S 1434 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO - BUILDING-ELECTRICAL Pe ITS
_BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL J 1434
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
7817 L`'uNAR Ct,p`CUpewr iwO, CA 95014
AiWNERSNAMEi PHONE r ourrONYYi�I�_ (40P/446t-p23� CO.NTRATOR'SNAMfi LIC NO NIC CON"1ROL#
ARCHITECT/ENGINEER: LIC NO: ADDRESS:
CONTACT: PHONE: BUILDING PERMIT INFO
El Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm that]am fiaeased ander proNore, nfehal a, 9(commencing JOB DESCRIPTION
�WZ with Section an effecEivision3ofrheBueinmsrna Prnfccsions Code,and my Incense is RESIDENTIAL:
QUF in immaceond effect PERMIT ISSUANCE.
U License Class Liab ❑SFIIWL El KITCHEN REMODEI.
FZW ).te Cmahoula, APPLIANCES-RESIDENTIAL EI ADDITION ❑PLUMBING RE PIPE
Zpy2baa' ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
lundemmmd my plans shall be used as public records MODIFICATION
Oz.. UP TO 200 AMPS
A El INTERIOR ❑CHIMNEY REPAIR
F(r W Licensed Pmfessloml - 201-1000AMPS IMPROVEMENT
.J L]SWIMMING POOLS
W OWNER-BUILDER DECLARATION
C4 I hereby affirm that 1 off exempt from rhe Commemrs License Law far the OVER RMOAMPS H REMODEL/REPAIR ❑DEMOLITION
'3 d O following reason(Sci 9031.5,Business and PmfesSm oCada Any city or county OTHER
W yFy which requires a permit to consumer,alter,improve,demolish,or repair any.structure BIONS ELECTRICAL
prior to its overreact also requires the applicant for such permit to File a signed statement SPECIAL CIRCUIT/MISC-
�.r��rrll that he is licensed pursuant to the provisoes of the Caramemr'a License Law(Chapter 9
W aC (commencing with Section 9000)of Division 3 of the Business and Professions Cade)or 'TEMP ME,FE OR POLE INST. COMMERCIAL'
t1 p,o E that he is exempt merchant and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
'4 Section 90315 by any applicant for a varmi(subjects the applicant m o civil penalty of POWER DEVICES
r, am ore man live hundred dallaa($500). ❑TENANT ❑FOODSERVICE
FZa 01 as owner of the prepeny,or my employees with wages as their sale compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
0 will do me rook.and thesmemmis notimm�ded or offered far sola(Sec91W4,Bualmae [I OTHER
W antl Professions Cade:The Contractor's License Law does not upply 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 am not intended or offered for NEW RESIDENTIAL ELECfR SQ FT.
sale If.however,We building or i mprovemeal is sold within one year of completion,the SQ.FT.FLOOR AREA $/SQ.Cr
orwasor,larildin will have the human of proving that he did not build or improve for par-
pe of sale.).
[1 1,as owner of the progeny,am exclusively contracting with licensed conumemrs t0 L, `
construct the pr jeer.(Sec.8144,Busineax and Professions Cast no Ccnhaeore Li- 0
came Law docs at apply m an owner m,ni,erty who bulldsar improve.thereon,and QTY, PLUMBING PERMIT FEE
wboc0mracts forsuchpjects with acareartares)licensed pursuant nothe Contractors �� du'I
License Law. PERMIT ISSUANCE f1NS,y
C]I am exempt under Sec. B&P C for this mason «rtrN11II,V
Z D ALTER-DRAIN&VENT-WATER BEA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE !Y Vr_Vurcnllly�
1 hereby affirm under penalty of perjury,one of the following declarations:
❑I have and will maintain aCertificateof Comenv0 self-insure far Worker's Camper- DRAINS-FLOOR.ROOF,AREA,CONE. STORIES TYPE CONSTRUCTION
sation,as provided for by Section 3701 of the Labor Code,for the performance of the
work for which this permit is I.sued. FIX9'ORES-PER TRAP
❑ 1 hove and will mainmin Worker's Compeionam msumnce.us required by Section
3900ufthe Labor Cade,In dna perfarmarecofthe work forwhfch this permit isissucd. 1 GAS-EA.SYSTEM-1 INC.4 OUTLETS OCC.GROUP APN
My Worker's Compensation Insurance carrier and Policy number are
Carrier: Polley N0.', GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASE/INDUS'FRI.WASTE INTERCEPTOR BUILDING DIVISION FEES
(Thissecfi0n need ant be completed if the permit lsI nnehundretldallms($If0) GREASETRAP
or less) PhANCHP.CK
I eerily that inthe ratmamence of the work fin,whichmis permit is issued,l shall SEWER-SANITARY-XI ORM EA.200 FT.
Pa
not employ any person in any mann,,so as m become subpar a he Workers'Crampon- ENERGY FE
,7.t saline Luwsof California,Date
O Applicant ' t WATER HEATER WNENT/ELF,CTR GRADING F
tiNOTICE TO APPLICANT:If,after making this Certiticam of Exemption,you should WATER SYSTEMITREATING SOILS FE
ahecrmesnbje u m the Workers Cmeopra setinn pmvisians of the Labor Code,you must
Forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
U 0 Ihemby affirm lM1auhere ierconstruction lending agency for the performance of Data Receipt#
W r. the wed for Which'his permit is issued(Sec.3097,Cm C)
O L.1 lender's Name TOTAL:
W Lender's Address AL:
1 certify that 1 have read this application and state that the above information is BUILDING FEE
CO) coact.l agree to comply with all city and county ordinances and state laws rdatlng to QTY. MECHANICAL PERMIT I FEE
U ,�7a. baildingconsmmtium,andhereby authorize mpwentmives oftbis city marerupme the SEISMIC FEB
above-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against PERMIT ISSUANCE ELECTRIC FE
liabilities,judgments,cases and expenses which may in any way accrue cannot said City ALTER ORADD TO MECH. PLUMBING
a. oasegrence of rhe gnml Ing of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UN 1'1(TO 10,000 CFM) MECHANICA FEE
SOURCE REGULATIONS.
3v AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCI'1
Signature od ApplieantoContracha Date EXHAUST HOOD(W/DUCT) HOUSINGUSINC MIIN TAX
RHH
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant stare or handle hazardous material H EATING ON IT(TO 100.000 BTU)
re defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cade,Section 25532(x)I HEATING UNIT(OVER I mht)W BTU)
(]Yes 0N PAID
VENTILATION PAN(SINGLE RESID) Dnte Reeeiptb
Will the applicant or ante building occupant use equipment artanna which BOILER-COMP(3HP OR 100,000 BTU
v cranthuzmt
ams air contaminants as defined by the Ray AnM
Area Air Quality unrgmncnl ) TOTAU
District❑4
Yea (]No BOILER-COMP(OVER 100,000 BTU)
1 have real the hmareous moments requlmmems under ChaAIR CONDITIONERpter fi95 of the Cali- ISSUANCE D
forma Healm&Safety CrMe,Sections 25505,25533 and 25534.1 understand that done NEW RESIDESH IAL MECH. SQ.FT.
building does on,currently have a tenant,mat it is my responsibility to malty the ncrupanl
of the requirements which must he met prior to issuance of a Certificate of Occupancy.
Owner or authorized agent DateTOtRISSUED BY:
OFFICE