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APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF C INO NUfLDING -ELECTRICAL
PERM
BUII,'�Sf: oIVISION APYLICAT'ION/PF.RMIT PI-UMBING-MF.CHANICAI.
DIVISi
BUILDING PROJECT IDENTIFICATION.• Y
BILtiDIN(`n DDRF.SS:
SANITARY NO.
APPLICATION SUBMITTAL DA'Z'E
ul �J b
OWNER'S AMP.: PHONE:
CONTRACTOR'S NAME: LIC NO:
NIC
O 'R LM
1 Se.0
6EA�
'HITECIII3NGINEI3R;( hIC NO:
ADDRESS:, 0Ilii
❑
eoNTAGT. PI E
'BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant (Initial)
BLDG ELECT PLUMB MECH
El El RL ❑
qry ELECTRIC PERMIT FEE
LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm that 1 an, eeensed ander provisions of chapter 9 (commencing
JOB DESCRIPTION
wiOi Section 7)00) of Division 3 of the Business and Professions Code, and my license is
I full farce a -d f1j
License Clu.aa Lica
Dam Comm
PERMIT ISSUANCE
RESIDENTIAL:
❑SPUWI. ❑KITCHEN REMODEL
❑ADDITION El PLUMBING RE -PIPE.
APPLIANCES -RESIDENTIAL
ARCHI'1£CTS DECLARATION
I understand my plans Shall be used we public records
❑ MULTI -UNIT El STRUCTURAL
MODIFICATION
PANELS
UP 10 200 AMPS
❑INTERIOR [I CHIMNEY REPAIR
IMPROVEMENT E] SWIMMING POOLS
❑ BATH REMODELBE AIR DUEM_OLITION
❑ OTHER �J�1
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm thin 1 am exempt from the Commerce's License Law for the
l allowing reamer. (Section 9031.5, Bu,ine&, and Professions Code Any city or county
201-1000AMPS
OVER 1011(1 AMPS
SIGNS ELECTRICAL
which requires a permit to coriander, alter, improve, demolish, of repair any swcmre
pd.,1.its diamond. also requimsthe applicant forsuch peril on Mentioned attention
SPECIAL CIRCUITMISC.
thin he is licensed pursuant to the provision, of the Corrosions License Law (Chapter 9
TIN P. ME' FR OR POLIS INST.
COMMERCIAL:
(commencing with Sem'loll]000)of Division Sof the Hiloncas and Innessiti Code) or
that he is exempt thernmon and the basis far the alleged exemption. Any violation of
❑ NEW BLDG/ADDITION ❑ DEMOLITION
Section 7031.5 by any applicant for a Permit subjects the applicant to a civil penally of
nm marc than Eve hundred dollars ($500).
(] Las owner of the property, or my employees with wages as their sale cmnpensmion,
will do the work, and the&nature is not intended or offered for sale (Sm. 744. Business
POWER DEVICES
El TENANT [I FOOD SERVICE
IMPROVEME T
010TUER 14
SWIMMING POOLELECfRIC
Professions Cade: The Contractor's License Law does not apply to an oamer of
OUTLETS - SWITCHES -FI
R14and
property who builds or improves thereon, and who does such work himself or through
his own employees• provided mm aneh inmpmvemena are not intended or uttered for
N13W RESIDENTIAL El. R SQ M.
FI'.FLOUR AREA
$SQ. FT
sale. If,however, the building.,impmvemefit i& sold within one year of rnmpletion, me
1 1
owner -builder will have the burden of proving that he did not build or improve for put-
pow of sale.).[:]1. as owner of the property.inn exclusively contracting with eamed Contractors to.nsuuer
the project (Sec. 7141, Business and Professions Gde:)'Me Contractors Li-censeLawdoes
nonapplytoanownerofproenywhobuildsorimprove&thereon,and
or, d ntmet& forwch pmjed, with o candachods) licensed pursuant the Commctor's
QTY. PLUMBING
1 6L
I
PI7RMIT ISSUANCE
License Law,
I] I am exempt under Sm. ,B&1'C for Nis reamer
-L
AUGER - DRAIN & VENT -WAT13R (EA)
wrier Data
y,(,., ION
WORKER'S COMPENSATION DECLARATION
I hereby of trod under penalty of perjury one of the following declarations:
BACK FLOW PROTECT'. DEVICE
DRAINS- FLOOR. ROOF, AREA. COND.
