B 0621 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NOPLUMB .
BUILDING DIVISION APPLICATIONIPERMIT BUILDING
PROJECT
s.00o� �Cl too' . '
BUILpING PROJECT IDRNTIFIGATION
BUILDING ADDRESS: SANITARY NO, APPLICATION SUBMITTAL DATI
2
0 ,7
OWN R'S NAME NIC CONTROL#
: " PHONE: CONTRACTOR'S NAME: LIC NO
_
ARCHITECT pSGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUUMB/ MECH
LICENSED CON'TRACTOR'S DECLARATION QTY. ELLCI'RIC PERMIT FEE
I hereby affirm that I am honed ardor provision.ar Chapter 9 memneuciag .. JOB DESCRIPTION
QaZwbn sect;as 7nw)o[Diviainn3aDhe Easiness and vra0+eatim Cade,shdmy BcenL:
ris RESIDENTIAL
W p PERMIT ISSUANCE
Flys in full forceandeffec 7023 J� 0SFDWL ❑KITCHEN REMODEL.
�UU License Cla Lic.# �/ O pPphIANCEs—RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE
vFi¢ww Dam�'—��/=F�% a+mmotar 6!�r�"�=
FDrn ARCHITECT"S DECLARATION PANELS El MULTI-UNIT ❑STRUCTURAL.
z C�z I understand sed my plans shall be uas public records MODIFICATION
Oz- UP TO 200 AMPS [I INTERIOR [ICHIMNEY REPAIR
kwLy Licensed Pmfcaaienal 201 tlfkril IMPROVEMENT E]SWIMMING POOLS
��y OWNER-BUILDER DECLARATION OV 111AMP ❑BATH RE B)DEUREPAIR 0DEMOLITION
C a I hereby affirm that i arm exempt from the Commences'License Law for the
G7y5 o L U fallowing reason.(Section 7031.5,Business and Professions Cade:Any city intensity SIT144kCIAeAlU ❑OTHER
which requires a permit to comlrvm.altar,improve,demolish,or repair any structure
prior to its issuance,also requires the applicant for such permit is)do a signed statement S
CRd Ihat be is licensed,..scamsro
I.the pvisicaralthe Commerce,License Law(Clapta9
W 00 (commencing wiN Secdah70011Division 3ofthe Basinewsund Professions Gde)or T .METER PO tl 'I'.IVZ1ZJ COMMERCIAL'
d c C that he is exam,,mention.and the basis far the alleged exemption.Any violation or C1 NEW BLI3G/ADDITION ❑DEMOLITION
�R+ Section 7031.5 by any applicant fora sa mu subjects the applicurn o u civil penally of P WRR DEVICES O TENANT ❑FOOD SERVICE
N notmore@an five hundred dollars(S500). IMPROVEMENT
� d� ❑
I.as owner of the property,or my employees with wages as their sale compensation, S
S' willdo the work,and theswewreisveti License
Law does ntl apply to an Business El OTHER
3
and Professions Coda the Gmvenor'e License Law docs not apply m to owner of OUTLETS-5WITGHES—FIXTIIRE,S
property who builds or improves Iheaon,and who docs such work himselfOr Waugh
his own employees,provided that such improvements are nal intended or offered far NEW RESIDENTIAL ELECTR SQ ET.
sale.IL m
however,the building or lmproveenlis sold within one
year ofcompletioh,the SQ.t AREA 5/SQ.Ff.
owner-builder will have the burden of proving that be did not build or improve for par,
pose o[Bale.).
