILER-COMP(OVER 1Xk000B1U)
_
AIR CONDI'I TONER
1 have Octal the to, Clu,no, 6o5 of the Cali
monia II 111 K Safely Club, Societe, 25505 5513 add 25514 1 andodderal the, if the
hadifir on, courmal,l t art hat it is ity res,saisidailitytnotify the occupant
ISSUANCE DAFT
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NEW RISIDEN'I'IAL MFCll, SQ. IT.
oI the mgwremmnls whultut xI lrnot"i In maaanca of a Cenlhcate nfOauponey.
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yr,.-��( �1/�/
ISSUED RY:k / s^� • ` `�
'T'OT'AL:
n..............m,,....n 1—ni Date