B 0266 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPFRTINO BUILDING•ELECTRICAL PERMIT NO.q O 2 6 6
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. SOOOI u�!{!,
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. I APPLICATION SUBMITTAL DATE
OWNER'SN E PHONE CONT CTOR'SNAMF, LIC NO:
-'T O N/C C(1Nl'ROhX
ARCHITECIPEN INF . LIC NO. ADDRESS: a/'f ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DFICLARATIONQTY - ELECTRIC PERMIT FEE
1 hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
004Z with Section7000)ofDivision 3 of the Business and Professions Cade.and my license is RESIDENTIAL:
won PERMIT ISSUANCE
Fw� full force eM effect. qq OSFDWL ❑KITCHEN REMODEL'
aFUZV LicertLic.X �a A PC-1 g' APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
NQ WW Date Comm ❑MUI.n.UNIT ❑STRUCTURAL
ly , ARCHITECTS DECLARATION PANELS
F
Z O v�ZW7 I understand my plans shall be used m public records MODIFICATION
OZnppp UP TO 200 AMPS C1 INTERIOR El CHIMNEY REPAIR
174 e,W Licensed Pmfesinnal 201-0IX10AMPS IMPROVEMENT E]SWIMMING POOLS
C kaOWNER-BUILDER DECLARATION ` OVER 1000AMPS [I BATH REMODELIREPAIR El DEMOLITION
m
OC 1 hereby ann dam hI am exempt from the Contractors License Law for the
LOaV fullowingreneort(Ssvrkx703115,Basinessend Professions Cade:Anycitym unly SIGNS ELECTRICAL ❑OTHER _
3 LL{- which requires a pewit to'constmct,Me,,improve,demolish,or repair any swcmre
F_1*0 prior to its issuance.almrequires timmplicum forsuch pewitm file.signedsutement SPECIALCIRCUIT/MLSC.
>, that he is Licensed pursuant to the provisions of the Contractors License L inv Chapter 9
.ae� (commencing with Section 7(100)of Division 3 of the Business and Professiam Code)or TEMP.METER OR POLE INST COMMERCIAL:
C that he is exempt therefrom and Ne basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION [I DEMOLITION
i� Yy Scrim.7031.5 byuny applicant fora p,noitauhjecwthomplicant to n civil penalty d POWER DEVICES El TENANT ❑FOOD SERVICE
t more Nan live hundred dollars(8500). IMPROVEMENT
C]Lazowner of the property,or my employenwith w.gea as theinolccompensetion, SWIMMING POOL ELECTRI
will dome work,and the suumme is not intended or offered formle(Sec.7044,Business ❑OTHER
W mad Professions Cade:The Contmcmrs License Low does not apply to an owner of OUTLETS-SWITCHES-FIXTURES , 10
property who builds or impmers summit.and who does such wmk himself mthrough -
his own employees,provided that such imprommenn are not intended or offered for NEW RESIDE- IAL ELECI'R SQ
safe.If,however the building or improvement is sold within one year of completion,the SQ.Fr.FLOOR AREA VSQ.PC
owner-builder will have the burden of proving that he did not build or improve for pur-
i Paae ar, v fir. B D
[-]1,as owner of the property,am exclusively contracting with licensed contractors In TOTAL:
construct the project(Sec.7044.Business and Professions Code:)The Contractor's Li- - r
cense law does not apply to an.onerof pmm
py who builds or improves the..and QTY, PLUMBINOPERMIT FEE JUL OV ANSU
whocontrmts for such pmjeCts with a commands)Licensed pursuant to the Contractors
License Law. PERMIT ISSUANCE
I am exempt under Sec. ,B&P C Car this reason - tt
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Owner Date
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE.
I hereby affirm under penalty of perjury one of the fallowing declarationv:
❑I have and will maintain u Certificate of Consent to self-insure for Worker's Compen- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCT ION
ration,as Provided for by Section 37M of the labor Cork,for the performance of Ne
wmk far which this pewit is issmsL FIXTURM-PER TRAP
I have and will maintain Workers Compensation Insurance,as required by Section
3700.f the lobar Cade,frdic perfomunceof the work forwhich Nis permit is issued. GAS-EA.SYSTEMA INC.4 OUTLETS OCC.GROUP APN
My Work$�is/S'G!C�oty an Insumnesc tut Policynum rate: GAS-EA,SYSTEM-OVER 4(EA)
Carrier ! Policy No.:
CERTIFICA +OFEXEMPTION FROM WORKERS' GREASE/INDUSTRI,WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION PEGS _ _
(Thlssection need not W completed if the pewit is forone hundred dollars(SIM) GREASETRAP
ar lees.) PLANCHECK FEE
I certify that in the performance of the work for which this permit is issued,l shall SEWER-SANITARY-STORM EA.200 Ff.
not employ any Person in any msmer so res to become subject to the Workeri Campcn- ENERGY HE
Z s arm laws of California.Data WATER HEATER WIVENT/HLFCTR
G Applicant t - GRADING FEE
r, NOTICE TO APPLICANT:If,after making this Certifies.of Exemption,you should WATER SYSTEMIfREATING
a y
become object o the Worker's Compensation provisions of the labor Code,you must SOILS FEE
forthwith comply with such provisions or this permit shall be deemed revoked. WATHR SERVICE
CONSTRUCTION LENDING
leading
ag,AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
V Q Ihercby aRwtheuhere is aconswmion lending agewyfor the Performance of Uma Receiptp
(L F the work for which this pewit is issued(Star.3097,Civ.C.) TOTAL:
U Lenders Name
Lenders Address TOTAL"'
W I certify that 1 have read this application and state at the above information is BUILDING FEB
L11 N
fA correct.I agree to comply with all city and county ordinances and state laws relating to- QTY. MECHANICAL PERMIT FEE
V rZi building construction,and hereby amhoriee representatives of this City to enter upon the SEISMIC PGE
above-mentioned properly for inspection purposes. PERMIT ISSUANCE ELECTRIC FEE
(We)agree m save,indemnify unit keep harmless the City of Cupertino against
liabilities,judgmenta costa and expenses which may in any way accrue against said City ALTER OR ADD TO MECH. PLUMBING FEEC
in consequence of Ne granting of this .it.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.00)CFM) MECHANICAL HE
SOURCE REGULATIONS. -
AIR HANDLING UNIT(OVER ILL1100CFM) CONSTRUCTION TAX
Signature of ApplieanUContmcmr Data EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE.
Will the upplicunt or furore building occupant stare or handle hmallous material HEATING UNIT(TO 100.011)BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health.nil Safety
Cade.Section 25532(u)7 HEATING UNIT(OVER 100,000 BTU)
E]Yes ❑No VENTILATION FAN ISINGLE RESID) PAID
Dam Receipt X
Will the applicant or future building oecupant use equipment or devices which BOILER-COMP(3HP OR 100,000 BTU)
emit Warrdous air contaminants as defined by the Bay Ams Air Quality Management TOTAL: 3
District? BOILER-COMP(OVER 100,(1(10 BTU)
El Yes E3 No
I have recd Nau
the hicas materials requirements ander Chapter 6.95 ofthe Cali- AIR CONDITIONER ISSUANCE DATE
fora Health&Safety Code.Sections 8505.2533 and 25534.1 understand Jut if the NEW RESIDENTIAL MECH. SQ.IT.
building does not currently have a terms,and it is my responsibility to notify the occupant
Mtbe u must W met prim m iiia..,of.Certificate of Occu c.
�� r 7-45;—
Owner or themed agent Date TOTAL ISSUED BY:
OFFICE