99080113APPLICANTTO FILL IN INFORMATION WITHIN RED LINES • USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING -ELF,CI'RICAL 44
BUILDING DIVISION APPLICATION/PERMIT PLUMBING -MECHANICAL J
/ F BUILDING PROJECT IDENTIFICATION
I herchy aftirm that I am licensed under provisions of Chapter 9 (commencing
withSwtinn TNNq of Divisian3of the Busine.ssand l'raf ximu Cude,and my license,,
in lull force and elfecl.
License Class Lica
ARCHITECTS DECLARATION
Z O
,Az 1 understand my plans shall W used as public rccoNs
OZ -L
Licensed Pm(essional
OWNER -BUILDER DECLARATION
C WI hereby a1Rrm Lha 1 am exempt from the Contractor's License I.aw for the
xL O a U following mason. (Semon 7031.5. Business and Profcssiom QNB: Any city or County
41 W LLO i which requires a permit to cunaruct, alter, improve. demolish, or repair any structure,
pr.rt I .1homquirs, the ppl t for sochp l to file a signed statement
E } .hal he is firensellp a u the p (If the CaMI License Law Chapter
1 0 (commencing with Section 700) of Or vision J of the Business and Professions Codi
a a c C that he is exempt therefrom and the basis for the alleged exemption. Any violation of
W Section 7131.5 by any applicant for a permit subjects the applicant to a civil penalty of
gym' t atom than five hundred dolls, .Sys))
SSG wl-Rl�thwner of the p upi or my employees with wagesas their sole rompessiumn,
ot�F. Ao e work. and the arrame is not intended amlrerd for sale (See 7044, Business /
3
all and Prafo'siana Code: the Coaremor's License Inw docs not apply to an mvner of
property who Wili improv.. dwram, and who docs such work himself err through
his own employees. provided that such improvements are not imended or offend for
sale. If, however, the building or improvement is sold xithin one year of completion, the
er-huilder will have the hold... of proving than he did not hand or improve for pur-
le se of avle.).
❑ 1, as owner of the pn.pery, am exclusively contracting with licensed contactors al
construct the project (Sec. Tota, Business and Professions Code:) The Conuanors U.
ocave Law docs not apply to on awacr of properly who builds or improves thereon, and QTY,
wlo compacts for such prtjms w hh o contra 6ns)T. sal strum ill the Coorcror'x
License Law.
❑ I am emmupt under Stt .B&PC for th¢remmm
OR
'S NAME: U. . %lti=�
Consultant Fees Paid by Applicant (Initial)
ELECTRIC PERMIT
PERMIT ISSUANCE
APPLIANCES -RESIDENTIAL
non
sr W( CIiR'. COMPENSATION DECLARATION
�e y i fOmt under penally of Mdory one of the following declaroname:
❑ I haveand will maintain a Cem flume of Consent n self -insure for Worker's Compen-
sallin. as provided for by Section 37X1 of the Labor Code. fur the Emlor grove or the
work far which this pemtlt is issued.
❑ 1 have and will maintain Worker's Compensation Insurance, as required by Section
370 of the LaMn Qsle, lin the performance of the work for which th,s pernit is iswed.
My Worker's Compenmrian Insurance camel Call Policy mother are:
Carrier: Pulley No -
CERTIFICATE 01; EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thi. stttom need Bol N aan.Ised If the permh is formal, hundred dollars ($10)
less
I certify that in the performance of the work for which this pcmdt i.. issued, I .hall
Bat employ any person in any ........... to become sobjea m the Worke,' Counter.
0.Z .whom Laws of Callfmmin.Dam
Z o Applicant
y NOTICE TO APPLICANT. If, for making this Certificate of Exemption, you should
a? became .subject to the Workers Compensation provisions of the Labor Code, you must
W forthwith comply with such pro, moisorthis permit shall be deemed rewkcd.
Q
CONSTRUCTION LENDING AGENCY
U 0 .herchy affirm that there is aconswetion leading agency for the performance of
W. F the work for which this permit is issued (See. 307, Cis. C.)
0 U Isndcrs Nn.nC
} LLI Lender's Address
1 certify that I have read this application and stare that the aMrve information is
coral, l agree to comply with all city and county ordinances and state laws mating to QTY.
UZ he lldiog Const MCI on. and hereby Coihorire representative. ol'this Sly lr emu upninhe
aMwomemioned properly fminspection for lues.
lWe) agree Io save, indemnify and keep hnmile" the City of Cu c:na eguimt
liabilities, judgments, costs and expenses which may in any was accme against laid City
mscyucncc nr the grunting nl this perrn.
APPLICANT UNDERS11.ADS AN��COMPLY WITH ALL NONPOINT
IIALMRUOIIS MATENIAI S DISCLOSURE
Will the applicant or furore building occupant store or handle hazardous material
xs defined by the Cupertino Municipal Cade. Chapter 9.12, and rhe Health and Safety
Cale, Scctinn 25532(x)7
❑Yes 0 N
Will the applicant or future building occupant use equipment or devices which
.,at
hmunlo., air Ci two nuns us jefrad by the Buy Area Air Quality Management
DiamctT
❑Yes ON.
1 hove rmd be h:vnNaux ntatcrial rn(uu ".�atund'rChnpmrfi.YSoftheC'ali-
Immia Her llh & Snlety Q Sections 2550 53 - 5534. 1 understand that if the
building docs no¢urcyy ylhn ty responsibility to notify the, occapam
aGdm rxcmrementsylfm nanp nn suenccafe Certified of O,cupancy.
