S 0093 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO.
BUILDING DIVISION APPLICATION/PERMITPLUMBING-MECHANICAL 1_
BUILDING PROJECT IDENTIFICATION Q
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBM17TTAL DATE
ta- OWT[ SNAME' ` PHONE: N CfOR'S AME: LIC O` r
hh'- N/C CONTROL#
ARCHITECT/ENGINEER: LIC NO: A4&
❑
CONTACT. PHONE: BUILDING PERMIT INFO
L_. _ ❑ consultant Fees Paid by Applicant(Initial) BL❑UG ELECT PLUM MF.0
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE S
I hereby.Mort mm 1 am licensed under provisions of Chapter 9(cnmmenem, _ JOB DESCRIPTION
Qzz with Section 1000)of Division 3of the fueou„and limfiae. Chee,and my licenseis RESIDENTIAL:
4100 / PERMIT ISSUANCE
C�� in full in can of t. IiMDWL ❑KITCHEN REMODEL
FEzU Llccase s _Lie.# APPLIANCES—RESfDENTIAL El ADDITION ❑PLUMBING RE-PIPE.
Q� Da Cannacmr ____
ARCHITECTS DECLARATION El MULTI-UNIT ❑STRUCTURAL
Z FO h Z 1 understand my plans shall be used ex public records PANELS MODIFICATION
OZ�� UP T0200AMP5 [_1 INTERIOR El CHIMNEY REPAIR
Fall-w Licensed Professional 201-10NAMPS IMPROVEMENT E]SWIMMING POOLS
.•.'11 OWNER-BUILDER DECLARATION OVER IOp(I AMPS L1 BATH REMODEWREPAIR LI DEMOLITION
1 hereby affirm that 11. exempt from the Cnnions Co License Law for the
iyy 060 following ream.(Section 703 construct,
Business and Professions Cele:Any city stcounty SIGNS ELECTRICAL ❑OTHER
rR In 19
Oy which requires a permit r1.e ares t e alter,improve,demolish,or repair any structure -
yy�
that
its lcense purse requires thovisio sof for wchpetminoicese Lawd hapternt SPECIAL CIRCUITIMIS .
y toot he it licensed pursuant loth)of Division 3 f tContractor'sni Professions
Laws Code)r9 v
� a� (commencing with Section 7000)of Division of the Business and PrafessionsCWe)or TEMP.METER iNST. COMMERCIAL;
that he is exempt therefrom and the basis for Ne alleged exemption.Any violation of El NEW BLDG/ADDITION []DEMOLITION
4h1! tyL Section 9031.5 byany applicant for.permitsubjects the applicant too civil penalty of POW BR DBVI
not more Nan five hundred dollars($500). ❑TENANT ❑FOODSERVICE
6Dl,.,iwnca of thepmpedy,or my employees with wages m their sole compensati)n, MING P& L RI IMPROVEMENT
SQ wdl do the work,and the structure isnot intendedoroRered for sale l5----044,Business ❑OTHER
�"ca and Prof)s.im,Code:The Contractor's License Law does nm apply to an owner of , OUTLETS—SWITCHES-
6 3^ property who builds or improves 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 n'.
