30504 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL- PERMIT NO. O O q
4
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL'
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARYNO. APPLICATION SUBMITTAL DATI
OSNA E: PHONE: CONTRACTOR'S NAME: LIC NO:
- N/C CONTROL k
ARCHI E T/E IN L R: _ LIC ADDRESS: ❑ _
CONTACT: PHONE: _ BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
O ❑ EJX
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
.1 hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
{Q{yyOp with Secpien]IIDII)ofDivision3ofthe Business and Professions Code;andmylicensels RESIDENTIAL
F� full force and -( PERMIT ISSUANCE
Uz V License Class ,3 G zo Lic.M yf J / ❑SFDWL .�KITCHEN REMODEL
HQL Date Commcvx APPLIANCES—RESIDENTIAL, ❑ADDITION ❑PLUMBING RE-PIPE
ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
ZO Z G I understand my plums shall be used as pmblie records MODIFICATION
�'4W
pp Lncensed Professional UP T0200AMP5 ElINTERIOR C1CHIMNEY REPAIR
4 ,4 201-I WO AMPS IMPROVEMENT
OWNER-BUILDER DECLARATION
W U � I hereby,offifir.Ser that 1 em exempt from the Contractor's Co a Anne Law for the OVER I(NID AMPS ❑BATH REMODEL/REPAIR (]DEMOLITION
O L U followwhich re reason. arraftm,,construct,
Business andmpr Professions Cale:Any city structure
SIGNS ELECTRICAL ❑OTHER.
F rF'jf which requires a permit to construct,alleG improve,demolixh,or repair any swc Wrc
N prior m its issuance,also requires the applicant fmrsuchtsmardm flea signedweemem SPECIALCIRCUIT/MISC. _
9+ that he is licensed pursaam to the pervisionsofthe Contractors License Law(Chapter 9
(commencing with Section]II00)of Division 3 efthe Business and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL,
that he is exempt therefrom and the basis for the alleged exemption.Any violuticn of Ll NEW BLDG/ADDITION [I DEMOLITION
fi�Cl WSection]031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES
F N not more than five hundred dollars($500). ❑TENANT El FOOD SERVICE
ed>t ❑1.as owner of the properry,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC 01 IMPROVEMENT
a o will dobe work,and the structure is not intended or offered forsole(Site 9044,Business []OTHER
and Professions Code:The Commerce,License Law does not apply to an owner of OUTLETS—SWITCHES—FIXTURES
property who builds or improves thereon,and who does such work himself or through'
his..a employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ PT.
sale.If,however,the building or improvement is sold within one year ofcempletiom,the Q.FT.FLOOR AREA E/SQ.PI'.
owner-builder will have the burden of proving that he did net build or improve for par-
pose of Hale,. .
[IJ,as owner of the property,am exclusively contractingwith licensed cor;consumerTOTAL:
consumer the project(gpc.9044;Business and Professionss Code:)no Contractor's
LL
annew Law dues not apply to an owner of property who builds or improves thereon,and QTY, PLUMBING PERMIT FEE
who contracts for such projects with a contracror(s)licensed pumuant to the Contractors
License Law., PERMIT ISSUANCE
❑I.m exempt under Sec. ,B&P C for this recon.
G
ALTER—DRAIN ffiVENT—WATER(EA)
.. Owner Date IY/Jf�UAT10N
WORKER'S COMPENSATION DE CLARATION BACK PLOW PROTECT.DEVICE -
1 hereby affirm
underander penalty of perjury one of the following declarations:.
❑Ihave and will forbilneCion 37 to ofCs,Lab to rude,for for Worker's Compen- DRAINS—FLOOR,ROOE AREA,COND. STORIES TYPE CONSTRUCTION
senor,as provided formi Section J]Od of the Labor Code,for the performance of the
work have
this permit is issued, FIXTURES—PER TRAP
❑Lhav .La will maintain Workers Compensation Insurance,h required by Section
My Wakw Labor Code,fer the pounceoneer and Palley
forwhich this permit is issued. GAS—EA.SYSTEM-1 INC.4OUTLETS OCC.GRDUP 'ATN
My Works's Iexse smion esomnce carrierold Policy numbers
Carier.�e �.dr �_ -Policy N�.:� : GAS—EA:SYSTEM-OVER 4(EA)
R' 'ICOMP A PNINN FROM WORKE S' GREASOINDUSTRL WASTE.COMPENSATION INSURANCE FEES
(Thio section used nm be completed Its,permit is for ovehundred dollars($100)
oc3essJ - GREASE TRAP BUILDING DIVISION
-
PLANCHECK FE8
Icertify that in the any
immic nnerof the work for which pt to the Wieiss'Comon. SEWER—SANITARY—STORM EA.200 Ff.
not employ any person is any manner so as to become subject the Workers'Compen- ENERGY FEE
',2.• Apple Laws of Culifomia.Dare.
y�y O Applicant WATER HEATER W/VENT/ELECTRGRADING FEE
r7y NOTICE TO APPLICANT If.after making this Certificate of Exemption,you should WATER SYSTEM(TREATINC
aImo^ become subject to the Workers Compensation provisions of the Labor Code,you must SOILS HE ,
W Iti forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
a Q
UO
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.ET. PAID
I hereby which
that there issued((See.
construction0 lending agency for performance of Date ReceipbM
fl, I••i the work for which this permit is issued(Sec.309'/,Civ.CJ
V' Lender's Name - - - TOTAL:
Lenders Address TOTAL:
tn Icertify that I have read this application and said,that the above information g is BUILDING ME -
N cordingco rcetocomply with
yaucity and muntymativeces and emm lawterupnge QTY. MECHANICAL PERMIT F
V 4 building construction,and herebyauthoriu reprcsenmlives mf this city menrer upon Ne SEISMIC FEE
above-mentioned property for inspection purposes.
(We)agree m save,indemnify and keep harmless the City of Cupertino against PERMIT ISSUANCE ELECTRIC FEE
liabilities,judgments,costs and expenses which may in any way name against said City ALTER OR ADD TO MECH.
in consequence of the granting of this permit. PLUMBING PEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
SOURCE REGULATIONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTIONTAX
Signature o'ApplicablContmcmr Dote EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazmdous material HEATING UNIT(TO I MIKE BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? HEATING.UNIT(OVER 100.000 BTU)
F1 Yes E]No VENTILATION FAN IMNGLERESID) PAID
Will the applicant or future building eccupant use equipment or devices which Date Receipt N
unit hatardous air conmminants as defined by the Bay Area Air Quality Management BOILER—COMP(3HP OR 100,000 BTU) "
Distral TOTAL:
'(]Yes E]N. BOILER—COME(OVER IIX1,000 BTU) '
1 have read the hazardous materials requirements under Chapter fi 95 of the Cali- AIR CONDITIONER 6 ISSUANCE DATE
harbor Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if Ne NEW RESIDENTIAL MECH. SQ.FT.
building Bros not currently have.barrel,that it is my responsibility to notify the occupant• _
efthere trementwhichmustbemetpriortoissuancc ofa Cadbficlaof Occupancy. -
Own tbenze agent Dale I', ISSUED BY:
OFFICE