S 0254 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY '
CITY OF CUPERTINO BUILDING-ELECTRICAL. PE IT NO
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 0254
BUILDING PROJECT IDEwrIFIC'ATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
10IC3 Mater Moate
HRIS NAME: I- 1 PHONE: O CONTRACTOR'S NAME: LIC NO: NIC CONTROLN
ARCHI'I ECT/ENGIEEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) RLDO ELECTPLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
h SI hereby affirm that I am licensed under provisions of Chapter 9(commencing - JOB DESCRIPTION
OmZ with 7000).(Division 3 ofthe Bminessand ProfessionsCede.andmylicenscis RESIDENTIAL:
W O p
,oLLF in full tome enPERMIT ISSUANCE [Id effect. 0SPDWL KITCHEN REMODEL
aVLicense Class Lic.g
Z H DagppLIANCFS-
e Cornmomr RESIDENTIAL ❑ADDITION [I PLUMBING RE-PIPE
-stFOy ARCHITECT'S DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
Z O�2? 1 undersand my plans shall be used as public records MODIFICATION
OZ.,,, UP TO 200 AMPS [I INTERIOR [I CHIMNEY REPAIR
Licensed Professional - 201.1000AMPS IMPROVEMENT SWIMMING POOLS
thatIa DECLARATION Contractor's
ON OVER 1000AMPS ❑BATH REMODIiI/REPAIR_ D DEMOLITION
t I hereby affirm That 1 OWNER-BUILDER exempt tram the RATION License Lew for the }VODE[[JR _QAIR
�yGi(5O W U ❑GTHER
following reason(Section 7031 5,Business and Profession,Cade:Any city or county SIGNS ELECTRICAL. '
which requires u permit to conswcl,alter,improve,demolish or repair any snamure
prior mits issuance,also requires the applicant forsuch Permit to file a signed statement SPECIAL CI RCUIT/MISC _ a
that he is licensed pursuant o the provisions of the Contructoex License Law(Chapter 9
(commencing with Section 7")of Division 3 of the Business and Professions Code)or TEMP.MUTER OR POLE INST. COMMERCIAL:
4 6 o Oa' that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
LL^oO Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES
n one than Bvehundred dollars($500). ❑TENANT' ❑FOODSERVICE
^Z ,vs cove
ofNe norm employees with wags as their,ole mm tion. SWIMMING POOLELECTRIC OTHER IMPROVEMENT
PTOPe Y Yer^P Y 8 Pennaask
O ill dothewons and the ph Contracting
License
La a dors not
to an Business I ❑OTHER
W a d Pmfessinns Code:The Cnmrazmre License law dors nm apply m an owner of llfLfffS-SWITCHES-FIXTURBSAl Id
propmy who builds or improves thereon,and who docs such wask himself or thmug
his own employees,provided that such improvements am not imende l or offered for NE RESIDENTIAL ELELTIt S PT.
sale.IL however,the building orimprovement is sold within oneyem of completiogthe SQ.FT.FLUOR AREA g1SQ.FT.'
owar,builder will have the burden of proving that he did non build ar improve for par- a i9 A I D
pas.of sato.). - -
I,as owner of the property,am exclusively contracting with licensed comsat ons 1.