[have and will maintain a Certificate of Consent to self -insure for Workers Compeer-
n Labor Codr. for e p,rfoltorr the
,alio,, as providul fist by Section 3900 of inthof
STORIES TYPE CONS'1'HUCLION
FIXTURES - PER TRAP
work for which thio permit is issued.
I 1 I have and rill maintain Wafture, Compersons. bandana. az reyuireJ by Section
39W of the Labor Code. for the performance of the work for ishiijchp this permit is issued.
myM yryly' ut lonypa�danic Policy
GAS -EA. SYSTEM -I INC. 4 OUTLETS
OCC GROUP APN
Co erMy skcry('rp
Policy No.M/Sl{.r1��10/�
C-LCJERRTf IIFIICCAATEI /OJF EXEMPTION FROM WORKERS'
GAS -EA. SYSTEM -OVER 4(EA)
q
COMPENSATION INSURANCE
fIhis section need not be completed i I the Ormot is for one hundred dol Ins, IS l On
or less.)
GREASERNDUSTRL WASTE IM'ERCEPTOR
B111LDIN0 DIVISION E£FS
GRIMSETRAP
PLANCHECK FEE
SI7WER- SANITARY -STORM EA. 200 FT.
I certify that in the performance ofthe work for which dust permit is issued, l shall
not employ any person in any dander m as to become subject to the Workers' Compeer-
ENERGY FEE
WRIER HEATER WIVI3NT/ELF.CI'N
.Colo La�y`f C�nlilyfn �D
ApPlicadtj/� r
GRADING FEE
NOTICE TO APPLICA : 1 aftnr making this C fiome of Exempuoq you should
become ,uhim, to the Workers Conpedsmion provision, of the Lol o, Code, you must
WATER SYSTEMITREATING
I
SOILS FEE
WATER SERVICE
nrthwith comply hit such provisnarx err this permit shill be decided revoked.
NEW RESIDENTIAL PLMH. SQ. FT.
CONSTRUCTION LENDING AGENCY
I hereby afftnd that there is a conuuctinn lending agency for the permindance of
PAID
Data Receipt#
the work In, which Oils Permit ix Issued (Sec. 3097, Co. C.)
Lender's Name
TOTAL:
Lenders Address
TOTAL:
I cmily ova I holo rood this opplicminn and nurse that the nhnve information is
BUILDING FEE
- -
QTY. MECHANICAL PERMIT FEE
correct. l agree to comply with all city and county ordinances and state laws relining to
building v.mlamthm, and hereby mahee rcpmsentalivcs of this city to mear upon the
SEISMIC FEE
aMve-mentioned property for inspection purposes.
(We) agree it rave, indemnify and keep hamdass the City of Cupertino again,,
PERMIT ISSUANCE
ELECTRIC FEE
A[;LER OR ADD TO MI3CH'
PLUMBING FEE
Iiabililics,judgmems,ennsandexpeme& which may many wayaccmeagaina,did Ci,y
in rix pundeeofthe graming ofthis Permit.
AIR HANDLING UNIT (TO 10,0(0 CFM)
MECHANICAL FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER I0,000 CFM)
CONSTRUCTION TAX
Signature of ApplicantlConnctor Doc
IAZARDOUS MATERIALS DISCLOSURE
EXHAUST HOOD(W/DUCT)
HOUSING MITIGATION HE
HEATING UNT!(TO 100,000 BTU)
Will the applicant or future huilding occupant store or handle haamdnix material
as defined by the Cupertino Municipal Cede. Chapter 9.12. and the Health and Safety
Code. Section 255320)?
1117ATING UNI'[ (OVER IIXLDXI RTU)
E] Ya,
which
Will the applicant or furore building by the B use ea Air
lor ily Management
emit haennloua air tnmvminuna ux defined by the Pay Area Air Quvllry Munagunenl
U1101n^
C] Yes �Nn
PAID
VI3N'1'ILAT'ION FAN (SINGLE RC.SIO)
Date Receipt#
BOILER -COMP (3HP OR 100.00l
TOTAL
BOILF.R -COMP (OVER 1 W.OW BTU)
AIR CONDITIONER
I have rued,hv h' vNom •enol, ruryiremena nodes, Chupmr 6.95 of the Culi-
ISS T8
NEW RESIUI3N'1'IAI. 511iCH, SQ. FT.
foetid I lealth & Saf r m,In s 2550 A 33 and understand that if the
M1uiln dmmex not eat ant that it my iliry minify thadem�ypanl
aRherc man per ifiamydFtJ
�+-I—
Ow m - Data
V
ISSUE
TOTAL.
OFFICE