99110055APPLICANTTO FILL IN INFORMATION WITHIN RED LINES • USE SALL POINT PEN ONLY 9 Q / O 0,
CITY OF CUPERTINO BUILDING - ELECTRICAL
P O.
BUILDING DIVISION APPIACATION/PERMIT PLUMBING - MECHANICAL.
s► BUILDING PROJECT IDENTIFICATION
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SANITARY NO.R ATE
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CHYFECUENGINE.P.R LIC NO:
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CONTACT PHONE:
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BUILDING PERMIT INFO
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❑ Consultant Fees Paid by Applicant (Initial)
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing
QTY ELECTRIC PERMIT FEE
JOB DESCRIPTION
withSeason 9000)of Diviuon3 onhedusinessatl Ponficilovs Code, and my lbeosels
in full force and effect.
License Class Liap
Date Comrncmr
-
PERMIT ISSUANCE
RESIDENTIAL:
❑SFDWL ❑KITCHEN REMODEL
El ADDITION El PLUMBING RE -PIPE
APPLIANCES -RESIDENTIAL.
ARCHITECT'SDECLARATIO
1 understand my plans .ball be used vs public rectmls
❑MULTI -UNIT [D STRUCTURAL
MODIFICATION
PANELS
UP TO 200 AMPS
[I INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT SWIMMING POOLS
❑ BATH REMODEIJREPAIR El DEMOLITION
� OTHER
Licensed Pr.Rcssiorol
OWNER -BUILDER DECLARATION
Comm ON
O for the
I hereby affirm that 1 em exempt from the Contracmol License city
following reason. it ]onto loill's and Professions Code: Any city or county
201-IOf10AMPS
OVER 1000 AMPS
SIGNS ELECTRICAL
which (Smit repair any
a permit Ie contract, aper, improve, demolish,
SPECIAL CIRCUIT/MISC.
caucmre
its issuance
uonca also requires the nt such file s Cnmmuv
tprior hat hnim6
provisions of 9
that he is licensed parrs ant m the provisions o[ the Contractor's License Laws
Contrarmi'tLice Law
TEMP. METER OR POLE INST.
COMMERCIAL:
of the Code)
Business andlation or
(commencing wilb Section 70(g) and
tham a is the basis or vi
that he is therefrom end the basis for the alleged exemption. Any violation of
aged on Any
[I NEW BLDG/ADDITION ❑ DEMOLITION
POWER DEVICES
Semon ]031.5 by any applicant our a pormit su12ccas the applicunl I0. civil penalty of
31.5 b
not mom than five hundred dollars ($500).
❑I,vv owner of the property, or my employees with wages vs Wtirsole compensatioq
will do the work, and the evuctim is not imended oroffered for sale (Sea 9044, Business
and Professions Code: The Convector's License Law does not apply man owner of
NT [D FOOD SERVICE
MPROVP.MENT
❑ OTHER
SWIMMING POOL ELECTRIC
LETS -SWITCHES -FIXTURE
property who builds or improves thereon, and who does such work himself or through
his own employees, provided that such improvements are not intended or offered for
sale. IL however, the building or improvement is sold within one year of completion,the
NEW RESIDENTIAL. ELECTR SQ FT
SQ. FT. FLOOR AREA
$/SQ. IT.
wn
er-builder will have the burden Of proving that he did not build or improve for puKr-
Oof sole.),
owneras of the properly. am exclusively contracting with licensed contractors to
TOTAL:
nnahpcl the project (Sec. 70004, Business and Professions Code) The Contractor's Li -
se Law does not apply to an owner of property who builds or improves thereon, and
QTY� LUMBING PERMIT FEE
who contracts for such projects with a contractuds) licensed pursuant to the Contractors
PERMIT ISSUANCE
License Law.
❑ l rte exempt Order See ,B&P C to 'his reasoa
Date
ALTER- DRAIN&V WATER(EA)
VALUATION
O O
W iKER'S OMPENSATION DECLARATION
BACK PLOW PROTECT. i
I north, vffiimruder penalty of perjury one 0fthe following eclarmicns:
DRAINS- FLOOR, ROOF. AR EA, O U.