construct the project(Sec.7144,Business and professions Code:)The Contractor'sY��
coma Luwdoes nm upply to an owner of prupery who builds or improves thereon,and TY
Q , PLUMBING PERMIT FEE JUL t� RE
CI conlrans for such pmjects with a cotnractor(s)licensed pursuant to the Contractors
License Co. PERMIT ISSUANCE
Cl Iame,em an&,SO .B&PC for this reason CITY Ur WrtHIIN
AI TER-DRAIN&VENT-WATER(RA) VALUATION
Date _
IJ
L WORKER'S COM 'ATION DECLARATION BACK FLOW PROTEGE DEVICE
I hereby aRrm under penallyNote 11 if,N of perjury one of the following declarations:
❑I have mW will maintain a Certificate ofComent to self-insure for Warkers Camper- DRAINS-FLOOR,ROOF AREA.CORD, STORIES TYPE CONSTRUCTION
satin,as provided for by Section 3700 of the Labor Code,for the perfommnce of the
work for which this permit is issued. FIXTURES-PER TRAP
1 have and will maintain Workers Compensat inn Imi mace,as required by Section '
3700 of the Labor Code,for the performance of the work fm which this permit is issued. GAS-FA.SYSTEM-I INC.4 OUTLETS OCC.CROUP APN
My Workers Campensalion Insurance canner and Policy number ere:
Currier - PN icy No.: GAS-FA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASIVINDUS'I R.L WASTE INI ERCHMOR
❑UILDINO DIVISION FEES
('Ibis senior need not be complemJifrhe permit is fnrnne hundred dollars($I(p)' GRPASE TRAP
or IcssJ PLANCHECK I+lilt
I certify that in the performanecofthe work forwhich this permit is issued)shall SEWER-SANITARY-STORM EA.2W W.
not employ any person in any manner sl)as ht become subject to the Workers'Compcn- ENERGY FEF.
Z
sari's.Laws of C.lifomia.Date' WATER HEATER WNENT/ELECfR
Z Q Applicant I GRADING FEE
Ey NOTICE TO APPLICANT.IL after making this Certificate of Exemption,you should WATER SYSTEM/IREATING
F' because subject to da,Workers Compensation provisions of the Labor Code,you mast SOILS FEE
Rmhwuh comply with such provisions or this permit shall be dcemed revoked. WATER SERVICE
L Q CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.Fr,a� z pglD Doe Receipt p
U I for whihthithat there isaud(Sec.31ROnding agency for the performance of
the work for which This permit is issoeJ(Sec.3097,Civ,C.)
LL (~ Lender's Name TOTAL:
17 {U benders Address DOTAL:
��,tt py 1 certify thou I have read this application unJ style Ihm the above infimnminn is BUILDING PF,Ii
La In sonnet.l agree to comply with all city and county ordinances and stale laws relating to QTY. MECHANICAL PERMIT ' FEE
U i� building constriction,and hereby authorize representatives of this city to enteruponfle SEISMIC FEE
above mentioned pmpeny for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino against EL
31
F.CfRIC HE
liabilities,judgments,count and expenses which may in any way access,against said City ACI'RR OR ADDTO NIECE.
in consequence of the 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 PEE
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signamre of ApplicantlContmcmr Date EXIIAUSTHOOD(W/DUC) HOUSING MITIGATION ITE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant on future building occupant store or handle hazurdous material HEATING UNIT(TO 1W,(W BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cola,Section 25532(a)7 I HEATING UNIT(OVER 10091100 BTU)
❑Yes ❑No VENTILATION FAN(SINGLE RBSID) PAIR DPIc ReceiptN
Will the applicant or furore building occupant use equipment or devices which
emit hazardous air computations as defined by the Buy Area Air Quality Management " ROILER-COMP(3HP OR 1)11,0110 BTU)
TOTAL:
District? BOILER-COMP(OVER 100,000 BTU)
GYc, ONO
I have read the hav7rdons materials nequlmntelns under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
fouia Health&Safety Code,Sections 25505.25533 ami 2.5534.1 undersand that if the NEW RESIDENTIAL MECH. SQ.FT.
building does not currently have a lawn,that it is my resrymsibility In notify the Occupant
of the mgnirtments which most be ton prior to issuance o(u Cenificute of Ove.paoey.
Owner or...honzest agent Data I TOTAL: ISSUED BY:
OFFICE !
t:
coy °
JUL 31997
S—SU BLDG. INSPECTION RoeeSs� TG ON DEPARTMENT
ewiCITY OFCUPERTINO
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