30880APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL. PERMIT No � O 8 8 O
BUILDING DIVISION APPLICATION/PERMIT PLUMBING_ MECHANICAL
CONTACT:
411�p
v 14_ 00-1 1p%c) _
LICENSED CONORACTORS IIECLARAT'ION QTY.
1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing
O=Z withSacfM7UW)of Division 3 if Ne Business and Professions Code, and my license is
F W O in full force and effect.
TUU LicenceClas Lic.N
<2 Date Conueeor
ARCHITECTS DECLARATION
Z O,� Z 1 understand my plans shall he used as public records
OZ -o
F .te'. t:W Licensed Professional
Sid J OWNER -BUILDER DECLARATION
d�( C
3W Q 1 hereby affirm m that 1 aexempt from the Contractors License Law far the
W W F following reason. (Section 7031.5, Iausine's and Professions Code: Any city or county
u1 W y which requires a permit to construct. alter, improve, demolish, or repair any structure
F�0¢ prior to its issuance, also requires the applicant for such permitn file a signed statement
that he is licensed pursuant to the provisions of the Contractors License Law (Chapter 9
tti--p0 (commencing with Section 7000) of Division 3 of the Business and Professions Code)or
a X n that hew exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for o permit suhjms the applicant to a civil penalty of
k z y not more than five hundred dollars ($500).
C] L as owner of the property, or my employees with wagce as their side compeaswion,
p., will do the work, and me smcmre is not intended cambered for sale (See 7(W, Business
a3 and Professions Codc: The Contractor's License law doses act apply to an owner of
property who builds or improves daemon, and who does such work himself or through
his own ommIces, provided that such improvements am not intended it offered for
sack. If, however, the building or improvement is sold within one year of completion, the
er-builder will have the burden of proving that he did nod build or improve for pur-
pou of sale.),
❑ 1, as owner of the prolnny, am exclusively contracting with beamed commmirs to
consumer the pnuject (Sec. 7014, Business and Professions Code:) The Contractor's Li.
u Law docs not apply to an owner of property who builds or improves thereon, and QTY,
who contracts for such projects with a connotations) licensed pursuant to the Contractors
License Law.
0 lam exempt under Sea, ,B&P C for this reason
•Owner Dae
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty operjuryore ofthe following orkee Co
❑ ( have and will for by
a Certificateio37 of me Lab r scif-Code. for me Wmkmance of the
mpen-
'stick, as which 'his
for ri Ss issued. 3]00 of me LeMn Code, for me performance of the
work hvwhich this permit is issued.
❑ have and will maimor Worker's Came of
work
far husrequired by fallen
37W of the Lahr Code, for the performance of the work for which this permit is issued.
My Workers Compensation Insurance eerier and Policy number are:
Carrier; Policy FROM
CERTIFICATEOF COMPENSATION
INS PROM WOk KERS'
COMPENSATION INSURANCE
(This cation nccJ not buomPlned ifthe permit is for hundred dollars P$100)
or less.)
I sanity that in the performance of the work fir which this permit is issued 1'hall
not employ any person m any mann Rat to the Workers pete
Com
0 z cortin law' of -ami I e F=
z 2 A Beam j .< L 6
to )TICF: TO AI'PLICAN ': 11, after making this Certificate of Exemption, you .should
Cbecome subjce to the Worker's Compensation provisions of me Labor Code. you must
[1.1M
forthwith comply with such provisions or this Permit shall be deemed mvoked.
0.
Z) z CONSTRUCTION LENDING AGENCY
V Q (hereby affirm mauhem is a emeraw ion lending agency for me performance of
IL F the walk for which mix permit is iVmed (Sec. 3007, Civ. C.)
Q U Lenders Name
Brea 'Address
FCL I 1 certify that I have read this application and late the the above information is
h correct, l agree m comply with all city and county ordinances and state laws relining m QTY
�.)Z building conxtrvnion. and hereby authume representatives of this city to enter upon the
shoveauentioned properly lin inspection purposes.
