29882 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO. ^^ �a ,.a
BUILDING DIVISION APPLICATION/PF,RMIT PLUINMBING-MECHANICAL L xlJ1 SV!lyJ(L
BUILDG PROJECTIDEN'TIFIC'ATION
BUILDING/ ^DDR� � � 1 �� � SANITARY NO. APCLICATION SUBMITTAL DAPI!
fg 46
OWNER'SN M^ PHONE: CONTRAC'FOR TS NAME: LIC NO:
NIC CONTROL 0
U CHITECTiENGINEER: LIC NO: ADDRESS: ❑
COMACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fccs Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
ad incense Class Divid i3ofthe llusitanoas and Professions Codcsond my license is ,
TDO w PERMITISSUANCE
CadF full force and vBcn. _ FDWI. [:1 KITCHEN RIiMODEI,
QUU Li APPLIANCES—RESIDENTIAL ADDITION C1 PLUMBING RE-PIPE
Q,L Dam TS DECLARATION
F Z
ARCHITECTS use DECblic me ON PANELS ❑MULTIANIT ❑STRUCNkAL
OO-Z 1 understand my plain shall M used as public rcnmds MODIFCHIMNEY
IJON
REPAIR O Z UPTO 2011 AMPS
OZ-0 ❑INTERIOR ❑CHIMNEY REPAIR
14 k:_1 Licensed Rofeaxional 201-1010AMPS IMPROVEMENT
k that I a OWNER-BUILDER DECLARATION meCor .. OVER IWAMPS ❑BATH RF:MODF.UREPAIR DEMOLITION
1 hereby.(firm thin I IS exempt tram the Cssions o License city
Iia the
xx�01U whichfollaw
nquires a Permi(Sectt
703IS, and improve.
demolish,
Code:epaiAnyray anscruy SIGNS ELECTRICAL ❑OTHER
W 3 LL yQ which requires.permit m c.nzwct altcc improve,demoli.M1,m repair any swaurt
F'yO.] prior to its issuance.also requires the applicant for such Permit o file a signed statement SPECIAL CIRCUITIAISC.
1try that he is ltcemcd,rsuontm[tic provisions of the Contractor's License Law(Chapter 9 +
=00 (commencing with Section 7000)of Division 3 of the Business and Pmfeoftnis Code)or TEMR METER OR POLO INST.
6 a e C that he is exempt themfmm and the basis for the alleged exemption.Any violation of ❑NEW BLD / T11SN(I DEMOLITION
msection]031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICIS //rte t7
n more than live hundred dollars(5500. TENANT SERVICE
F E Y IMPROVEMENT
_< wiLothe vo ofthe property,nmycmployreswithwagesas 1"Sc.7s .Buutioo, SWIMMING POOL ELECTRIC
�' O will do work,.ndtM awcturc i...t immrdcd or.(feted for sale lSmA014,Rosiness ❑OTHER
W m and property
is
Cade:The ovex th ora License Low docs not apply to if owner
ou or OUTLETS—SWITCHES—FIXTURES ''V
3.. prnpeny who huilds or improves Nerenn,and who does such work himself or through
his own employees,provided nonsuch improvements are not intended or offered for NEW RESIDENTIAL ELECT'R SQ FT.
sale.If.hnwawea the building s improvement ksuld within one year of cnmplomn.Ne Ia� tf� SQ.IT,FLOOR AREA SISQ.FI'.
erbuilder will have the burden of proving thm he did not build or improve for par- LV \�yt1/I� /III aPl
pose of sore.).
