30001APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING • ELECTRICAL.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING • MECHANICAL
IIHII,DING PRo ,IEC'r IDENTLFICA'FION
PERMIT NO. ^ O 001_
1
BIIILOINGAUDRESS:
bio PROVIDENCE Gov RT CUPE2TI1to Cn 9SOly
SANI'IARYNO.
APPLICATIONSUHMOTALDATI
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v
O ER'S NAME: PHONE
,I✓ WILTEdS 2$$'isz.
(
CONTRACDTRB NAME: LIC NO.
NIC
❑
CONTROL.#
ARCHITECT/IINGINEER: - LIC NO',
ADDRESS,
CONTACT. PHONE:
❑ COngultant Fees Paid by Applicant (Initial)
BUILDING PERMIT ENI°O
BLDG - ELECT PLUMB MECH
❑ ❑
LICENSED CON'IRACnr DECLARATION
1 hereby affirm Nm I am licensed under P provisions of Chapter 9 (commencing
with Section ndeecDivisionJof the Business anW Professions Com. and my license is
in force and effect.
License Clos LiaN 3
Date Contractor
QTY ELEC'fIiIC PERMIT FEE
JOB DESCRIPTION
RESIDENTIAL:
CSFDWL C KITCHEN REMODEL.
❑ADDITION ❑ PLUM BING RE -PIPE
CMULThUN1T ❑STRUCTURAL
M
MODIFICATION
❑INTERIOR ❑CHIMNEYREPAIR
PROVEMENT
TH REMODEVREPAIR El DEMOLITION
ATH
OTHER
PERMIT' ISSUANCE
APPLIANCES-RESIDLNTIAL
j ARCHITECT'S DECLARATION
I understand my plans shall be used as public records
'
PANELS
UPT0200 AMPS
Licensed Professional201-100DAMPS
DECLARATION
1 hereby affirm that I on exempt from the Conlmcmrs License Law for the
following reason. Illation 1011.5, Business and Professions Code: Any city or army
which requires a permit to contract, alter, improve, demolish, art repair any strumnre
poor to its issuance, also requires the applicant for such pemdvo file a signed stateroom
that he is IicenseJ pursuant o the Provisions of the Commcmr:s License Law IChxp er 9
(commencing with Smdon 7000)of Division J of the Business and Professions Cale) or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section ?031.3 by any applicant for a pewit subjects the applicant to a civil penalty of
than five hundred dollar, I.11).
T as owner ofthe propery, or my employees with wages as their sole compensation,
Al Bothe work, and the structural is not intended oroffered for sale (Sec. 7054, Business
Professions Cade: The Conwn.rs License Law does not apply to an owner of
property who buil& or improves thereon, and who dms such work himself or through
his own employees, provided that such improvemems me not intended or offered for
sale. IL however, the building or improvement i.s.ndd within one year of completion, the
owncolmilder will have the burden of proving that he did not build (i, innprove for par -
pose of sown).
❑1,asowner of the propthty, contracting with licensed comemess i-
construct the pmjea (Sec. ]044, Business and Professions Cade:) The Contractors Li-
cense Law does nm apply to an owner of,ho eny who builds or impmvw thereon, and
who convects for such projects with a contractors) licensed pursuant the Contractors
License l.aw.
I sat exempt under Sec. ,B&PC far this reawn,
'f
OVERIM)AMPS
SIGNS ELECTRICAL,
SPECIAL CIRCUIT/MISC.
TEMP. METER OR POLE INST.
COMMERCIAL,
❑ NEW BLDG/ADDITION C DEMOLITION
❑TENANT El FOOD SERVICE
IMPROVEMENT '
COTTER
POWER DEVICES
SWIMMING POOL ELECT RIC
OUTLETS -SWITCHES -FIXTURES
NEW RESIDENTIAL ELECTR SQ FT.
/i1 n
&
SQ. Fr.F AREA
IIS/
(//((
Ct rl rI 996
(Jut Lij II[YU
$/SQ. FT.
