30206APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING -ELECTRICAL PERMITNO. p r)O`+
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING - MECHANICAL J L O
l o3sz S S
OWNER'S NAME:
ARCHITECT/ENGINEER: -
CONTACT:
DI(M:HT
❑ Consultant Fees Paid by Applicant (Initial)
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F W O
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LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I um licensed under pmvieiom of Chapter 9 (commencing
with Section 7000) of Division 3 of l he Banes, and Pmfexniom Code, army l icenseic
in full farce and effect.
License Class Lim. #
Ci ntracmr
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ELECTRIC PERMIT
FEE
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ARCHITECTS DECLARATION
1 understand m l b II he used public mcmds
ypanssa as
APPLIANCES -RESIDENTIAL
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OF!�
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11�01,1VLL
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Licensed Prufex.innul .
Oat I am exempt R DECLARATION
I hereby affirm that I am exempt from the Conbanors License Law for the
following ...isection 7031.5, Nosiness and Professions Code: Any city or county
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which requires a permit to construct, alcor, improve, demolish, ar repair any structure
pfimmitsisanime,.k.beuiresthe applicant for such proof to file a signed statement
thm wit he orthe License Law (, 9
OVER 1000AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC
'1'13MP. METER Oil POLE INST
VENTILATION PAN (SINGLE RESII3)
COMMERCIAL,
❑NEiW BLDG/ADDITION El DEMOLITION
[]TENANT ❑ FOOD SERVICE
IMPROVEMENT
[]OTHER
CGC
0.q oL
❑Xl ELN
Qnot
1..
ria ,ing Section 70 of UMans inm'e
theCode)
of Dlvisi f meof Runinas andon. Ani sithum) ar
(hm he is exempt airman.
Nat he is exempt any. ]I and Nc Amis fnr Ne cts am exemption. Any violation of
S by any applicam fnr a permiuubjects the applicam to a civil penahy of
am river,
more Nan five hundred dollars ($500).
❑ I, as owners( the property, or my employ«s with wages n their sole compensation.
will do the work, and the structure is not intended mothered for sale (Sec. 7044, Business
and Professions Code: The Contractor's License Law does not apply to an owner of
Property who huilds or improves thereon, and who Bros such work himself or through
OUTLETS -SWITCHES - FIXTURES
AIR CONDITIONER
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his awn cam lnyce.. provided Nat such improvements arc not intended ar offered for
SQ. IT. FLUOR AREA
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sale. If. however, the building or improvement is sold within one year of completion, the
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owner -builder will have the burden of proving that he did not build or improve for put -
PERMIT ISSUANCE
ALTER - DRAIN
pow of sale.).
UATION
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BACK FLOW PROTECT. DEVICER(IiA)
❑ 1, as owner of the property, am exclusively contracting with licensed conuamors to
STORIES
amshuct the project (Seo. 7044, Business and Professions Coda:) The Comnmtmd Li-
FIV URES-PERTRAP
GAS- EA. SYSTEM. I INC. 4 OUTLETS
nseLawdoexnotapplyroannwnet- of property whit to Ids or Improves thnenn,:rad
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'
who contracts for such projects with a commemod licensed pursuant to the Contractors
GRCASEANDUSTNL WASTE INTERCHITOR
BUILDING DIVISION FEES
License Law.
❑ I am exempt under Sec. ,B& P C for this reason
SEWER -SANITARY -STORM EA. 200 ff.
ENERGY PEE -
Owner Date
GRADING FEE
- WORKER'S COMPENSATION DECLARATION
SOILS PL'E
I hemby affirm under penalty of penury one of The following doalarminnx:
PAID
Dote Ndecipt#
(have anti will nmin.ib aCenif icme of Consenun sen Flnxare for Workers Cnnnpro.
ration, as provided for by Section 3700 of the Labor CtWe, for the perfammnce of the
TOTAL.:
TOTAL:
work for which this permit is issue.
BUILDING FEE
MECHANICAL PERMIT
❑ I'have and will maintain Workers Compensation Insurance, as hNuired by Section
SEISMIC FEE
3700ofthe LaburCedi he perfur meofthasankforwhichfuspermitis ixjjueI
My Worker ranee arzierandy No: num `�,
.
Comer:[ Policy No: TS
- CER'( IF tlPFl3 EMOTION FROM ORKER.' T/ly-�-
COMPENSATION INSURANCE '
(This section need mol bccnmpleted ifthe pcmdt is Gtonehundred dollars ($100)
or less)
1 certify Nat in the performance. work this permit is shall
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not employ any person in any manner xo as to become suhjccuo the Warkec2 Cnmpen-
ast nm,,.hjr
mian Laws of California. Dam
Applicant'
NOTICE TO APPLICANT,.If, derandirg this Certificate of Exemption, you should
become.bj.1 m the Workers Compensation provisions of the ladder Cale, you mint
foMwim comply with such pfovisians or this permit shall he deemed revoked.
