S 0966 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PF$NIT NO. 0966
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL `v
BUILDING PROJECT IDENTIFICATION
,BUILDING ADDRESS' - SANITARY NO. APPLICATION SUBMITTAL DATI
�i6S6I
OER'S NAME: PHON � ' CONT A OR'S N IC NO.
i' 'L N/C CONTROL»
LAR ITECT/ENGINEER: - LIC NO�� / ADDIiFS�:
iy( 6� aLVA ❑
CONTACT: - PHONE
BUILDING PERMIT INFO
N/ 2r �k 9 3 3 JI
El Consultant Fees Paid 6y Applicant(Initial) -BI.DG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
C,Z th Sedian]0(10)nfDrvtsio Sof@e Business and Professions Cale,and my PERMIT ISSUANCE
00 car RESIDENTIAL'
full force and a e�y
UZ V License Cl y 1' �6 S Lic,N Q s C ❑SFDWI. C1 KITCHEN REMODEL
yQ�h Date' Contactor APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING REPIPE
ARCHITECT'S DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
Z 0 ei❑ 1 understand my plans shall he used as public records MODIFICATION
024 UP TO 2W AMPS
H 4�0
Licensed Professional ❑INTERIOR ❑CHIMNEY REPAIR
CCC •.I 201-1000AMPS IMPROVEMENT 0SWIMMING POOLS
Oat I am
DECLARATION Contractor's
ON OVER 10011 AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
y I hereby affirm that I am exempt from the ComraCVrt a License Inco for the -/J---
x R:,f following reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
Y]�Om¢ which requires a permit m concoct,altar improve,demolish,or repair any structure 1q. m.i prior to its issuance,also requires the applicant for such permit o file assigned statement SPECIAL CIRCUITIMISC.
thin he is licensed pumuant to the provisions ofthe Contramors license Law(Chapter 9
W�00 (commencing with Section 7")of Division 3 ofthe Business and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL:
that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
W y Section 9031,5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES
not more Nan five hundred dollars($500).
❑TENANT ❑FOODSERVICE
esI,as owner of the IMPROVEMENT
C ❑ property,or my employees with wages us their soleenmpensmian, SWIMMING POOL ELPA'[kIC
will do the walk,and the structure is not intended or offered for sale(Sec.70,44,Business ❑OTHER
and Professions Code:The Convector's License Law does not apply to an owner of OUTLBCS-SWITCHES-FIXTURES
ec .. property who builds or improves thereon,and who does such work himself or through
his awn employees,provided that such improvements are but intended or offered far NEW RESIDENTIAL ELECTR SQ PT.
sale.IL however,the building or improvement is sold within one year of completion,do, - SQ.FT.FLOOR AREA $/SQ.ET.
owner-builder will have the burden of proving that he did not build or improve for pur-
pose of sale.).
El I,as owner of the property,am exclusively contracting with licensed contractors to TOTAL:
construct the project(Sec.7044,Business uad Professions Gale:)The Commences Li-
cense Law does not apply to an owner of property who builds or improves thereon,and QTY, PLUMBING PERMIT FEE
whocontmcts forsueh projects with recommits)licemsadpursuamnothe Gmtracem's -
License I. PERMIT ISSUANCE
❑I am exempt under Sec. B&P C for has reason
Owner
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Ume
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm under penalty of perjury one of the[.lowing declarations: -
_ ❑I have and will maintain a Certificate of Comenuoself-Insure for Worker's Compen- DRAINS-FLOOR,ROOF,AREA,COND. STORIES 'IYPECONSTRUCTION
saber,as provided for by Section 37W of the Labor Code,for the Performance of the -
wnrkforwhichthiapernitisissued. FIXTURES-PERTRAP
and will maintain Worker's Compensation Insurance,as required by Section
3700of1he abet Code,fi,r theperformance of the work for which this permit is issued. GAS-EA.SYSTEM-11NC.40UTLE'IS OCC.GROUP APN
My War r ion lnsu nee carr- and Policy nnrnf Mr
MyCarrierWa Policy Ne.: I�DGAS-EA.SYSTEM-OVER 4(EA)
'CER171FICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASE9NDUSTRL WASTE INTERCEPTOR
("is scedish eeirmle,completed ifthe permit is forone hundred dollars PH 00) BUILDING DIVISION FEES
or less.) GREASETRAP PLANCHECK FEE
I certify that in the performance ofthe work forwhich this Permit is issued,1s1Ba11 SEWER-SANITARY-STORM EA.200 FT.
not employ any Novas in any manner so as'.become subject the Wnrkeri Compen- ENERGY FEE
O Z saticn Laws of California.Date WATER HEATER WNENT/ELECTR
Q Applicant GRADING FEE
y NOTICE TO APPLICANT If,after making this Certificate of Exemption,you should WATER SYSTEM/TREATING
a ;
become subject to the Worker's Compensation provisions of the Labor Cade,you must SOILS FEE -
Qforthwith comply with such provisions or this permitshall he deemed revoked WATER SERVICE --
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
L) I hereby affirm that hem iso concoction leadingagency for perfsmance of Date Rc ypt#
ILO t-1 the work for which this permit Is issued(Sec 3097,Civ.C.)
Q Lender's Name -- TOTAL:
Lenders Address TOTA
1 certify than I have read this application and state that he above information is BUILDING FEE
ZI correct,Iagree'.comply with all city and county ordinances and state lows reining to QTY. MECHANICAL PERMIT FEE
C.) building concoction,and hereby anthorin representatives ofthis city to enter upon the SEISMIC FEE
above-mentioned property for inspection purposes. PERMIT ISSUANCE k� p
(Win)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC 17EE r M
liabilities,judgments,costs and expenses which may in any way accrue against said City
in consequence ofthe granting of this Permit. ALTER OR ADD TO MECH. PLUMBINGF v
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IO,OW CFM7
SOURCE REGULATIONS. MECHANICAL�E
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION X
Signature in Aplicant/Commetor Date EXHAUST HOOD(W/DUC) - s+'
HAZARDOUS MATERIALS DISCLOSURE
HOUSING MITIGATION FEE
Willy the Cupertinoecrocar
Municipal
ode,Chapter
stoner handle Health and Safety, HEATING UNIT(TO 100,000 BTU)
as defined by the Cuparino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)7 HEATING UNIT(OVER IIN),(M,fl BTU)
EI Yes C]No VENTILATION FAN(SINGLE RESID) PAID -`
Dale Receipt ise.
Will the air conn or future building by the D use equipment or devices which BOILER-COMP(3HP OR 100,000 BTU)
mit
District? us air contaminants as defined by the Bay Area Air Quality Management T(TAL.
District?
ED Yes ❑No - BOILER-COME(OVER 100,001)RTU)
Ihave readrd
the hazaous materials requirements under Chapter fi.95ofthe he AIR CONDITIONER ISSUANCE DATE ,a
].or.Health&Safety Cale,Sections 25505,25533 and 25534.1 understand that if
if the NE
RF;SIUF,NTIAI.MECH. SQ.fl'.
building does stmt urennl M1evoatenwt,that It ie myresp faslbillrymnotifyt cupwo pant
.,,he mquireme sw u'st tanpd9r 11 issuanceof aosift caned cec"
Owner or thonzed agent JDate TOTAL: ISSUED BY:
OFFICE