S 0713 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY -
CITYOFCOPERTINO BUILDING-ELECTRICAL PERMITNO:
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL S 0713
BUILDING PROJECT IDENTIFICATION
B ILDINGADDRESS: - SANITARY NO. APPLICATION SUBMITTAL DATE
NE� PHONE: - CONTRACTOR'S NAME: LIC NO:
�� n/i0 - NIC CONTROL#
ARC TELT/ENGINEER: LIC NO: iYY ADDRESS: ❑
CONTACT, PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTORS DECLARATION QTY, ELECTRIC PERMIT- -FEE
a ZSection
1 hereby affirm that 1 am licensed oder previsions of Chapter 9(commencing ' . . - JOB DESCRIPTION
with Se ti n7000)of h ision 3 ofthe Bu dProfessions Code,and my RESIDENTIAL:
00 wtPERMIT ISSUANCE
infulle Class
effect
6 Vz� License Class - Lic.# _ ❑SFDWL C1 KITCHEN RHMOUEI.
Pv6 Dale Contractor APPLIANCES-RESIDENTIAL ❑ADDITION EJ PLUMBING RE-PIPE
'Dili, ARCHITECT'S DECLARATION PANELS El MULTI-UNIT ❑STRUCTURAL
Z O v�� 1 understand my plans shah use
ll d as public arrand, - MODIFICATION
O Z�-f - I UP TO 200 AMPS
Licensed Professional - El INTERIOR El CHIMNEY REPAIR
EaV •aj OWNER-BUILDER DECLARATION OVER 10 AMPS .IMPROVEMENT C]SWIMMING POOLS
1 hereby affirm that 1 am exempt from the Contractor's License Law for the OVER I WOAMPS ❑BATH REM/O�DE�L/REPA DEMOLITION
?yy O d V following reason,(Section 7031.5,Business and Professions Code:Any ciry or county SIGNS ELECTRICAL I]AV -f l
W a W I"' which requires a permit 1.construct,alma improva,deardieb,m repair amy strdcrdre ,�'�[J ` ,
=�0 prior to its issuance.also requires the applicant for such permit file a signN statement SPECIAL CIRCUITIMISC. 1'
GGG^GEEE that he is licensed pursuant to the provisions of the Camraanr's License Law(Chapter 9
(commencing with Section](KK)ofDi,mon]of the Business and Pmkssions Code)tor TEMP,METER OR POLE?NST. COMMERCIAL: -
2 q Q a that he is exempt therefrom and thebasis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
iC an Section 1011 S by any applicant for a permit subjects the applicant m.civil penalty of POWER DEVICES
W^m ❑TENANT El FOOD SERVICE .
ps nm mare ma five ft hundred d.11 larsyempl - IMPROVEMENT
Q ❑Do the work,and
the thesomeormyemntendes with ed muwagesas rlalei(Sec.compensation. SWIMMING POOL ELECTRIC t
F� will Posh work,ande:The Contrane is ctors
License
Pawsed of apply to aBusiness []OTHER
F a and Professions Cade:The Contmcmrs License Law tines not apply s if owner of OUTLETS-SWITCHES-FI%T his
own who builds or improves thereon,and who does such tine himself or through .
his own employees,provided that such improvements ere not intended or offered for NEW RESIDENTIAL ELECTR FT.
sale.If,however,the building or improvement is sold within one yearofcompletion,the SQ,FT.FLOOR AL6_A $/SQ.FT.
