B 0114 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
CITY OF GDIVISION BUILDING-ELECTRICAL PERMI ' 0'114
BUILDING DIVISION APPLICATION/PERMIT PLUMPING MECHANICAL
p�
BUILDING PROJECT IDENTIFICATION 1
BUILDING SANITARY NO. APPLICATION SUBMITTAL DATE
S C�
O N'B'S NAME PHO 0 ^ry / CONTRACTOR'S NAME, LIC NO'. NIC •CONTROL#
ARCHITECT(ENGINEER^ LIC NO: oV rOY AWXJ
� A ^ �� ElCONTACT: PHONE: (? ` BUILDING PE IT INFO
❑ Cormultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
u
r MLGYZ a -777 ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that 1 am licensed antler provisions of Chapter 9(omarrop Ing JOB DESCRIPTION
{poo, with Suction900(pid Division 3.1 he Business and Professions Code. dmylicenseis RESIDENTIAL
F in full force and effese q PERMIT ISSUANCE
GVU LicensgClaq�r---{SIB
Lor.# `� ❑SFDWL ❑K 11 CHEN REMODEL
F�ml Uamf�L3eCnntlactorcsltGL, APPLIANCES-RESIDENTIAL ❑ADDITION [I PLUMBING RE-PIPE
m L ARCHITEC'PS DECLARATION
p.pm PANELS El MULTI-UNIT ❑STRUCTURAL
O Z=i 4 1 understand my plans shell he use)os public records .MODIFICATION
UP TO 200AMP$
P a`F'OW Licensed Pro
OWNER-BUILDER DECLARATION
fessional L1 INTERIOR ❑CHIMNEY REPAIR
201-10WAMPS IMPROVEMENT SWIMMING POOLS
I herchy afErte Nnt I am exempt from the Convadnr's License Law for the OVER 11100 AMPS ❑BATH REMODEL/REPAIR 0 DEMOLITION-
following reason.(Section 7031.5,Business and Prnfcssions Code:Any city or county SIGNS ELECTRICAL ❑OTHE °'ovit�
which requires a permit 0 construct,altar,improve,demolish,or repair any aronure
r�I Prior to its elmame,alsmrequires he applard,for such Permit to foe a signed smtemem SPECIAL CIRCUITIMISC. /I rTT
y that he is licensed pmsuant..the ynwi,mal,off be Commerce,License Law(Chapler 9 _./ 49)99
0�0 (commencing with Serino TOW)of Division 3 of the Business and Professions Code)or TEMP.METER OR POLE INS . COMMERCIAL,
6 y m yv that he is exempt therefrom vntl the basis for the allege)exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
fiiC1 t�
Section 7031.5 by anyupplicant for ap run,turbine,,the applicant ton civil penalty of POWER DEVICES y not more than five hundred dollars($508). ❑TENANT ❑FOOD SERVICE
CEl 1,as ownerof the pmpmy,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
X o will do the work,and the structure is not intended cautioned forsale(See.9044,Business ❑OTHER
4 and Promp,imns Cade:The Conlmctor's License Low does not apply to an owner of OUTLETS,_SWITCHES-FIXTURES
properly who builds or improves thereon,and who does such work himself or through _
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 of completion,the SQ.FT.FLOOR AREA $/SQ.PC
owner-builder will have the burden of proving that he did not build or improve for per
pose of sale). ,
I,as owner of the property,am exclusively contracting with licensed contractors to TOTAL'
construct the project(Sec.70t4,Business and Professions Cade:)The Contractor's Li- -
4"7
cense 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 canvecmr(-s)licensed pursuant to the Commeme.s
'
Licence Law. PERMIT ISSUANCE
❑Iameopinfa aki-Sec. ,B&PCfimthisreason
ALTER-DRAIN&VENT-WATER(EA)
Owner _ Date VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE'
1 hereby affirm under penalty of perjury one of Ne following declarations:
❑ I have and will maintain a Cerificate of Consent to self-insure for Worker's Compen- DRAINS-FLOOR,ROOF,AREA.GOND. STORIES TVPF.CONSTRUCTION
salon,us p dad for by Section 3900 of the Labor Code,for the performance of the
We kfe ich this per mit is issued FIXTURES-PER TRAP
ter ave and will maintain Worker's Compensation Insurance,as required by Section
Wof the Labor Cafe,for performance cattle work for which this permit is issued GAS-EA.SYSTEM-1 INC.4 OUTLETS OCC.GROUP APN
My Wort Compensation ln55l1BBancecarner end Policgqum�b r� D
Cartier:L�HP11 LAl\ Policy No: -n alGAS-EA.SYSTEM-OVER 4
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEANDUSTRL WASTE INTERCEPT - BUILDING DIVISION FEES
(This sectionoeed nm bea,mpleted if,hepermil itfimm bmadred dollars($100) GREASE TRAP
to local IIT' ksr vvt t-till
PLANCHECK HE _
Toy any Noted in performaany
of the work for which this perthe it Wnsipa Co plea-shall SEWER-SANITARY-STORM EA 200 FT.
not employ of parson in any manner so as to became subject m the Workers'Compen- ENERGY FEE
Off. Ample Laws of California.Use WATER HEATER W/VENT/ELECTR -
Applicant I GRADING FEE
h NOTICE TO APPLICANT:If,after making this Certifiatm of Exemption,you should WATER SYSTEMNIZEATING
aheels subject to the Worker's Compensation provismis of the Labor Code,you must SOILS FEE
W forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
Q
� z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
V Iherebyaf onithavherelsaaonstown..lenll.g.genvy for the pulformaucec, 't Receipt#
W f~- the work for which this permit is issued(See.3097,Civ.C.)
O U Lender's Name TOTAL:
WLender's Address TOTAL:
ly 1 certify that 1 have read this application and state Nat the above information is BUILDING FE
rA 1.0,1.9.to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
building consumption,and hereby authorize representatives of this city to enter apiece SEISMIC rEmIssit
.trove-mentioned property,for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
liabilities. en"costsand expenses which one,in any way,accrueageinst said City ALTER OR ADD TO MECH. PLUMBING FEE
pence fNe 7f this permit
^PConICANT N STA SAND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IB,000CFM) MECHANICAL PEE '
It
RE JL, O '
s ���/ � AIR HANDLING UNIT IR,000 CFM) CONSTRUCTION TAX
in ure of ApIO&OKintractor Date EXHAUST HOLD(W/DUCT) -
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(TO 100.000 BTU) '
as defined by the Columba Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU)
❑Yes PAID
1 VENTILATION FAN(SINGLE kESID) Date Receipt#
Will the applicant in furore building bytheoccupant use equipment or Micas which BOILER-COMP DHP OR 10TOD)BTU)
emit hazardous air crntantinenks as de0nal by the Bay Area Air Quality Management TOTAL
El Yet,District' � BOILER-COMP(OVER 100,000 BTU)
AIR CONDITIONER
e hazardous ateri.ls requirememsoMer Chapter fi.95 of the Cali- ISSUANCE DATE
to r Health en afety Code,S tiers 25505.25533 and 25534.I undeclared that if the NEW RESIDENTIAL.MF.CI{, SQ.Ff. �7
lldingdces of city mixed Nat it is myresponsibility m redly the exermunt r 7
file mqui hie be et 'tet is ce ofn Cenif mo� cups
ra Nomzill.! t Dale TOTAL: ISSUEDBY:
OFFICE