sale.If.however.the building or improvement is sold within one year of completion,the SQ.IT.FLOOR AREA $/SQ
mer-builder will have the burden of proving that he did not build or improve for pun-
pos)hfed..) -
❑ 1.as owner of the property,am exclusively contracting with licensed tommcmrs to TOTAL:
o e oust the project(Sec.70IL Business and Professions Code:)no Certmemds Li- - - P A
use Law does not apply to an owner of property who bwlds or improves thereon,and QTYPLUMBING PERMIT - FEE
who eommets for such projects with acupuncturist licensed pursunnr to the Contmcmr,
License Law. PERMIT ISSUANCE Q
❑'I amexemptunder .Sec. ,B&PCford,knwsw t JUfy, {l r
Owner Date ALTER—DRAIN&VENT—WATER(EA, VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT,DEVICE C)ir Vs s+vf'[nj live
1 hereby affirm under penalty of perjury one of the following declarations:
'have and will maintain a Certificate of Consent m seltinsum for Workers Cnmpen- DRAINS—FLOOR,ROOF,AREA,GOND. STORIES TYPE CONSTRUCTION
salon,as provided(a,by Suction 3700 of the Labor Code,for the prrlbrman-e of the
work for which this permit is issued. FIXTURES-PER TRAP
1 have and will maintain Worker')Compensation Insurance,as required by Section '
3700 ofthe Labor Code.for performance of the work for which this potion is issued. GAS—EA.SYSTEM-i INC,4 OUTLETS OCC,GROUP ' ARE
My Wo�R�h Compensa(tun Insurance tamer and Policy nu •
Caries:�l.,nz xiS Policyb1c, Sue(p t�s1 GAS—EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASMNDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(This sectinowednotbe completed if thepetmit is throne hundred dollam($100) GREASETRAP
or less) PLANCHECK FEE
I crafty that in the perfomrmteeofthe work for which this permit is issued,I shall SEWER-SANITARY—STORM EA.2N)FT
not employ any person in any manna so as m become subject to the Workers ConiENERGY FEE. �. o
O Z maim,Laws of California.Data WATER HEATER W/VENTIELECTR GRADING PGG
Z Applicant
y NOTICE TO APPLICANT If,after making Nis Certificate of Exemption,you should WATER SYSI'ENYTREATING
(ti become subject m the Worker's Compensation Imoso es hf rho Labor Code,you ma,t SOILS FEE
forthwith comply with such provisions or this permit shall be deemed reviled. WATER SERVICE
Q
r0.U. 2CONSONLENDING AGENCY NEW RESIDENTIAL PLMB. SQ,Er. PAID Date Receipt If
L) ^ Iherehy affirm tont chemem is is aconstruction lending agency for the performance af. - •
Ill..yyyy the work for which this permit is issued(See.3097,Civ.CJ
W lenders Name TOTAL:
U Lcndcrs Address TOTAL: s
1 certify that 1 have read this application and state that the above information is BUILDING FEE
U njj corral 1 agree to comply with all city and county ordinances and state laws relating m QTY. .MECHANICAL PERMIT FEE
C.) Z building construction,and hereby authorize representatives of this city to enter upon the SEISMIC FEE I
.hove-mentioned property for inspection purposes, PERMIT ISSUANCE
(We)agree m save,indemnity and keep formless the City of Cupertino against O ELECTRIC FEE
E.bilidrs,judgments,unsound expenses which may money way acemeagaireq,wd City ALTER OR ADD TO MECH.
asequence of the growing of this Permit. PLUMBING PEE
APPLICANT UNDERSTANDS AND,WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO E),000CFM) 'U
SOURCE REGULATIONS,
MECHANICAL PGE 0
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX '
Signature ofApplicant/Conimctur - Date EXHAUST HOOD(WMUCD HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store on handle hazardous material HEATING UNIT(TO 100,000 BTU) .
as defined by the Cupertino Zinged Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(.)'! HEATING UNIT(OVER 100.000 BTU)
0 Y. No VENTILATION FAN(SINGLE REBID) PAID
Dom IFtraps M
Will he applicant or
rearimfuture bundled occupancy A .Air Qnt uordeviceswhich BOILER—COMP QHP OR 100,000 BTU)
If hazardhue air conmminenls ut efined by the Bay Area Air Quality Management T O
.JVmt^ BOILER—COMP(OVER 100,000 BTU)
E]Via, No
1 have read the hamNous m aerials r AIR CONDITIONER
) road.Chapter fi.95ofib)Cwi- ISSUANCE ATB
forma Health&Safety Gide Seco s 25505.25533iatiismy and 25534.I undasfand that if the NEW RESIDENTIAL MECH. SQ,FT.
building does not currently have ate tiumnfitwomerpfa Celificate I a upam
.(Do ants which mu wptiermis,vance of.Ceaifcate f vp nom/
Owner arm onzz ant Hire IV AL ISSUED BY:
OFFICE