:)I,as owner of the property,am exclusively contracting with licensed contractors to TOTAL:
construct the project(Sec.9044,Business and Professions Code:)The Contractor's 1,1- _
crime Law does not apply to an owner of property who builds or improves thereon,and ,QTY. PLUMBING PERMIT FEE /
who convects barman pjectswithaemarcrtm(s)licensed par rsuratio the Connector's
License Law. f PERMIT ISSUANCE . 9
0 I am exempt under Seo. B he P C far this reason
ALTER—DRAIN&VENT—WATER RA) VALUAT N
Owner Data -
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT'.DEVICE
I hereby affirm under pomhy of perjury one of the following declamdona
❑ I have and will maintain a Certificam of Consent to self-insure for Worker's Camper- DRAINS—FLOOR,ROOF,AREA,CONU. STORIES TYPE CONS'IRUCGOS
satlan,as provided for by Section 3700 of the Labor Cale,for the performance of the
work far which this permit is issued. FIXTURES—PER TRAP
1 have and will maintain Worker's Compensation Insurance,as required by Section
3710 of the Labor Code,fm for performance of the work for which this permit is issued. GAS—EA.SYSTEM-I INC,4 OUTLETS OCC GROUP APN
My Worker's enc Inv neer dpolicy numb
f� n at �%(ta gam_ GAS—EA.SYSTEM-OVER4(EA)
Carrier: L n Policy Nn:r J�
CERTIFI TE OFEXEMPTION FROM WORKERS' GREASMISDUSTRI.WAS'T'E INTERCEPTOR
COMPENSATION INSURANCE BUILDING❑IVIBION PEES _
(Thisseetior need not be completed ifthe permit is&none hundred dollars Slap GRPASETRAP
a,less.)
99�� PLANCIIP.CK PEE
I cenify that in the performanceofthe work for which ihis,ennit isstand,[,halt SEWER—SANITARY—STORM EA.200 FF. r�v
not employ any person in any manner so as m become subject to the Workers'Compaq- ENERGY FEE
Z cation Laws al'California.Data WATER HEATER WNENT/ELECTR
>� O Applicant ) GRADING FEE
q h NOTICE TO APPLICANT:If,arm,making this Carafiade of Exemption,you should WATER SYS'IEM/I'BEATING
a M1ecmne subject lathe Worker's Compensation pro bounce of the Labor Cone,you most
SOILS FEB
w forthwith comply with such proviemr,or this permit shall be deemed avoked, WATER SERVICE
Q
Fa z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FE PAID Data #
IheaM1yrfOrm that is u corporation lending agency for the performance 0f _
V ,be work for which this permit is issued(See.3097,Civ.C.)
Lenders Name "TOI'A L:
W Lender's Address TO L: v C BUILDING FEE
ly I certify that I have read this application and sm,e that tire above infatuation is
L4iy corzecL lagaomwmplywith all citysad countyordlnances and mate laws relatingm QTY MECHANICAL PERMIT FEE
V Z balldingennstraction,and hereby aulhodzo representatives of this city to cateripan the ISEISMIC FEE
above-mentioned propeny for inspection purposes, PERMIT ISSUANCE
(We)agree to save,indemnity and keep harmless We City of Cupertino agafan ELECTRIC PEE
liabilities,judgments,casts and expenses which may in any way aomucagainst said City AL'PER OR ADD TO MECH.
in convenience of the painting or this permit PLUMPING FEE _
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING ON IT(TO 10,000CFM) MECHANICALFE
SOUR EGULATIONS
2 11—?2 AIR HANDLING UNIT(OVER 10,000 CPM) CONSTRUC'T'ION TA
Signature m pplicanUCmines r '1 Data EXHAUST HOOD OVMUCT) HOUSING MITIGATIO •.E
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant motion,building occupant store or handle hazardous material HEATING UNIT(TO 100,000 BTU)
as defined by,he Calamine Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(x)7 HEATING UNIT(OVER 110,000 B'UA
❑Yes No VENTILATION FAN(I INGLE RES ID) PAID
Data Receipt
Will the applicant or future building occupant use equipment or devices which BOILER—COMP CHP OR In"Fil1 BTU)
ami,hazardous air contaminants as defined by the Bay Area Air Quality Management 'f L:
District? BOILER—COMP(OVER 100,000 BTU)
❑Yes E]No
I have madthe hleuv atenrcyuire
ale is under Chapter 6.95 of the Cali- ATR CONDITIONER
mmmISSUANCE DATE
hernia Has &Sa[cry Code,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MSCI I. SQ.Er.
building not currently have a tenant,that It is my responsibility to hardly the oocupan
ofthe mens which toast amen,harm Issuance oft Canifi ate of Oceupuncy.•
Owner or i mho;'ad iincan Date TOTAL: ISSUED BY:
OFFICE