(We) agree to cove, indemnify and kap summits, the City of Cupertino against
liabilities,judgmems, costs and expenses which may in any way accme against said City
in consequence of the erantine of this memit.
COMPLY WITH ALL NON -POINT
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 25532(a)1
E] Yes 0 N
Will the applicant or future building occupant use equipment or devices which
Iran hamrdoos or comamnwnts as defined by the Bay Area Air Quality Management
C]Yex MN.
I have read me hazardous materials requirements under Chapter 6.95 of the Cali.
forma Health & Safety Code. Sections 25505, 25533 and 51XF I understand that if the
building does not currently have a tenant that it is my responsibility to notify me compant
of the myulrementy which must be met prior nr issuance of a Cem Bone of Ocmupmcy.
Owner or aumoriecd agent Uade
Consultant Fees Paid by Applicant (Initial)
ELECTRIC PERMIT
PERMIT ISSUANCE
APPLIANCES - RIS IDENTIAL
PANELS
UP 1'0 200 AMPS .
201 ["AMPS
OVER HICOAMPS
SIGNS ELECTRICAL
TEMP METER OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS - SWITCHES - FIXTURES
NEW RESIDENTIAL ELECTS SQ FT.
PLUMBING PERMIT
PERMIT ISSUANCE
ALTER- DRAIN & VENT- WATER
BACK FLOW PROI'EC'n DEVICE
DRAINS - BOOR. ROOF, AREA. COND.
FIXTUR17S - PER TRAP
GAS - EA. SYSTEM -I INC.4 OUTLETS
OAS - BA, SYSTEM -OVER 4 (EA)
GREASMNDUSTRL WASTE INTERCEPTOR
ORGSE TRAP
SEWER -SANITARY -STORM EA. 200 Ff.
WATER HEATER W'NENT/ELECTR
WATER SYSTEA17REATING
WATER SERVICE
NEW RESIDENTIAL PLMB. SQ. ET.
MECHANICAL PERMIT
PERMIT ISSUANCE
ALTER OR ADDTO MUCH.
AIR HANDLING UNIT (TO 10,000 CFM)
AIR HANDLING UNIT (OVER Id000 CFM)
EXHAUST HOOD (W/DUCT)
HEATING UNIT TO 100,000 BTU)
HEATING UNIT (OVER 100,000 BTU)
VENTILATION FAN (SINGLE RLSID)
BOILER -COMP (311P OR 100,010 BTU)
BOILER -COMP (OVER 100.000 BTU)
AIR CONDITIONER
NEW RESIDENTIAL. MECH. SQ. ET.
OFFICE
TOTAL:
7i
2
FTE JOB DESCRIPTION
❑SFDWL
❑ KITCHEN REMODEL.
ADDITION
El PLUMBING RE -PIPE
❑MULTI -UNIT
❑STRUCTURAL
MODIFICATION
❑ INTERIOR -
❑ CHIMNEY REPAIR
IMPROVEMENT
HU
❑ BATH REMODEUREPAIR ❑ DEMOLITION
]OTHER
❑NEN'( %11904 LJU�S(EOLff10N
jQN
11MP$[IVEN1pWTuyrrl'IIIIV�ID SERVICE
❑OTHER=— --- .
SQ. FT. FLOOR AREA
FEE �OD
Ws Q. ET.
PLANCHECK FE19 \ s
ENERGY FEE
GRAVING FEE
SOILS FEE
PAID
Date diol
BUILDING
FEE
SEISMIC FE
ELECTRIC FEE
PLDMHING FE
MECHANICAL FUE
CONS i'I2UCTION TAX
HOUSING MITIGATION FEE
PAID
Date Receipt#
STORIES�p
TYPE CONSTRUC IOt
OCC GROUP
APN
HU
(VISION FEES
PLANCHECK FE19 \ s
ENERGY FEE
GRAVING FEE
SOILS FEE
PAID
Date diol
BUILDING
FEE
SEISMIC FE
ELECTRIC FEE
PLDMHING FE
MECHANICAL FUE
CONS i'I2UCTION TAX
HOUSING MITIGATION FEE
PAID
Date Receipt#