S 1025 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATIOrERMIT PLUMBING.MECHANICAL.
S 1025
11 BUILDING JEL W DE IF 'ATION V
BUILDING ADDRESS: SANITARY N APPLICATION SUBMITTAL DATE
OW AME, €MP f�ft'wrG ejy CONTRACTOR NAME: LIC NO: y�- N/C CON I'R0//L#
G
kCHITECT/ENGINIJ L /o. ADDRESS: ❑ � Q
CONTACT: PHONE: BUILDING PERMIT INFO
,. ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB - MECI I
LICENSED CONTRACTOR'S DECLARATION QTY.' ELECTRIC PERMIT FEE
I hereby affirm that 1 am licensed under provisions of chapter 9 cm
omencing -. JOB DESCRIPTION
µMµ]WZ Ili Sectinn9W0)oF Division3nYlho Business and Professions Cede,anJ mylieense iv RESIDENTIAL,
F00iafu114nceandelfecc PERMITISSUANCE _ ❑SPDWL [IKITCHIiN REMODEL
auu License Class Lic.p APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RE-PIP13
F'�j-W Date Contactor
ARCHITECT'S DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
FyZ I understand my der,,hall be used as uniamerml, PANELS MODIFICATION
OZ`=0 UPTO200AMPS I El INTERIOR El CHIMNEY REPAIR
P:tzt u0Licemed Professional 201-1000AMPS IMPROVEMENT I]SWIMMING POOLS,
IM s4 OWNER-BUILDER DECLARATION OVER II)(I(IAMPS ❑BATH Rh:MODE REl'Alk El DEMOLITION
hereby xftrm mpt fthat 1 am exefnvn ontm
ne Corrosion,License Law for the
iy�O ad V fanowinb reason.(S tion 70315,Busineex and Professions Cede:Any city m county SIGNS ELECTRICAL El OTHER
Yl a fL t✓ which acquires a permit a construct,alter,improve,demolish,or repair any....pure -
�� Inform its Issuance,also requires the applicant for such pemnit to file o signed stnmment SPECIAL CIRCUIT/MISC.
m menhe is licensed provieionsn ( p
y iSedicmmlhe "I'll License Law Cha ter9
W00 (cnmmeneing with Section 9utID)ofDivision3 of the Business and Professions Codo)or 'fP.MP.METER OR POLE INS'P. COMMERCIAL:
0.0.o flim he Is exempt therefrom and the basis for the alleged nxmnption.Any vinlwinn of
[I NEW BLDG/ADDITION ❑DEMOLITION
iCm
Section 7031.5 by any applicant for a permit subjects the applicant m a civil penally of POWER DEVICES ❑TENANT ❑FOODSERVICE
why not more than five hundred dollars($500) IMPROVEMENT
QctLas nwnor of the property,nr my employees with wugee ax their sole compensation, SWIMMING POOL ELECTRIC
F will do the work.and the structure is not intended oroffered far sale(See91144;Business ❑OTHER
0.a
and Professions Code:The Contractors License Law does
not apply m m owner of OUThBTS-SWITCHES-PIXTURP
property 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 ELECTS
sale.if,however.the building or improvement is sold within one year of completion,the SQ,FT.FLOOR AREA $/SQ.FT.
evemer,imilderwillhavetheburdenofprovingthathedidnotbuildorimprovefarpar-
p�s (sole.),
sow ref the property,am exclusively contracting with licensed contractors to
emosbact the pmjcd(Sop,9044,Bmsimco and PomeWons Cade:)The Contractor's Li- - {1_
ovnm Law does not apply it)an owner of properly who builds or improves(hereom and QTY., - PLUMBING PERMIT EE A
who contracts for such projects with a contmctons)licensed pursuant to the Contractor's
License law. f PERMIT ISSUANCE (.
