B 0419 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES USE BALL POINT PEN ONLY -
CITYOPCUPEiRTINO BUILDING-ELECTRICALS PERMITN
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL S0001 0419
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRE ISANITARY NO. APPLICATION SUBMITTAL DATE
tJD
ER'S E: ' PONE: CONTRACfOR'S NAME: (y� LIC NO: / r F�
,;�/f NIC CONTROL#
ARCHIT CT/ENGINEER: LIC NO: ADDRESS'. tJC. ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUM13 MECH
S I ❑ 1 K ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
wan with Section 701g).f Division 3ofthe Buainceival Professi...Ced,andmylicenseis
won PERMIT ISSUANCE RESIDENTIAL,
FUF Livenin force ndc_ ❑SFDWL ❑KITCHEN REMODEL
N�UU LicenseC Cnndmct Can APPLIANCES-RESIDENTIAL [I ADDITION [I PLUMBING RE-PIPE
66 Dam
ARCHITECTAS DEC ATION PANELS ❑MULTI-UNIT El STRUCTURAL
Z p h Z I underxwnd my plans shall Be used as public records MODIFICATION
O4. UP T02tN1AMPS
�l"m ❑ ❑
INTERIOR CHIMNEY REPAIR
rr � Licensed Professional 201-1000 AMPS IMPROVEMENT SWIMMING POOLS
�d
OWNER-BUILDER DECLARATION Eh]01•ITI(1
C Q 1 hereby affirm OWI OVER I"AMPS El BATH REMODELREP9JR_L1 D
that exempt from the Contractor's License Law for the �£�
G 3 0.0 following reason.(Section 70315,Business and Professions Code:Any city o,county SIGNS ELECTRICAL ❑0 ER/��.(J
0.H which requires.permit to consirnet,alter,improve,demolish,or repair any structure
prior to its issuance,also requires the applicant for such permit to file a signed statement SPECIAL CIRCUIT/MISC. -
y that he is licensed pursuant to the provisions of the Contractor's license Law(Chapter 9
W <� (commeocin with Section 700( of Division 3.fmc Bunnessand Professions Code or COMMERCIAL'
g w ) ) TEMP.METER OR POLB INST.
that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDGIADDITION [I DEMOLITION
a1 w Scmi.o]OJ LS by any applicant for a permit subjects The applicant 1.a civil penalty of POWER DEVICES
not more than five hundred dollars($500), ❑TENANT FOOD SERVICE
>' IMPROVEMENT
6 ❑ 1,as rwneraf theproperty,or my employees with wages as their sole compensation, SWIMMING POOL P,LP.CTItIC
$�+ G will do the work,and the structure i.s not inte.dedorolfered for sale(Sec.]044,Business OTHER
W and Professions Code:The Commclols License Law does not apply to an owner(if OUTLETS-SWITCHES-FIXTURES
,,.,city who builds or improves Ihercnn,and who does such work himself mannish
his own employees,provided that such improvements are not intended m offered for NEW RESIDENTIAL ELECTR SQ FT.
sale.ILhowever,are building or improvement is sold within one year ofcompbither,the SQ.PI'.FLOOR AREA $/SQ.FT.
u-builder will have the burden of Forcing that he did not build or improve for par- 1
own
,an at wale.).