sap
❑ L u owner Of et(See ery,.m .mess ad contracting Cesheth yen cd contractors m
.rise La the project(Sec.o an Baines property
Professions Cocky The es dical.rs Li-
nscLawdmsnot apply toanowncnnfpmpony whesedparnimprO the Nereonandors QTy, PLUMBING PERMIT FEE
whocontracts forsuch pmjecb with a mmmemr(s)licensed pursuanuo the Contractor's '
License Law. PERMIT ISSUANCE
❑ I am exempt under Sec. ,B&P C for this reason
ALTER—DRAIN&VENT—WATER(EA) VALUATION
Owner Date 1
WORdiCOMPENSATION DECLARATION PACK FLOW PROTECT DEVICE 1 Z7 .,�
Iherthy affirm under
pPenalty of Perjury one of the following Jedmtions:v ` �J
❑ Ihave and will maimaim Cenificam ofConum inset(-imam for Worker's Compcn- DRAINS—FlAOR,ROOF AREA,COND. STORIES TYPE CONS'TRUCIION
coin,as provided for by Section 3701 of me Labor Code,for the performance of me
work for which this permit is issued. FIXTURES—PER TRAP
El I have and will mainwin Workers Compensation Insurance,as required by Section
37M ofthe Labor Code,for the performance of the work for which Nis permit is issued. GAS—EA.SYSTEM-I INC.J OUTLETS OCC,CROUP AM
My Worker's Compensation Insurance cancer and Policy number are:
Carrier: Policy No.: GAS—EA.SYSTEM-OVCR 4(EA)
CERT'IPICA'lli OF EXEMP PION FROM WORKERS'
COMPENSATION INSURANCE GRIiASEIINUUti I'RI."AS'1'li INTERCEPTOR
BUILDING DIVISION FEES
Mins section need not be completed if the permit is format hundred dollars(SIM)
m less.) GREASE TRAP PLANCHECK FEE 1 O
Icenilythat inthe performanceot Newark liawhichihi.s permit is issued.I mall SEWER—SANITARY—S'IORM P.A.200 FT
not employ any Person in any manner so as to become.subject to the WorkersCompen- ENERGY IT:]:
ZZ ..tion laws of California.Dote WATER HEATER W/VENT/ELECR iA PQ
Applicant GRADING FEE
NOTICE T'O APPLICANT:If,after making this Ccnif m of Exemption,you should WATER SYSTEM/TREATING
a ; become subject to the Worker'.Cotnpens.tion Pmvidn.s 01 the Labor Gore,you must SOILS Plili
L31 forthwith comply with such previsions or this permit%hall be deemed revoked. WATER SERVICE
aQ
z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID Receipt Date Ri I N
U 0 I hereby affirm that is a ennswetion lending agency for the per!mmuce.f p
the work for which Nis permit is issued(Sec.3(197,CO.C.)
0 U Leader's No. TOTAL:
Lender's Address
D+ 0. BUILDING FEE
F' I eerily that I have read this application and note that theabove information is
N correct.I agree to comply with all city and county.thinness and shim laws relating to QTY. MECHANICAL PERMIT FEE
6.) sZ building construction,and hereby zc representatives of this cirymenmr upon Ne SEISMIC FF.E
F. .bove-memioncd pr y for' .pectin puryases. PERMITISSUANCE ELECTRIC TLE
(Wel ugr Wahnnify at 1 keep bamdeas the City of Cupertino against
Iiabilities,juJ rte andexpensc which may in anyway.ccme against said City ALTER OR ADD'rOMECH.
m
in com e n tingo(this nit. PLUMBING FEE
APPLICA f c' STANDS D WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,0MCFM) � p
S0 RCE r IONS. MECHANICAL FEE
7 sPJAIR HANDLING ON]f(OVER 10, MI CFM)
0 � CONS'IRUCI'[ON TAX
Signature ppli nuContraator Dae EXHAUST HOOD(W/DUCD HOUSING MITIGATION FEE
HA%ARDOUS MATERIALS DISCLOSURE
Will In up licont ur future building ociapard,one or handle Is...Nnus maentil IMATING UNIT(TO I00,000 BTU)
efined by t .penin.Municipal Code.Chapter 9.12,and Ne Health and Safety
C c.Smtion2 32(0)? HEATING UNIT(OVER 100,000 BTU)
C]No VENTILATION FAN(SINGLE RESID) PAID
ill thea applicant or future building t use equipment or devices which Dau Rnapt p
pp gocmpen Area
n BOILER—COMP(3HP OR 100.00)BTU)
emit bazadous air ronmminants as Defined by the Bay Arta Air Quality Management TOTAL:
District? BOILER—COMP(OVER 100,000 BTU)
❑Ycx E]No
haw or i hasmdmsm crick requirtnncnhs umkr Chapmrfi95 of Ne CWi AIR CONDITIONER ISSUANCE DATE
fomi Heat n S cry Cale,Sent s 25505.25533 and 25534.1 understand Na if the NEW RESIDENTIAL MECH. SQ.14.
builds . nm
entlyhave nn6 that it is my resrymsim alrynotify the occupant -
nigh tswhichum met Prinna l...mo,of.CmiGc.m at gec...ncy.
o
O n gem Dam T .� ISSUED BY:
OFFICE