30572 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. 3 O rVl2
7
'BUILDING DIVISION ' APPLICATION/PERMIT PLUMBING-MECHANICAL _ I L
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS. .SANITARY NO. APPLICATION SUBMITTAL DATE
OWNER'S NAME: PHONE: CONTRACTOR'S NAME: LIC NO: -
.-O 6 - N/C - CONTROL M
1 HITECT/E INE fti - - LIC NO: ADDRESS: ' !Lb, ❑ ��
CONTACT: PHO E: 5 - BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) B EK PLUMB MECH
Z ❑ ❑-..
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE -
I hereby affirm that I vn licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
WOO with Seen..7000)of Division 3 of In,Business and Professions Coda and any license is RESIDENTIAL: .
I" in full force and effect. - PERMIT ISSUANCE ❑SFDWL - ❑KITCHEN REMODEL
�J Contractor License Claes
Fr Conor APPLIANCES-RENTAL
ESIDI '
Ful Date'' actor ❑ADDITION [3 PLUMBING RE-PIPE
tN-FDh ARCHITECTS DECLARATION ❑MULITUNIT ❑STRUCTURAL
Z O-3 1 understand my plans shall be used as public records PANEfS ! MODIFICATION
O z UP TO 2M AMPS ,�/
P4 Licensed Professional LSINTERIOR El CHIMNEY REPAIR
peek' OWNER-BUILDER DECLARATION 201-1110AMPS /,' IMPROVEMENT
I hereby affirm that I am exempt from the Contractor's License Law for the OVER 1000 AMPS - ❑BATH REMODELREPAIR 0 DEMOLITION
t7yC O 0.V following reason,(Section 9031.5,Business and Profession,Code Any city in county SIGNS ELECTRICAL ❑OTHER
W 4 O I, whichrrequires a permit to construct,alter,impmv0.demolish,or repair any announce
y prior to its issuance,also requires the applicant for such permit In file aligned statement SPECIAL GIRGDIT/MI$G.
} that heis licensed pursuant o the pmsounisoflhe Camucmrs License Law(Chapter 9
(commencing with Section 7")of Division 3 ufthe Business And Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL:
dolt he is exempt therefrom and did basis for the alleged exemption.Any violation or ❑NEW BLDG/ADDITION ❑DEMOLITION
_LL, Section 7031.5 by any applicant for a permit subjects the applicant a civil penalty of POWER DEVICES ��,,�
H LlIENANT - ❑FOODSERVICE
'Z not more Nen five hundred dollars($500).G IMPROVEMENT
❑ has owner of the propcny,or my employees with wages as their Bole compensmion, SWIMMING POOL ELECTRIC - w - -
CC will do the work,and the structure is not intended oroffand fur sale(Sto7044,Business ❑OTHER
W� and Professions Code:The Contractor's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES C
n' properly who builds or improves Hereon,and who does such work himself or through '
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ FT.
sale.If.however,the building or improvement is sold within one yezrofaxmpielion.the SQ.IT.FLOOR gRF.Ah $ISQ.FT.
owner-builder will have the burden of proving that he did not build or improve for pur- SED 2 4 1UJ1J1 V
poseofaale.), GIS
❑ 1,as owner of the pmpeny,am exclusively contracting with licensed eontrachav o, TOTAL:
commit,me Project(Sea 9044,Business adeProtµessiore Cole:)The Conductors Li- QTY PLUMBING PERMIT FEE 0 Y Vi kaV('1-ltluvJ
u Law does nota I man owner of n who builds or improves thereon,and
who contracts for such projects with a cold ichads)licensed pursuant to the Contractor's -
License Law. PERMIT ISSUANCE
I am exempt under Sec, ,B&P C for this reason 1
Owner
ALTER-DRAIN&VENT-WATER(EA)
Dmc VALUATION
'
WORKER'S COMPENSATION DECLARATIONBACK FLOW PROTECTDEVICE
1 hereby affirm under,penalty of perjury dna of the following declautiuns: .