I have and will maintain a Certificate of Consenuo self -insure for Worker's Compen-
sation, .as provided for by Section 3000 of the ].shot Cole, for the performance of the
STORIES
TYPE CONSTRUCTION
work for which this pemtit is issued
FIXTURES - PER'TRAP
❑ 1 have and will maintain Worker's Compensation Insurance, as required by Section
370Oef the Labor Code, for the pe,brome,cof the work for which this permit is issued.
GAS - EA. SYSTEM -1 INC.4 OUTLETS
OCC. GROUP
APN
44��
Caerier:rker' nen trios upol ey No.��Pb l
GAS -EA.SYSTEM-OVER 4(EAT
ilepilt I IC E OF EXF.MNION FROM WORKERS'
COMPENSATION INSURANCE
'his.vedinn need not be, mmplemdd the pemtit is for one hundred dollars(% 1010)
or less.)
[�
GREASIUINUUSNO. WASTE. INTERCEPTOR
BUILDING DIVISION FEES
GREASETRAP
PLANCHECK FEE
Icertify that in the performance efthe work for which this permit is issued l shall
not employ any person in any manner ao as in become subjecr m the Workers' Compen-
SEWER - SANITARY - STORM EA. 200 FT.
ENERGY FEE
WATER HEATER W/VENTMLECTR
,audit Laws or Calffjj��
Applicam /��T _
GRADING FEE
NOTICE TSHPPLICAN : R, aft r making this Conificate of 5xemption, yon should
become subject I0 the Worker's Compensation provisions of We Labor Code, you must
WATER SYSTEMGFREA1'ING
SOILS PEE
forthwith comply with such provisions Or this permit shall he deemed revoke,
WATER SERVICE
CONSTRUCTION LENDING AGENCY
Ihereby affimthat them is a coretrunion lending agency for the performance of
NEW RESIDENTIAL PLMB. SQ. Fr.
PAID
Dem. Receipt#
the work for which this permit is issued (See 3097, Civ. C.)
Lender's Name
TOTAL:
Lender's Address
TOTAL:
BUILDING FEE
I certify that I have read this application and state that the above information is
order. I agree as comply with all city and county rudimnw and sante TO,, elating to
building construction, and hereby authorize representatives of this city to enter upon the
QTY. MECHANICAL PERMIT FEE
SEISMIC FEE
PERMIT ISSUANCE
ELECTRIC FEE
above-mentioned pmpeny for inspection purposes,
(We) agree to save, indemnify and keep harmless the City of Cupertino against
ALTER 911 TO MECH.
PLUMBINGFEE
in liabilities, judgments, costs and expenses which may In any way accrue against said City
asequence of the granting of this permit.
AIR HANDLING UNIT (TO 10,000 CFM)
MECHANICAL FEE
APPLICANT UNDERSEA S A D WILL COMPLY WITH ALL NON -POINT
SOURCER C ATI
AIR HANDLING UNI 'I'(OVER IQ000CFM)
CONSTRUCTION TAX
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!late?
Signallcc Appl con afar
HAZA DOUS MATERIALS DISCLOSURE
EXHAUST HOOD (W/DUCT)
HOUSING MITIGATION FEE
HEATING UNIT (TO 100.000 BTU)
Will the applicamor future building occupant store or handle hazardous mmedal
as defined by the Cupertino Monte I Code, Chapter 9.12, and he Health and Safety
Code, Section 25532(.)1
HEATING UNIT (OVER 100,000 BTU)
El Yes
WiII the applicant or fumrc building occupant use equipment or devices which
nit hazardous air contaminants defined by the Bay Area Air Quality Management
Dislricln
❑Yes No
PAID
--
VENTILATION CAN (SINGLE RESID)
Date Receipt #
BOILER - COMP (3HP OR 100,000 RTU)
TOTAL:
BOILER - COMP(OVP,R 100.000 BTU)
AIR CONDITIONER
I have read tho hezvNnus materials requirements under Chapin 6.95 el the call-
forma Health ty 505, 25533 and 25534. 1 undersand that if the
-bvslthup y!.4 atilivmy Tesponsihilitymnetythepp9cu�pant
(((
ISS ANCE DATE
r /
NEW RESIDENTIAL MECH. SQ. FT.
��p�,r (�jJ' �¢¢¢¢n
n! I `_51-5i nnn'ssuvnce oft Cert�� �/
`Owwnnerr
ISSUED BY:�
!
or authorized agent I IDde
_ _ TOTAL:
OFFICE