TOTAL:
QTY. PLUMBING PERMIT FEE
PERMIT ISSUANCE
ALTER -DRAIN&VENT AInLt (EA)
BACK FLOW PROTECr. CE
r
e Date
VALUATION
WORKER'S COMPENSATION DECLARATION
1 hereby union under Penalty of perjury one of the following declarations:
'C lhaveenJ will mninminaCcrificnm ofConsm mseif-insure for W..kmx Compcm•
cation, as provided for by Section 37M of the Labe Cale, for the performance of the
work for which this pewit is issued
❑ I have and will maintain Workcfs Compensation Insurance, m required by Section
37W of the Lobar Call, for the performance of the work for which this permit is issued.
performanceGROUP
My Workers Compensation Insurance carrier and Policy number are:
Carver: Policy No.:
CERTIFICA'TL OP EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section necdnm he completed ifthe pcwir is forom hunairtd dollars (81(Np
or less.)
I cenify that in the performance ofthe work for which this pewit is issued, Ishall
not employ any person in any manner ms as m hemme subject m the Workers' Compen-
sation Laws of Culimmin. Date
Applicant
DRAINS -FLOOR, ROOKA EA, <SoSTORIES
TYPE CONSTRUCTION
FIXTURES - PER TRAP
GAS - FA. SYSTEM -I INC, 40 S
O
Q
C
APN
GAS -PA. SYSTEMOVER4
GREASE/INDUSTRL WASTE IN EPPOR
BUILDING DIVISION FEES
GREASE TRAP
PLANCHECK FEE
SEWER - SANITARY - STORM F.A. 2W Fr.
ENERGY FEE
WATER HEATER W/VF.NT/ELECfR
GRADING FEE
NOTICE TO APPLICANT: IL otter making this Certificaw of Exemption, you should
become subject to the Workers Compensation provisions of rhe Labor Cale, you must
forthwith comply withmeh provisions., this pewit shall he decimal revoked.
CONS'rRUCT10N LENDING AGENCY
i hereby a(fiw chat there isucanswdinn lenAing agency fonhe performance n(
the work for which this permit Is Issued (Sea. 91197, Civ. C.)
Under's Name
WATER SYSTEM/TREATING '
WATER SERVICE
SOILS FEE
PAID
- Date Receipt#
NEW RESIDENTIAL PLMH. SQ. Fr.
-
TOTAL:
Lenders Address
TOTAL:
BUILDING FEE
I cenify that 1 have mad this application and scow than dre above information is
cowl. I agree to comply with all city and county ordinances and state laws relating to
building com uction, and herehy;mthonze representatives of this city m enter upon tho
above-mentioned property for inspection purposes.
(We) .gree no save, indemnify and keep hmmleas the City of Cupertino agaimn
liabilities,judgments, costs and expenses which may in any waymmon against said City
in consequence of the gmoar,of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALI,NON-POINT
SOURCE REGULATIONS,
QTY. MECHANICAL, PERMIT FEE
SEISMIC FEE
PERMIT ISSUANCE
ELECTRIC FEE
ALTER OR ADD TO MECIL
PLUMBING FEE �r
AIR HANDLING UNIT (TO 10.00O CFM)
MECHANICAL FEE
AIR HANDLING UNIT (OVER IO,000 CFM)
CONSTRUCTIONTAX
Signamreof ApplicanVC.nwche Date
HAZARDOUS MATERIALS DISCLOSURE.
Willtheapplicim or furore building.ecupam somem handle haearkar, material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Hasidism! Safety
Code, Section 25532(v)]
❑Yea XNo
Will the applicant orfuture building bytheoccupant use equipment or Maas which
us air contaminants as defined by the Bay Area Air Quality Management
emit bacDistrict?
Dtwian
CYcs 'n
I have read the hazvdons matMalsAIR
wquiremcnts under Chapter 6.95 of doe Cali
Fonda Health & Safety Cale. Sections 25505, 25533 anal 25514. I understand that if the
building does na curemly have a ,nam, Nm. is .. msaf e C rdrct notify the..re, m
of doe rcgmircmcnn which must NL mm prior m issuance of a CeniOcvm of (kcupancy.
EXHAUSTHOOD(W/DUC)
HOUSING MITIGATION FEL
HEATING UNIT (TO 100,00)BTU)
HEATING UNIT (OVER 100,000 BTU)
PAID
Date Receipt #
VENTILATION FAN (SINGLE RESID)
BOILER -COMP OHP OR 100,000 BTU)
TOTAL:
BOILER- COME (OVER 100.110 BTU)
CONDITIONER
ISSUANCE -DATE
'
ISSUED BY:
NEW RESIDENTIAL. MECIL SQ. FI',
Owner art vuthorved ager Data
TOTAL:
OFFICE