CONSTRUCTION LENDING AGENCYIherehy
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uffmUhat them isacnnabuctian lending agency fur the perfnmmnce of
the work for which this permit is issued (Sec. 3097, Cie. C.)
Lender's Name
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Lender's Address
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I certify that 1 have read this application and state that the above information is
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correct. l agree rat comply with all city and county ordinances and nate laws relining m
bui lding concoction, and hereby authorize representatives of this city to enter upon the
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alcove -mentioned property for inspection purposes.
(We) agree m save. Indemnify anti keep hi mdess the City of Cupertino against
liahilitmajudgments, costs and expenses which may in any way accrue against said City
in onsequence of Ne granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURTE REGULATIONS.
Signature of Apphd.m 7mumctor Duro
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
ex defined by the Cupertino Municipal Cade, Chapter 9.12. and the Health and Safety
Codd, Section 25532(x)? ,
❑Yes ❑No
Will the applicant or future building occupant use oquipment or devices which
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tit hazardous Dir contaminants as defined by the Bay Area Air Quality Management
Dkoist?
❑Yes Fl No
I have mal the hazardous materials requirements under Chapter ASS of the Cali-
main Health & Safety Code, Sections 25505, 25533 and 25534. 1 understand that If the
huilding less n i curently have. tenant, Nat it is in, rexpnn'Rahly m no dy lite accapnm
of the oxmirrmrms which must b, met prior m Issuance of a Certificate of Occupancy.
Owner at authorized age. Dae
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PERMIT ISSUANCI3
ELECT Ric THE
❑ ❑ ❑
ELECTRIC PERMIT
FEE
JOB DESCRIPTION
RESIDENTIAL:
❑SPDWL ❑ KITCHEN REMODEL
❑ADDITION C3 PLUMBING RE -PIPE
C3 MULTI -UNIT ❑STRUCTURAL
MODIFICATION
El INTERIOR El CHIMNEY REPAIR
IMPROVEMENT
❑ BATH REMODEUREPAIR ❑DEMOLITION
❑ OTHER
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PERMIT ISSUANC17
APPLIANCES -RESIDENTIAL
PANELS
UP TO 200 AMPS
201 -II MAMPS
OVER 1000AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC
'1'13MP. METER Oil POLE INST
VENTILATION PAN (SINGLE RESII3)
COMMERCIAL,
❑NEiW BLDG/ADDITION El DEMOLITION
[]TENANT ❑ FOOD SERVICE
IMPROVEMENT
[]OTHER
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS -SWITCHES - FIXTURES
AIR CONDITIONER
NHW RESIDENTIAL ELEC'I'R. SQ Fr.
NI3W RESIDENTIAL. MECH. SQ. FT.
SQ. IT. FLUOR AREA
Y^ A
UC 11 f�k
$/SQ. FT.
IAL:
PLUMBING PERMIT PEE
PERMIT ISSUANCE
ALTER - DRAIN
�,
UATION
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BACK FLOW PROTECT. DEVICER(IiA)
DRAINS- FLOOR, ROOF. AREA, COND.
STORIES
TYPE CONSTRUCTION
FIV URES-PERTRAP
GAS- EA. SYSTEM. I INC. 4 OUTLETS
OCCGROUP
AIN
GAS- EA. SYSTRM-OVER 4 (EA)
GRCASEANDUSTNL WASTE INTERCHITOR
BUILDING DIVISION FEES
GREASETRAY
PLANCHECK FEE
SEWER -SANITARY -STORM EA. 200 ff.
ENERGY PEE -
WATER HEATER W/VENT/ELECTR
GRADING FEE
WATER SYSTEMC`RFATING
SOILS PL'E
WATER SERVICE
PAID
Dote Ndecipt#
NEW RESIDENTIAL PLMH. SQ. FT.
TOTAL.:
TOTAL:
BUILDING FEE
MECHANICAL PERMIT
FEE
SEISMIC FEE
PERMIT ISSUANCI3
ELECT Ric THE
ALTER OR ADD TO MECIL
PLUMBING FEE
AIR HANDLING UNIT (TO Indian CFM)
MECHANICAL FEE
AIR HANDLING UNIT (OVER 10,000 CFM)
CONSTRUCTIONTAX
HXHAUST HOOD (W/DUCI)
HOUSING MITIGATION FEE
BEATING UNIT (TO 100.000 BTU)
IIFNI'ING UNIT (OVER IM." BTU)
PAID
VENTILATION PAN (SINGLE RESII3)
Dale Roorim #
BOILER - COMP CHP OR 100,000 R1 U)
TOTAL:
BOILER -COMP (OVER 100.000 BTU)
AIR CONDITIONER
ISSUANCE DATE
ISSUE BY
NI3W RESIDENTIAL. MECH. SQ. FT.
T�'�
OFFICE