10068 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.ELECTRICAL rr
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING.MECHANICAL
BUILDING,PROJECTrDENTIFICATION
BUILDING ADDRESS: / I-1 �I
SANITARY NO. APPLICATION SUBMITTAL DATE
/dds Loer'� AIA ��_/Z_�
OW'
ERS NAME:
ADDRESS: ❑
coNTACf: PHONE: . , BUILDING PERMIT'IN
fg
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT B MECH
❑ ❑ ❑
LICENSED CONTRACTORS mad, awksoDECLARATION QTY ELECTRIC PERMIT FEE'
I Peter,union that 1 arm 1 unaed nmaer pro.idmmd ar Chapter 9(commencing - ,, ' JOB DESCRIPTION
gOZ wiO Sermon 7000)of Drvson iotlhe Business and Professions Gude,andmy Pearce is RESIDENTIAL
F,VO- in full force and effect. - PERMIT ISSUANCE _
G V(F License Class Lir.x ❑SFDWL ❑KITCHEN REMODEL
Date -Conlrucfor. APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RE-P[PE
D say ARCHITECTS DECLARATION
z h rZ. I understand my plans shall Mused as public records PANELS ❑MULTI-UNIT ❑STRUCNRAL
MODIFICATION
UP T0200AMP5 ❑INTERIOR CHIMNEY REPAIR
W Licensed Profese,onW ❑201-1000AMPS IMPROVEMENT E]SWIMMING POOLS
OWNER-BUILDERexempt front
OVER 1000AMPS ❑BATH REMODEUREPALR ❑D''MOLITION
Lu❑0 6 1 hereby affirm thin I am exempt from the Contractor's License Law 1'or the
W 3 q�„F following reason.(Section 7031.5,Business and Professions Cade:Any city or caumy SIGNS FLECfRICA
y which requires a occur,to cooswet,alma improve,demolish,or repair any structure
prior to its issuance,also requires the applicant for such permit o file a signed statement SPECIAL CIRCUIT C.
y. that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9
d� (commencing wiO Sm,ion70007O[Divisian3 oftM1C Bminess end Professions Code)or
¢� p O TEMP METER P .E ST COMMFRCiAL
F y e C that he is exempt therefrom and the basis for the alleged exeinpltnn.Any vialution of ❑NEW BLDG/ADDI Q ION
W�m Section 7031.5 by any upplicam for a pemtitsubjects the applicant to a civil penalty of POWER DEVICES
y„y is
not more than five hundred dollars($500). ❑TENANT ❑FOOD SERVICE
Sp D I,as owner of the Fortiori or my employees with wages as their solo comparison., SWIMMINGPOOLIL TRIC IMPROVEMENT
will do the work,and the structure is nm intended orofered for said(Said.7044,Business ❑OTHER
4 a paid Profesum,Cade:The Contractors License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon,and who docs such work himself(it hrough
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL.ELECTR SQ FT.
.sale.If,however,the building or improvement is sold within one year ofcampletion,the SQ.Fr.FLOOR AREA $/SQ.FT.
r-builder will have the burden of proving that he did not build or improve for our-
Poseofsvlder
❑ I.as owner of the property,am exclusively contracting with licensed emanations to TOTAL:
consumer he project(Sec.7044,Business and Profession,Gde:)The Contractor's Li-
c se Law does not apply m an owner of property who builds or improves,hereon,and QTY, 'PLUMBING PERMIT FEE U Nov
who contracts for men projects wit],a cnntintor(s)licensed pursuant a the Comracmr, IVOO Q ���
License Law. PERMIT ISSUANCE tl FI
E3 In funder. ,B&P C far Nis reason
Dam AFTER-DRAIN&VENT-WATER(EA) VALUATION
er WORKER'S COMPENSATION DECLARATION BACK FLAW PROTECT DEVICE DD
hereby affirm under penalty of perjury one of he following declarations: [�Y
I have and will maintain a Certificate of Consent to self-insure for Workers Compen- DRAINS-FLOOR,ROOF,AREA.COND,
mtimq as provided for by Section 3700 of the Labor Code,fm Om performance of the STORIES TYPE CONSTRUCTION
work far which this Permit is issued. FIXTURES-PER TRAP
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
3900 of lha Lahor Code,for the pccPormmce of,hework for which this permit is ismed. GAS-EA.SYSTEM-1 INC.4 OUTLETS OCC GROUP APN
My Worker's Compensation Insurance carrier evil Policy number are:
Carrier: Policy No., GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASMNDUSTRL WASTE INTERCEPTOR
This section meed not be completed ifthe po,mhBUILDING DIVISION FEESis far one hundred dollars GREASETRAP
m less) PLANCHECK FEE
ley any,per int hoanyumance wro,as a become sufor ich ject 1.perthe it is Workers
ued,I shelfCountr- SEWER-SANITARY-STORM EA.200 FT.
n toy y person In any manner so as m become subject the Workers'Counter- ENERGY FEB
WATER HEATER WNENT/FLECTR GRADING FEF
G 1 GTO APPLICANT If,afar making this Cettifwte mf Exemption,you should WATER SYSTEM?REATING
abecame subject m the Workers Compensation pmvisions of the Lab.,Code,you..at SOILS PEE
Wforthwith comply with such provisions of this parmitshall ba deemedrevoked. WATER SERVICE
0.
CONSTRUCTION LENDING AGENCY NEWRESIDENTIALPLMB. SQ,FT. PAID
Vhereby affirm thatthere is a conduction lending agency for the Performance of Date ReceiptN
L, the work for which this permit is issued(Site3197,Civ,C.)
O Leaders,Name TOTAL',
L) Lenders Address TOTAL:
I certify that 1 have read this appl Icaflon and state that,he above information is BUILDING FEE
car V) correct.l agree to comply with all city and county ordinances and state laws relating to 'QTY.' y MECHANICAL,PERMIT FEE'=
V Z building consusctiomand hereby authorxemprenenmtivas ofihis city toenterupon,hc SEISMIC FEE
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(Wo)agree,o save,indemnify and keep harmless the City Of Cupertino,gains, ELECTRIC PEE
liabilities,judgments,costs and expenses which may in any way meme against said City ALTER OR ADDTO MECH.
consequencein of me granting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
SOURCE REGULATIONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signature of Applleunl/Cmuncmf Date EXHAUST HOOD ONMUC) HOUSING MITIGATION PEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building rwcupam sore m handle hazardous muerial HEATING ON IT TO UYLN)BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cade,Section 25532(a17 HEATING UNIT(OVER 100,01)BTU)
❑Yes E]Nm
VENTILATION FAN(SINGLE RESID) PAID
Will the applicant or future building Occupant use equlpmen,or devices which Data Receipt
it hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(3HP OR 100,000 BTU)
District? TOT '
F1 You ❑NO BOILER-COME(OVER 100,00)BTU)
I have read the haameral materials requirements node,Chapter 6.95 of the Call- AIR CONDITIONER _ ISSUANCE DATE
fool.Health&Safety Code,Sections 25505,25533 and 25534.1 undersand that if the NEW RESIDENTIAL MECH. SQ.FT,
buildin does not cunemlyhave a,enanL,hvt,i,my responsibility mortify the oeeupam
of
Dam TOTAL', ISSUED BY
OFFICE