31450APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING: ELECTRICAL PERMU Na.
BUILDING DIVISION APPLICATION/PERNUT PLUMBING^ MECHANICAL MbU
OFFICE
he Qd hzL Z,57-061
❑Consultant Fees Paid by .Applicant (Initial)
BLDG ELECT PLUMB MECH
e- R?-� P--� ❑
LICENSED CONTRACTOR'S DECLARATION
1 hertby affirm that 1 am licensed under provisions of Chapter 9l commencing
with Section 70181 of Division 3 ofthe Busineesand PmfessionsCWe.andm license is
in fand
full aneffect. y
Licrnse Chir Lic.<
DateContractor
ARCHITECT'S DECLARATION
I understand my plans shall h used as public records
QTY ELECTRIC PERMIT FEE
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JOB DESCRIPTION
SFDWL EN REMODEL
❑ADDITION C: PLUMBING RE -PIPE.
❑MULThUMT ❑STRUCTURAL
MODIFICATION
C1 INTERIOR [I CHIMNEY REPAIR
IMPROVEMENT
❑BA DEL/REPAIR ❑DEMOLITION
&erHER
r(J
PERMIT ISSUANCE 35 Sa
��/5
APPLIANCES - RESIDENTIAL a yV
PANELS
..gg
L'P T0200 AMPS tOnO",
Licensed Prolnsional
OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt foam the Contractors License Law for the
following nomm.(Section 103 L5. Business and Pml'essioa CWC Any city or county
which requires a permit to construct, alter, improve, demolish, or mpnir any svucmre
prior to its issuance, also requires the applicant tm such Permit File a signed statement
that he is licensed isamamuo the provisions of the Comforter's License Law (Chapter 9
Icommencingwim Section 10001 of Division3ofine Business and Pmressioa Code)or
mat he is exempt memfmm and the basis for the alleged exemption. Any violutlos of
Section]031.5 by any applicant for a peormsubjects the applicant to a civil penalty of
not moan five hunched dullms S500).
Ndr
❑hmnwnerof the progeny. or myemployeeswim wages as lhcirsole compcnmtion,
will do me work, and the swcture is nm intanded...Hired for role (lies. 104L Business
and Prolecsinna CWe: ThComma,....aanrs License Law does no, apply to an owner of
properly, who builds or improves thereon and who does such work himself or through
101 OB)AMPS
OVER ❑N10AA1PS
SIGNS ELECTRICAL
SPECIAL CIRCUIT/M1SC.
/
TESIRMETERORPOLEINST.
COMMERCIAL
NEW BLDG/ADDITION El DEMOLITION
❑TENANT ❑FOODSERVICE
IMPROVEMENT
[:IOTHER
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS-SWRCHES-FlXTURES 3�
his own employees, pmvided that such improvements are not intended or offered fm
NEW RESIDENTIAL ELECfR SQ Fri. 0
sale. IL however the building or improvement is sold within one yearnfcompletiun. the
SQ. FT FLOORAA
95Q. PT.
owner -builder will ham the burden of proving that he did not build or improve for put-
poxetar sae.).
❑ 1, as owner of the property, am exclusively contracting with licensed contractors to
c nsrmct Ne project (Sec. 10 aL Business and Protrusions Cade;) The Contractor's Li.
6
996
TOTAL: Z
cense taw does not apply to an owner of properly who builds or improves theme",and
QTY, -., PLUMBINGPERMIT .-FEE
who contracts for such projects with a comracions) liccmcd pursuant to the Contractors
Licere. Law.
am exempt code Sec. , B & P C for this reason
f'a�
V�I I Ur 41.�1'C
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/
PERMIT ISSUANCE 37.5
er Date
WORKER't COMPENSATI ECLARATION
I hereby affirm under penalty of perju o of me following decimations:
ALTER - DRAIN & VENT- WATER IEA)
VALUATION
/QD�
BACK FLOW PROTECT. DEVICE
DRAINS- FLOOR, ROOF AREA. CONT).
-
❑ Ihaveand willmainctina C<nificate of Con Zelf-imam for Worker's Compen-
enion. as provided for by Section 3100 of the Labor Cotyle, far the permonew. a of the
work for which this perm, is issued.
❑ I have and will maintain Worker's Compensation Insurance, m required by Section
3100 of me labor Code, for me performance ofthe work forwhich this permit is issued.
