S 0675 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY '
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0675
OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING MECHANICAL h
' -BUILDING PROJECT IDENTIFICATIONS
ILDINGADDRESS: - SANITARY NO. APPLICATION SUBMITTAL.DATE
S CoG���o ►�-
ER's NAME: W CONTRACTOR'S NAME: LIC NO:
(,+VY N/C CONTROL M
LPAAA_ - 1
�4R HITECT/ENGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) LD ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby affirm that I am licensed under previsions of Coupon 9(commencing JOB DESCRIPTION
WQa'Z with Section9003)ofDivision 3ofthe Businessand Professions Cule.and my license is RESIDENTIAL'
00 full force and effect. PERMIT ISSUANCE
WP Li ❑SFDWL ❑KITCHEN REMODEL
h<UkU Data Class Cmc APPLIANCES-RESIDENTIAL. ❑ADDITION El PLUMBING RE-PIPE.
4 Dam Comracmr ..
ARCHITECTS DECLARATION ❑MULTIANIT ❑STRDCTURAI.
I understand I PANELS
Z O Y plains shall be used as public records MODIFICATION
0z _ DPTO 2IX1 AMPS
[-a Licensed Professionvl _ ERNE ❑SWIMMING POOL
Lq; -aJ 201-IOOOAMPS PROVF.MENT SWIMMING P001.5
OWNEm BUILDER m Ce CorbaON OVER 1001 AMPS TH REMODEL/REPAIR [I DEMOLITION
1 hereby affirm that 11Sexempt from the Cssions o License Law for the
3 f following reason.(Semon 90115.Business sup Professions Cade:Any city or county SIGNS ELECTRICAL OTHER
Ov1 which requires a permit to connmch alma,improve,demolish,or repair any stmemre
6 prior to its issuance,also requires the applicant for such permit file a signed statement SPECIAL CIRCUIT/Misc.
that he is licensed pursuant to dw Povimmaafthe Cmaracmr's License Law(Chapter9
(commencing with Section 7")of Division 3 ofthe Business and Professions Code)or TEMP METER OR POLE INST. 4. COMMERCIAL'
O's o e' that he is exempt therefrom and the basis for the alleged exemption.Any violation of CONEWBIDUADDITION ❑DEMOLITION
^y
Section 7031.5 by any applicant far a permit sobjects the applicant to is civil penalty of POWER DEVICES []TENANT ❑FOOD SERVICE
FZanot more than five hundred dollars($503). IMPROVEMENT
❑ has owner of the property.nr my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC
t7 will do the work,and the structure is not intended mothered for sale(See Al144,Business COFFEE
and Professions Code:The Contmcmr's 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 own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ ff.
sant.If.however,the building or improvement issold within one year ofeampletion,the PSW7,.FLOOR AREA $/SQ.FT
ownerhuilder will have the harden of proving that he did not build or improve for par
pose of sale.). -
❑I,as owner of the propmy,am exclusively contracting with licensed contractors m A
comstmct the project(Sac.9044,Business and Professions CWeO The Curricula's LI- � f �O
Li-
cense m se Law does not apply an owner ofproperty who builds or improves thereon,and QTY, PLUMBING PERMIT FEC
who contracts for such projects with a commctor(s)licensed pursuanto the Contractor's
License Law. PERMIT ISSUANCE
Is empt under Sec. ,B&PCfor this lea
sn
Own Due AFTER-DRAIN&VENT-WATER(EA) ^ VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE _—
I hereby affirm under penalty of perjury one of the following dealamtions:
•r7 I have and will maintain a Certificate ofConsentto self-insure far Worker's Compen- DRAINS-FLOOR,ROOF,AREA,COND. -
sation,as provided for by Section 3900 of the Labor Cade,for the performance of the STORIES TYPE CONSTRUCf10N
work for which this permit is issued. FIXTURES-PER TRAP
❑I have and will maintain Workers Compensation Insurance,as required by Section
3903 of the Labor Code,for the performance of the work for which this permit is issued, GAS-EA.SYSTEM-I INC.4 OUTLETS DEC.GROUP
My Worker's Compensation Insurance carrier and Policy manbcr are:
Cirri¢ Policy N., GAS-EA.SYSTEM-OVER 4 CA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASMNDUSTRL WASTE WfERCEPfOR BUILDING DIVISION FEES
(This section need not ed complemd ifthe permit is failure hundred dollars($IW) GREASETRAP
or less.)(This
FEE
I certify that in the pedommnceofrhe work far which this permit is issued,Ishvll SEWER-SANITARY-STORM EA.203 FT.
not employ any person in any manner so as to become subject m the Workers'Compen- ENERGY FEE
sation Laws of California.Date WATER HEATER W/VENT'/CLECTR
O O Applicant i GRADING FEE
y NOTICE TO APPLICANT:If,after makthg this Cerificme of Exemption,you should WATER SYSTENETREATING
abecome subject to the Worker's Compensation provisions of the Labor Code,you must SOILS FEE
F81 forthwith comply with such provisions or this permit shall be deemed revoked WATER SERVICE
a �
O z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PCMB. SQ,FT. PAID Dam ec t H
L) O (hereby affirm that here isaconstruction lending agency for the performance of
F-t the work far which this permit is issued(Sec.3099,Civ.C.)
u'" (~ Lender.,Name TOTAL'
O U Lender's Address TOTAL:
J+aBUILDING FEEr
F.t I certify that 1 have read this application and state that the above information is
t� tp comect.I agree to comply with all city and county ordinances and slate laws relating to QTY, MECHANICAL PERMIT FEE
U building construction,and hereby authorize representatives of this city to enter upon the SEISMICPEE
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree m save,indemnify and keep harmless the City of Cupertino against ELECTRIC PER
liabilities,judgments,costs and expenses which may in any way accme against said City ALTER OR ADD TO MECH.
in asequence M the granting of this permit. PLUMBING FEE
APPLIC UNDERSTANDS ANDJAILCOMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO I B,IHHI CFM) MECHANICAL FE
50URC,Ra 'ULATIONS. � ` rrr���
Et"
/) �r---�`i{!CK— 1 OA AIR HANDLING UNIT(OVER CFM) CONSTRUCTION TAX
Signamrei"ItF7,pplicantiCCormucmlr Dnm EXHAUST HOOD(WMUCD HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occepartshom or handle hazarchous material HEATING UNIT(TO 100,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code.Section 25532(a)4 HEATING UNIT(OVER 103,11!1(1 BTU)
C]Yes ❑No PAID
VENTILATION PAN(BINDLE REBID) Date Receipt
Will the it Contaminants
or amore building occupant as.equipment or devices which BOILER-COMPSHPOR 100,000 BTU)
mit it," us air conmminanrs as defined by the Bay Area Air Quality Management TOTAL;
'Di saleFl BOILER-COME(OVER 001.011(1 BTU)
❑Yew ❑No
(hove real the hvzallous materials reyuirements under Chapter fi.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
fmmia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. - SQ.Il'. "
building does not currently have tenant,that it is my responsibility to notify the occupant
of Ne requirements which must he met prim to issuance of a Certificate of Occupancy.
Owner nr authorized agent - Data TOTAL ISSUED BY:
OFFICE