❑ 1.as er of the prnpeny,am exclusively trained,with licensed mo ernme n, TOTAL:
ouswct the project(Sea 7044,Business and Professions Code:)The-i-mus a Li-
sc law does not apply to an owner of property who builds or improves thereon,and QTY PLUMBING PERMIT FEE
whincenoeas for such projects with a cianna of(s)licensed pursuant m the Conmmmrs
License Law. / PERMIT ISSUANCE 0"
[II am exempt under Sea •B&P C bonhis reason
Owner DateALTER-DRAIN Xe VENT-WATER THAT VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE `76 Oo
I hereby affirm under penalty of perjury one of the following declarations: ( xE I
•QE]I have and will maintain a Cenificate of Gmsan t.self-insure for Worker's Compen- DRAINS-FLOOR,ROOF,AREA,CONE). STORIES TYPE CONSTRUCTION
an..,as provided far by Section 37M of the labor Code,for the performance of the
work for which this permit is issued. FIXTURES-PER TRAP
Xhave and will maintain Worker's Compensation Insurance,as required by Section
of the Labor Code,for the Performance of the work for which this permit is issued. GAS-EA.SYSTEM-I INC,4 OUTLETS OCC,GROUP APE
My Work 's tIts P9 114V
Q I rance((artier and P.1my Na:Policy. I GAS-EA.SYSTEM-OVER 4([M)
Carver:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASE/INDUSTRLWASTE INTERCEPTOR
BUILDING DIVISION FEES
(Thisswllon need not be eor
mplamd ifthe permit is boron,hundred it.][ D10m GRE,ASETRAP
or less) PLANCHECK PEE
I certify that in the performance ofthe work for which this permit is issued,i shall SEWER-SANITARY-STORM EA.2W FE
not employ any person in any marnor so as to become subject to the Workers'Compen- ENERGY FEE
,Z cation Laws p(�ali�*,WJ)te WATER HEATER WNENT/ELECTR
�0 Applicant .j„�� I a - GRADING FEE
y NOTICE TO APPLICANT.If.after making this Certificate of Exemption,you should WATER SYSTEMOREATING
abecome subject to the Worker's Compensation previsions of the Labor Code,you must SOILS FEE
[1.1 forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
aQ
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.IT. PID
Z Iherehy affirm that there isaconstruction lending agency for performance of D%1\ ReclLi ei
V 0 the work for which do, carit is issued(See 3097,Civ.C.)
I"t Leader's Name TAL:
V Lenders Address TOTAL:
LS1 1 certify that 1 have read this ap,briumn and state that me above information is IN v iv
Apt correct.I agree ur comply with all city and cormy manicures and state laws relating'. QTY. MECHANICAL PERMIT FEE .+
U building conometi.n.and hereby authorize representatives ofthis city In enter upon the SMIC FEE
ab.ve-memloned p ,,my fur im vatimt a,.,e,. PERMIT ISSUANCE LrCTRIC FEE
' (We)agree m s ve,Indemnify and keep harmless the City of Cupertino against
liahilities,jndgran" rets and expenses which may in anyway accme against said City ALTER OR ADD TO MECH.
nseyLnceof 9ranI,n Ithis perm it.
,APPLICANT )ER S AN ,C PLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
MECHAN L E
SOUR LAT
AIRHANDLING UNIT(OVER 10,000CFM) CONSTR*Tlr TAX
Sietureo ApPltca Cant ` D to EXHAUST HOOD(W/DUCT) HOU G IGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(TO 100,000 BTU) ,
as defined by the Culwrtioo Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(1)] HEATING UNIT(OVER 103,000 BTU)
(]Yes " VENTILATION PANS INGLE RESID) PAID
Will thea applicant or future building t use or devices which arc Receipt#
pp gby then equipment BOILER-COMP QHP OR 100,0!X1 BTU)
emit hazardous air contaminants as defined by the Bay Area Air Quality Management L.
Disnicl'!
- E]Yes )tNo BOILER-COMP(OVER I00.I103 BTU)
I havemed the ous munatal,re moorems under Chapter 6.95 of the Cali- AIR CONDITIONER' ISSUANCE DATE
Tornio Health&Safety e.S 25505, 533 and 25534.I understand that if the NEW RESIDENTIAL MECH. SQ.FT. �J Q
In]it note nllyh t ant, u' my dblliry'.notify the ocw,am (" /
- of the req whle n ifieam of Occu nc. , -
Owne r authorized end Dae TOTAL: ISSUED BY.
OFFICE,