Ca Workers Compensation Insurance cartiermd Policy number arc:
Cartier. Policy
STORIES
/
OCCGROUP
'�i
TYPE CONSTRUCTION
VAI
v
APN
FIXTURES - PER TRAP
GAS - EA. SYSTEM.( NC.a OUTLETS a 410
GAS -EA. SYSTEM -OVER 4(EA)
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Li
CERTIFlCATE OF EXEMPTION FROM WORKERS'
FROM
COMPE pleted N INSURANCE
(This section need not he compineJ ifthe permit is (Drone hundarldollan 151001
or less.)
1 r<nirr mat in the performance nrme wok for which rola permit is iaaaed. I enrol
not employ any person in any mumncrsoas to hecinnotijecrto the W cars ere Comp
anon Laws of Califumia. Date
Applicant
NOTICE TO APPLICANT: IL afrer making this Certificate of Exemption, you .should
become subject to the Workers Compensation previsions of me labor Code, you must
foMwith comply with such provisions or this pemdt shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
(hereby offirth thauhcm is aconswctinn lending agency tense perfortnantt of
Lework for which this permit is issued (Sec. 3091. Civ. CJ
Lenders Name
`L-
GREASEIINDUSTRL WASTE INTERCEPTOR
a' "�•�.'vBIIBDING DIVISION FEES
GREASETRAP
PLANCHECK FEE
SEWER-SANITARY-STORM EA. FT.
ENERGY FEE
WATER HEATER WNENTMLECTR
WATER SYSTEM/TREATING
WATER SERVICE
GRADING FEE
SOILS FEE
PAID
Dae--Wep<
NEWRESIDENTIALPLMD. SQ. FT.
TOTAL:
F6
V!
V ,z
Landers Address
TOTAL:
BUILDING FEE
1 certify mat I have real oris application and sineohm me abav< information is
come[. l agree to comply with all city and county ordinances and state laws relating to
building construction. and hcrehy mahorim representatives ofthis city to enter upon the
above-men0oned property for inspection purposes.
(We)agree to save, indemnify and keep harmss
lete hCity or Capstan a against
QTY. MECHANICAL PERMIT -. FEE
SEISMIC FEE
PERMIT ISSUANCE
ELECTRIC FEE SatzIP
ALTER OR ADD TO MECfi.
Ilabilities,judgmeas. costs and expenses which may in any way accrue against imd City
in consequence quce of the granting of this permit.
PLUMBING FEE I'
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS,
AIR HANDLING UNIT(TO I0,000CFM1
MECHANICAL FEE
AIR HANDLING UNIT (OVER IQOIIO CFM)
CON,STRUCIONTAX
Signature of A,pliumaIComrucmr Date
HAZARDOUS MATERIALS DISCLOSURE
EXHAUST HOLD (W/DUCT)
HOUSING MITIGATION FEE
HEATING UNIT (TO ISN." BTU)
Will the ... heard or future building occupant store or handle harmdous mintoad
m defined by the Cupertino Municipal CW.. Chapter 9.12. and the Balm and Safety
Cwk, Section 255321ay)
❑Ycn ❑Nn
HEATING UNIT (OVER 100.000 BTU)
PAID
VENTILATION FAN (SINGLE RLSID)
-
use equipment of devices which
Will the applicant or future deffned by the
.mit hmmdnm air contaminants a Jclined by the Bay Area Air Quality Management
Dean,'
❑Yee C] No
Date Receipt 0
BOILER - COMP 13HP OR 100.000 BTIII
TOTAL a I
DOILER- COMP(OVER IIXI,q]O BTU)
AIR CONDITIONER
I have real the hmnrdous materials Chapter 695 of the Cali.
requirements under
ISSUANCE DATE
NEW RESIDENTIAL MECH. SQ. R.
Italia Halts&Safety CWe.ea tinan?55115.!SSAa"d]333J.I unJersmnd mutifthe
an
budding rims y nave a ¢nano, roam it my rt m
ddrto notify the
de t, whit
or the teyuimsmnts whichmu.m M: tan prior hs issuance of a Ccnilicate of tkcupuncy.
i uta C pow,
ISSUETSBY:
Ounernr man onace opens Dam
TOTAL,
OFFICE