S 1012 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY 9
CITY OF CUPERTINO BUILDING-ELECTRICAL HFIT NO. O i Z
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL V\
BUILDING PROJECT IDENTIFICATION
4HUILDINGADDRESS: SANITARY NO. AP/PLICATION SUBMITTAL DATE
R'SSSAME: O PHONE: CONTRACTOR'S NAME: LIC NO: ,V J`q
NEC CONTROL#
A ITECT/ENGINEER: - LIC NO: ADDRESS: ❑
CONTACT: - PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BE ELECT PLUMB MECH
❑. ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby affirm that I am licensed under provisions of Chapter 9(commencing - - JOB DESCRIPTION
woo with Section](MO)of Division lof the Business and Pmfessinns Code,and mylicense ie N I L-
F,Iyin Poll force and effect. - PERMIT ISSIIANCP. FDWL ❑KITCHEN REMODEL
V�U] License Class Lim.N APPLIANCES—RESIDENTIAL .C1 ADDITION [I PLUMBING RE-PIPE
yW Date Camtacter,
ARCHITECTS DECLARATION PANELS ElMULTI-UNIT ElSTRUCTURAL
z z4Z' londersmnd my plane shall be used as public records MODIFICATION
q y " - UP TO 21X)AMPS
q El INTERIOR, El CHIMNEY REPAIR
�+� Licensed Professional 201-1000AMPS IMPROVEMENT E]SWIMMING POOLS
Id OWNER-BUILDER DECLARATION OVER HI(I(IAMPS D BATH REMODEUREPAIR El DEMOLITION
0 I hercby'affirm that 1 am exempt from the Contractors License Law for the --
a0.V following reom.(Section 7071.5,Businessrhd Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
Owhich requires a permit to construct,alter,improve,demolish,or repair any structure _ /1
prior it)its issuance,also requires the applicant for such permit to ole a signed statement SPECIAL CIRCUIT/MISC.
} that heix licensed pursuant to the provi.ionsofthe Commemrs License Law(Chapter 9
Q�.(commencing with Section 7")of Division 3 ofthe Business and Professions Code)or TEMP.METER OR POLE INSL COMMERCIAL'
that he is exempt therefrom and the basis for the alleged exemption.Any violation of [I NEW BLDG/ADDITION ❑DEMOLITION
Section 7031. y y applicant fPermit the lit or a Permsubjects e appcanm a civil Penalty POWER DEVICES penay o
^m'y 5 banali ❑TENANT El FOOD SHRVICF.
Dot..as ohne B hundred dollars .
C]1.as owner of
t the property,or myy employees with wages as their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
QQQQ LGGGE: will do the work.and lheswcturc isnw intended araRered for sale(Sec.]fN4,Rosiness
02R
3 and Professions Code:The Contmclars 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 arc sat intended or offered far NEW RESIDENTIAL ELECT'S SQ FT.
sale.If,however,the hudding or improvement is sold within one year of completion,the SQ.FP.FLOOR AREA $/SQ.FL
owner-builder will have the burden of proving that he did not build or improve for par-
po'cidsale.).
❑1,as owner of the propeny,an exclusively contracting with licensed commerce,to TOTAL:
onsame,me project(Sec.7014,Business and Professions Code:)The Contmmor's Li- /
se Law does not apply to an owner of property who builds or improves thereon,and QTY PLUMBING PERMIT FEE
who contracts for such projects with a convacmds)licensed pontoon to the Csmtwont's _•-,.-"� ,
License Law. PERMIT ISSUANCE f " �-
❑InmexemptunderSee
. ,B&P C for this ream
ALTER—DRAIN&VENT—WATER(EA) VALUATION
Owner
iWORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby affirm under penalty of perjury one of the following declarations:
�❑I have and will maintain a Certificate ofConsem to self-insure for Worker's Comped. DRAINS—FLOOR,ROOF,AREA,COND.