,. ❑ Iamexempt under Sec. ;B&VCforthisrea,am
ALTER-DRAIN&VENT-WATER LEA)#1 OMP1 ��/yg1.UAT10N
wiser W ;i:� �SZbNMHNSATTON DECLARATION BACK PLOW PROTECT.DEVICE
I hereby affirm under penalty of perjury one of the following declarations:
�]I have and will complain a Cennscon,of Consent to selNesure for Workers Campos- DRAINS-FLOOR,ROOF,AREA,COND. STORIES I YPE CONSTRUCTION
option,as provided for by Section 3900 of the Labor Code,for the peffornaneo of the
work for which this permit is issued. FIXTURIIS-PER TRAP
❑ I have and will maintain Worker's Gcmpensvtian Insurance,as required by Section GAS-EA.SVSTP.M-I INCA OUTLL'I'S
3]0tl of the Labor Code,for performance of the work for which this permit is issued. OCC.GROUP APE
My Worker's Compensation Insurance carrier and Pot icy number are: _
Carrier, Policy Na.: GAS-BA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERSGREASF/INDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE -BUILDING D ISION PEGS
(This section need not he completed if the permit is for one hundred dollars($1Pon GREASETRAP
or less.) PLANCtIECK NHL?
Icertifylhalinthe performanpeof lhewmkforwhichthiscermit is,mcped,]shall SEWER-SANITARY-STORM EA.200 FT.
not employ any pmson in any manner so as m become subject to the Workers'Compos- - ENERGY FEE
0 $ cation Laws of Calif ornix.Date WATER HBArER WNENT/ELECTR GRADING PEE
7 Q Applicant
[[V/) NOTICE TO APPLICANT:If,after making this Cenificate of Exenlptma,you shanlA
WATER SVSTEMITRGTING SOILS FF.F.
a [^
become object to the Worker's Campennation provisions of the tabor Code,you must �J
W G forthwith comply with such provisions or this permit shall he deemed revoked WATER SERVICE
Q
� .� CONSTRUCTION LENDING AGENCY NEW RBSIDENTIALPLMB. SQ.Irf. PAID Date
RceclplN
I hereby affirm that is a consumption lending agency for performance of
V 0 the work for which this permit is issued(Sm.Nat Co.C.)
Lender's Name TOTAL,
V Lender's`Address TOTAL:
a1 codify Ibut I have read this application and state that the above information Is BUILDING FEE
V) corset.l agree to comply with all city and county ordinances and state lawsrelating to ()Ty, MECHANICAL-PERMIT FEE
C..) Zi building construction.and hereby authorize represcmmnyte,of this city to enter upon the SEISMICFEE
above-mentioned property for inspection purposes. - PERM IT ISSUANCE
(We)agree to save,indemnify and keep hvrtnlesn the Clly of Cupertino ugxinsl ELECTRIC NNH
liobilitin,judgurents,mets and ex es which may in any way occur,against said City AEFER OR ADD TO MUCH. PLUMBING FEE
in emnmquoocea t gamin Ihi�pennit.
'A PPL'
IIRSTA DS D ILL COM PLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000CFM) MECHANICAL s
SOUR 'E / V
AIR HANDLING UNIT(OVER IgIXlO CPM) CONSTRUCTION AX
Signa of AppllcanVCom et Date EXHAUST HOOD(W/DUC'q HOUSING MORGA ON FEE
HA DOUS MATERIALS DISCLOSURE
Will theapplicernin fmumbuildingaecupnestoremtoonle lmeradonsmvmrial HEATING UND'('TO 100,000 BTU)
as defined by the Coconino Municipal Cede,Chapter 9,12,and the Health and Safety
Code,Section 2553200? 1 HEATING UNIT(OVER 11)(,0011 BTU)
Yes FIN.
VENTILATION PAN(SINGLE RLSIU) PAID pore Receipt
Will the upplicum or froom building occupant use equlpmeenm devices which
mil hemrdoes uir c0u
nmiounts as defined by the Bay Area Air Quality Management BOILER-COMP[7HP OR 100,000 BTU) 'TOTAL:
District?
❑Yes C]No BOILER'COMP(OVER 100,()(1)BI U)
I have road the hmardmonirecoinarmarl,under Chapter 695 of(he Call- AIR CONDITIONER ISSUANCE DATE
fomla gdoes&Safety Coda,aSections tenant,that
25533 and 25534.i understand that if the NEW RESIDENTIAL MBCH. SQ.F1'.
building currently have tenet Fri
o is my responsibility ofaCto camofy the Occuancy.overprint
ofihe requirements which must he mw priorno issuance nfv Csrliflrate of Occupancy. -
Owneror authorized agent Date TOTAL: ISSUED BY.
OFFICE