owner-builder will have the burden of proving that he did not build or improve for pur- - (•7
pose of sale.). - A
E]1,as owner of the progeny,am exclusively contracting with licensed contractors to
construct 0e.project(Sea TV,l.Business and Profesoors Code:)The Contractor's Li-
ns - f� ` -
Li-
came anownerofpropertywhobuildsorimprovesthereon.and QTY" PLUMBING PERMIT FEE ®�aI 8
who contracts for such projects with a contrmmr(s)licensed pursuant to the Contractor's Cary License Law, PERMIT ISSUANCE H CU'1
❑Ism exemrt d ,B&P C fur this reason f• L(/�+"
ALTER-DRAIN&VENT-WATER(EA) - VALUATION
1zl1l boo
Date
WORKER'SOMPENSATION DECLARATIO BACK FLOW PROTECT.DEVICE
I hereby i irm under penalty of perjury one of the following fluctuations:
❑?have and will meimain aCertifcnte of Cbnsentmself-insure for Worker's Compen DRAINS-FLOOR,ROOF AREA,COND. STORIES TYPECONSTRUCTION
sation,as provided for by Section 37W of the labor Cade,for the performance of the _
work for which this permit is issued. FIXTURES=PERTRAP
Fl have and will maintain Worker's Compensation Insurance,as required by Section -
37W ofthe Labor Cade,for the performance of the work far which this permit is issued GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My Worker's Compensation Insurance conic,mrd Policy numhr are:
Carrier: Policy No.; GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' '
COMPENSATION INSURANCE GREASE/INDUSTRL WASTE INTERCEPTOR'
BUILDING DIVISION FEES
' (This union need not he completed if the permit is for me hundred dollars(SIfN1) GREASE TRAP
or lo..) PLANCHECK PEC .
I certify that in the pertmmence ofthe work for which this permit is issued,)shall SEWER-SANITARY-STORM EA.200 FT. -
not employ any person in any manner so as to become subject to the Workers'Compen- ENERGY FEE
zz sation Laws of California.Date WATER HEATER WNENTMLECTk
O Applicant i GRADING FEE
try NOTICETO APPLICANT.If,after making this Cenibcate of Exemption,you should WATER SYSTEM/TREATING
become subject to the Workers Compensation provisions of the Labor Code,you must SOILS FEE '
{2J forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
Q .
CONSTRUCTION LENDINGAGENCY NEW RESIDF,NTIAI.PLMB. SQ.FT. PAID
U O )forhereby which
this
that isaoo (Ser.30 lending agency Forth¢perfirmznce of - Date ReeeiPt#
w'Fthe.work for which this permh is issued(Sea J09],Civ.C.)
Lenders Name - x - ' TOTAL:
4Ukl Lenders Address TOTAL:
I certify that I have mad this application and state that the above information is BUILDING FEE
UF V7 corned )agree to comply du 11 city and county ordinance d some lowsoantmg to QTY. MECHANICAL PERMIT, MHOUSINGMUDGATIONF
G budding construction,ndhereby authorize representatives ofth city to enter upon the ISMIC FEE
abnve-meaOmsed Pro tan for inspection purposes. PERMIT ISSUANCE -
(We)agree to save,indemnify and keep harmless the City of Cupertino against ECTRIC FE
liabilities,judgmenrs,costs end expenses which may in any wayaccrue against said City ALTER OR ADD TO MECH. - UMBING FEE
inconsequence of the gmming of this permit. _
APPLICANT ANDR AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) ECHANICAL FEE
SOURCE RE L
AIR HANDLING UNIT(OVER 10,000 CFM) ONSTRUCTIONOle TA
Sign o pplicen rector - Date EXHAUST HOOD(W/DI1L'T) E '
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or forum building occupant store or handle hazardous material HEATING UNIT(TO 1010,000 BTU)
as defined by the Calandra Municipal Cade,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)7 HEATING UNIT(OVER I OQOOO BTU) -
' (]Yes ❑No VENTILATION FAN(SINGLE RESID) PAID -
• Data 'Receipt#
Will the applicant or future building occupant use equipment or devices which BOILER-COMP IMP OR 100.000 BTU)
mit hazardous air commoners s as defined by the Bay Area Air Quality Management - TOTAL
District? BOILER-COMP(OVER 100000BTU)
El yen No -
1 have read the hazardous materials requirements ander Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
Efrain Health&Safety Cade,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.PT.
building does nor currently have a tenant that it is my responsibility to amity Ne content
of the requirements which must be met prior to issuance of a Certificate of Occupancy.
Owner or authorized agent Data TOTAL: ISSUED BY:
OFFICE