❑'I have and will maintain a Certificate ofConsenno self-insure bu Worker's Compen- DRAINS-FLOOR,ROOF AREA,COND.
sation,as provided for by Section 37M of the Labor Code,for the performance of Na - STORIES TYPE CONSTRUCTION
work for which Nis permit is issued. FIXTURES-PER TRAP
❑I have and will maintain Workers Compensation Insurance,as required by Section
370af Ne Lahr Code,Ends,perld�umaceofthe work forwhicb thispermit is issued, GAS-EA SYSTEM-1 INC.4 OUTLETS OCC.GROUP / APN
My Worker's Compensation Insurance carrier and Policy number are: -
Carrier: Policy No.: GAS-EA.SYSTEM-OVER 4(EA) - -
CERTIFICATE OF EXEMPTION FROM WORKERS'
,COMPENSATION INSURANCE GREASUINUUSTRL WASTE INTERCEPTOR BUILDIIJ4DWAON FEES
This section need not becompleted iflhe permit is forone hundreddollars($100) GREASE TRAP.
or less.) * PLANCHECK FEE a �
I certify that in the performance of Ne work for which this permit is issued.i shall SEWER-SANITARY-STORM EA.200 FT
not employ any person in any manner so as to because subject to the Workers'Compen- - ENERGY E
0�.. action Laws of Califomia.Date mWATER HEATER W/VENTIELECTR FE
Applicant GRADING FEE
rjl NOTICE TO APPLICANT:If,after making this Cal ificam of Exemption,you should WATER SYSTEM/TREATING
F'! become subject m isi
the Workers Compensation provons of Ne Labor Code,you must SOILS FE
WW forthwith comply with such provisions or this permit shall be deemed mvoketl: WATER SERVICE
UQ CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB, SQ.FT. PAID'
0 (hereby affirm that there is a construction lending agency for the perfrrnance of Dale Receipt#
GLH the work for which this permit is issued(Sec.3097,Civ.C.)
O Lenders Name TOTAL:
V
W Lendels Address _ TOTAL:
Cy 1 cerify that I have read this application and emte that Ne above information is - - BUILDING F4
ycornet.I agree to comply with all city and county ordinances and state laws relating m QTY, MECHANICAL PERMIT FIE -
V building construction,and hereby authomm represenmtives ofthis city mouser upon he SEISMIC FE
shove-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino"against ELECTRICP
Iiabililies,judgmenls,costs and expenses which may in any way acemeagainst said City ALTER OR ADD'TO MECH. PLUMBING FEE
in consequence of she granting of this permit. _ '
APPLIC,IT U 1QERSTANDS AND WILT -OMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) -
SOUR tTiG sTIO S, MECHANICAL FEE
-� AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCITONTAX
Slgaamre dApplicarucantractor Date EXHAUST HOOD UVMUCT) HOUSING MITIGATION FEE
HAZARDOUS MATER S ISCLOSURC
Will the applicant or future building occupant store orhandle hazardous material HEATING UNIT ODD 100,000 BTU)
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
Code,Section 255320)? - HEATING UNIT(OVER 100,000 BTU)
❑Yes 'r .
VENTILATION FAN(SINGLE RESID) PAID
� Date Receipt q
Willthe applicant or furore bullNngo the
useequipAir QualitI more or y
deviceswhich
BOILER-COST(3HP OR 1(0,000 BTU)
mithazardnps air contaminonss as defined by the Bay Area Air Quality Management TOTAL:
Distrito" .L-1.W..'O// BOILER-COMP 100,000 BTU)
❑Yes ,.
I have read the hazardous materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
fnmin Health&Safety Code,Sections 25505,25533 end 255341 understand that if the NEW RESIDENTIAL,MECH. SQ.FT.
ad Id cesnot urren0y aveamnan,Nat it is responsibilitymnntify the occupant
of tho ulry a swhle ass be ri0,to is o[a CerIOcate a Ocau onoy '
n thorimd agent Dam !4 TOTAL: ISSUED Y.
OFFICE