PANELS
UP TO 200 AMPS
OVER IOW AMPS
SIGNS ELECTRICAL
TEMP. MI.1'BE OR POLE INST.
POWER DEVICES Bull
SWIMMING POOL ELECTRIC
OUTLETS - SWITCHES - FIXTURES
NEW RESIDENTIAL CLECTR
SQ Fel'.
M •
PLUN ! @IIT FEE
PCRMTr ISSUANCE
ALTER -DRAIN le VENT- WATER (EA)
BACK FI.0W PR Il' ICG
DRAINS - PLO R.RO P. CEA. COND.
FIXTURES -PER I RAI'
GAS -E:A. SYSTEM -1 E17 OUTLETS
OAS - EA. SYS'1'EMd3VER 4 (1:
ORC- SFIINDUSTRL WASTE INTCRCE
GREASIII'RAP
SEWER - SANITARY -STORM EA. 200 FT,
WATER HEATER WIVENT'ELECfR
WATER SYSTEMG`RHATING
WATER SERVICE
NEW RESIDENTIAI, PLM9.
MECHANICAL.
PER ISSHANCE \('
ALTER OR ADD TO MECH.
AIR HANDLING UNIT fro HL000CFM(.
AIR HANDLING UNIT (OVER IO.40I
EXHAUS II IOOD (WIDUCT)
HEATING UNIT (TO 100.000 BTU.
HEATING UNIT (OVER LOOdNNI BTU)
VENTILATION FAN (SINGLE RESIDE
BOILER -COME OHPOR 100.01)(1BTU)
BOILER - COMP (OVER 1110,000 B'FU)
SQ. Ll'.
AIR CONDITIONER
NEW RLSIDEN'TIAt, MECH. SQ. ET
OFFICE
TOTAL:
SQ, FT. FLOOR AREA EISA. Fr.
2,6,i7Cres� 9�.od
7UI TYPE CONSTRU. ION
OCC. GROUP APN
B ILDMG DIVISION Fli15
PLANCHI,CKFEHliti.2-0
ENERGY FEE a I n
GRADINGi
SOILS PE
Imfb
..�.1 n o R«eiptx
`1 \� T'OTAL:
4,16 NGFEE
SE,Tj FEE
ELECI'0I FEE
h mnusb FEE
MECHANICAL ITT
CONSTRUCTION TAX
HOUSING MITIGATION FEE
PAID
Dam Receipts
AL: '
ISSUANCE DATE
ISSUED BY'.
BLDG ELECT PLUMB M.UO
❑ ❑ ❑ ❑
FEE
JOB DESCRIPTION
RESIDENTIAL;
❑ SFDWI. ❑ KITCH17N REMODEL
❑ADDITION ❑PLUMBING RE -PIPE
,/
�Iv1 UI.TI-UNIT ❑STRUCTURAL
- ` MODIFICATION
❑ INTERIOR ❑ CHIMNEY REPAIR
IMPROVEMENT ❑SWIMMING POOLS
❑ BATH REMODHIIRCPAIR ❑ DEMoLi'r10N
❑ F.R
COMMERCIAL:
❑ NEW BLDG/ADDITION ❑DEMOLITION
❑TENANT ❑ FOOD SERVICE
IMPROVEMENT
❑ OTHER
PLUN ! @IIT FEE
PCRMTr ISSUANCE
ALTER -DRAIN le VENT- WATER (EA)
BACK FI.0W PR Il' ICG
DRAINS - PLO R.RO P. CEA. COND.
FIXTURES -PER I RAI'
GAS -E:A. SYSTEM -1 E17 OUTLETS
OAS - EA. SYS'1'EMd3VER 4 (1:
ORC- SFIINDUSTRL WASTE INTCRCE
GREASIII'RAP
SEWER - SANITARY -STORM EA. 200 FT,
WATER HEATER WIVENT'ELECfR
WATER SYSTEMG`RHATING
WATER SERVICE
NEW RESIDENTIAI, PLM9.
MECHANICAL.
PER ISSHANCE \('
ALTER OR ADD TO MECH.
AIR HANDLING UNIT fro HL000CFM(.
AIR HANDLING UNIT (OVER IO.40I
EXHAUS II IOOD (WIDUCT)
HEATING UNIT (TO 100.000 BTU.
HEATING UNIT (OVER LOOdNNI BTU)
VENTILATION FAN (SINGLE RESIDE
BOILER -COME OHPOR 100.01)(1BTU)
BOILER - COMP (OVER 1110,000 B'FU)
SQ. Ll'.
AIR CONDITIONER
NEW RLSIDEN'TIAt, MECH. SQ. ET
OFFICE
TOTAL:
SQ, FT. FLOOR AREA EISA. Fr.
2,6,i7Cres� 9�.od
7UI TYPE CONSTRU. ION
OCC. GROUP APN
B ILDMG DIVISION Fli15
PLANCHI,CKFEHliti.2-0
ENERGY FEE a I n
GRADINGi
SOILS PE
Imfb
..�.1 n o R«eiptx
`1 \� T'OTAL:
4,16 NGFEE
SE,Tj FEE
ELECI'0I FEE
h mnusb FEE
MECHANICAL ITT
CONSTRUCTION TAX
HOUSING MITIGATION FEE
PAID
Dam Receipts
AL: '
ISSUANCE DATE
ISSUED BY'.