IYPE CONSTRUCTION
.anon,as provided for by Section 37(q of the Lvboi Cude,for the perPom
rance of the -
'work for which this permit is issued. FIXTURES—PER TRAP '
❑ 1 have and will maintain Worker's Compensation Insurance,as required by Section
37M ofthe Labor-Code.for theperformance of the work for which this permit i,;issued, GAS—FA.SYSTEM-1 INC.40UTLETS OCC. R
CartAPN
Cw Workers Compensation Insurance carrier and Policy numher arc:
ier: Policy Nn.: GAS—EA SYSTEM-OVER 4(LA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEANDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
(This section need not hecompleted lDhepermit is for one hundred tlollare($I W) GREASETRAP
or less.) PLANCHECK PEE
certify that in the performance ofthe work forwhich this permit is issued.I shall SEWER—SANITARY—STORM EA.2W FT.
not employ any Person in any manner so as to become subject m the Workers'Comped- ENERGY FEE
0Z ..tion Laws of Califrraw.Date WATER HEATER WNENT/ELECfR
O Applicant 1 'GRADING FEE
fq NOTICE TO APPLICANTi IL after making this Cerificam or Exemption,you should WATERSYSTEM/TREATTNG
I" hecome subject to the Workers Compensation provisions of the Labor Code,you must SOILS FEE
�?y forthwith comply with such prmisica s or this permit shall be deemed revoked. WATER SERVICE
Q
7. CONSTRUCTIONLENDING AGENCY NEW RESIDENTIAL PLMtl. SQ.FT. PAID Dom Berylo
V 0 l for which thi that mit i is sued(Sec.3097ndis.agency far the performance of
the work for which this Permit iv issued(Sec.309],Civ.CJ
Lender's Name TOTAL:
fi4J Lenders Address
I codify that I have read this application and stem that the above information is BUILDING FEE
U ycorrect.I agree to comply with all city and caunry mes dinancand slate laws relating 10 QTY. MECHANICAL PERMIT - FEE
(,) 7 building construction,and hercbyauthmize representatives ofthis city to enter upon the SEISMIC FEE
ohave-mentioned propeny for inspection purpose.. PERMIT ISSUANCE
(We)agree to save,indernify and keep harmless the City of Cupertino against ELECTRIC FEE
liabilities,judgments costs and expenses which may in any way accme against said City ALTER OR ADD TO MECH.
consequencein of the Cannot ofthis permit. PLUMBING FEE T
APPLICANT UNDERSTANDStAND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.00)CPM)
SOURCE REGULATIONS. MECHANICAL FEE
I AIR HANDLING UNIT(OVER 10.000 CPM) CONSTRUCTION TAX
Signature of ApplicandConlmetor Date EXHAUSTHOOD GODUCT) HOUSING MITIGATION HE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or fitausubuilding occupant store or handle hicandmis material HEATING UNIT(TO 1(10,(00 BTU) .
as defnW by the Cupertino Munkipal Code,Chapter 9.12,and the Health and Safety
Coda Section 25532(x)] HEATING UNIT(OVER 100,0100 BTU) -
❑Yea F1 No VENTILATION FAN(SINGLE RESIDE PAID Ra
- Dale Receim4 V
Will the applicant
contaminants as
building occupant use equipment ardManawhich BOILER—COMPCHPOR 100,(It10BTU)
�. mia hazardous air crntvminams m defined by the Buy Area Air Quality Management . TOTAL:
❑Yes E]No
DlsviclBOILER—COME(OVER 100,00 BTU)
— ,
I have read the hazaMous twerials mquiremenas under Chapter fi 95 of thAIR CONDITIONERe Cali- ISSUANCE DATE
fomia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL havMECH. SQ.FT.
building does not currently e a accord.Nat it is my responsibility to modify occupant (/ .^ a I/
of ther•gciremcnm which must be mot prior 10 issueneeof a Cenificam of 0cougancy.
Owner or authorized agent Date TOTAL: ISSUED BY:
OFFICE