S 1073 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBINr.-MECHANICAL S 1073
BUILDING PROJECT IDENTIFICATION
�IL\DINGADDRESS: E
� SANITARY NO. APPLICATION SUBMITTAL DAT
rrou •L2
O ER'S NAME: PHONE: CONTRACTOR'S NAME: LIC NO: 40
NIC CONTROL#
ARCHITECTENGINE fE LIC NO: ADDRESS: _ ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) LUG ELECT PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
WON withSection 700T.f Division 3 oflhe Business and Professions Cade,and my license is PERMIT ISSUANCE RF ID�TIAL:
Fly.. in full force and effect. ❑SFDWL ❑KITCHEN REMODEL
TUU License Class Lia# APPLIANCES—RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE
y 0. Date mn
Caecmr
ARCHITECT'S DECLARATION ❑MULTI-UNIT El STRUCTURAL
PANELS
I undersmnJ my plans shall he used as public record.. MODIFICATION
0'y GUP TO 200 AMPS 11 INTERIOR El CHIMNEY REPAIR
Licensed Professional 20i-I"AMPS IMPROVEMENT ❑SWIMMING POOLS
Y OWNER-BUILDER DECLARATION OVER["AMPS - � ❑BATH REMODEUREPAIR ❑DEMOLITION
C 1 hereby affmn the I am exempt from the Contractors Ca License Law for the
- aFF
following rensoa(Section 9 construct,
Business and Professions Cade:Any oily tor county SIGNS ELECTRICAL ❑OTHER�� `
which requires a permit m e.nsnmcn,alter,improve,demolish,or repair any swcwre
un prior to its issuanceniumen
,also requires the applicant for such peno file a signed statement SPECIAL CIRCUIT/MISC.
y� that he is licensed pursuant..the provisions ofthe Contractors License Law(Chapter 9
(commencing with Section 7000)of Division 3 ofthe Business and Professions Code)or 'TEMP.METER OR POLE INST COMMERCIAL:
d y m ev that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑ BLDG/ADDITION ❑DEMOLITION
in li Section 7031.5 by any applicant for apennit subjectsthe applicant..a civil penalty of POWER DEVICES
51,1, ANT ❑FOOD SERVICE
ASOnot marc than five hundred dollars($500). IM VEMENT
❑1,as owner ofthe property,or my employees with wages as their sale compensation, SWIMMING POOL ELECTRIC
will do the work,and the structure is not intended oroffered for sale(See.70,14,Business ❑OTHF,R
and Professions Code:The Contractor's License Law does not apply.o an owner of OUTLETS—SWI'TCHFS—FIX'TURPS
C property who builds or improves thereon and who does such work himself or through
his own employees,provided that such impmvemenes are not intended or offered for NEW RESIDENTIAL ELECTS SQ En
colo.If.however.the building or improvement is sold within(me year ofeampletion,the SQ.E.FLOOR AREA $ISQ.ET.
owner-builder will have the burden of proving that he did not build or improve for put-
Poseofcale)�
❑1,as owner of the properly,am exclusively contracting with licensed c„ntmanrs to TOTAL:
construct the project(Sec.7040,Business and Prol'eadone Coi The Connector's Li-
cerise
i-c se Law does not apply to an owner of property who builds or improves thereon,and QTY, PLUMBING PERMIT FEE 4 /,D
who summers I'm each pmjects with a cwnuannrN)license pdratualw the Codirector's A
License La, PERMIT ISSUANCE
L] m ^/ �I I aexempt ander Sec. .B&P C ounhia reamn I. Rift� i.B
Owner Dulo r ALTER—DRAIN&VENT—WATER CA) j. VALUA
WORK 'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm under penalty of perjury one of the foll.wing declaations:
�❑I haveandwill maintain a Certificate of Consent to self-insure for Worker's Compen- DRAINS—FLOOR.ROOF,AREA.CONOSTORIES - YPECONSTRUCTION
sation,as provided for by Section 37M ofthe Labor Code,for the performance ofthe -
work for which this pemnilisissued. FIXTURES—PER TRAP
❑I have and will maintain Worker's Compensation Insurance,as required by Seniors
37W ofthe Labor Code,for the Performance ofthe work for which this permit is issued. GAS—EA.SYSTEM-I INC:4 OUTLETS
OCC.GROUP APN
My Worker's Compensation insurance carrier and Policy number are:
Cartier Policy No.: GAS—EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFJINDUSTRI.WASTE INTERCEPTOR
(This section need not be completed tithe permit is formic hundred dollars($100) BUILDING DIVISION PE65
'.r less) GREASE TRAP PLANCHECK FEE
I ecifty that in the perl'.nnance ofthe work for which this permit is issued,l shall SEWER—SANITARY—STORM EA.200 FT.
not employ any persan
on in y manner so as 1.become subject no the Workers'Compen- ENERGY FEF.
',Z cation Lawx.f Califomia.Date WATER HEATER WNENT/ELECTR
Applicant i GRADING FEE
NOTICE TO APPLICANT If,after makingthis Cenificatn of Exemption, should
ti p ion,you s.0 WATER SYSTEM/I'REATING
abecome subject to.it W.dm'a Compensation provisions of tde Labor Code,you mush SOILS PP.F.
L1a fonhwiN comply with such provisionsnnhis permit shall be deemed rcvokeJ. WATER SF.RVICF.
Q
CONSTRUCTION LENDINGAG agency NEW RESIDENT IAL PLMB. SQ.FT PAID
C].I I far by which thi that Formic lo,ded(Seeconstruction0 lending agency for the performance of Daae Receipt#
the work for which this permit is issue(Sen 3097,Civ.CJ
OF LenJerx Name TOTAL:
{UTa lender's Address TOTAL:
I codify that I have read this application and state that the above information is BUILDING FEE
Qn sorted.1 agree 1.comply with all city and county oNinarces and slab Iowa relating 1. QTY. MECHANICAL PERMIT FEE
V Z building csmemlction,and hereby authorize representatives of.his city to onto,upon the SEISMIC FEE
shove-mentioned progeny for impoei.m purPscs.
(We)agree to save,indemnify and keep harmless the City of Cupertino against PERMIT ISSUANCE ELECTRIC FEE
liabilities,judgments,costs and expenses which may in any way accrue against said City AEHRORADDTOMECIL
in onscquence of the granting of this permit. PLUMBING PEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) MECHANICAL FEE
SOURCE :C EATIO .
3W2
O A AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
/ Sig azure of Appica omracmr S DISCLOSUate EXHAUST HOOD(W/DUCD HOUSING MITIGATION FEE
AZARDOUS MATERIALS
Will the applicant or future Wilding occupant store or handle hazardous motorial HEATING UNIT(TO 100.000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532m)9 HEATING UNIT(OVER 100,000 BTU)
❑Yes ❑No VENTILATION FAN(SINGLE RLSID) PAID -`
Dm. -Receipt#
Will the applicant.,future building occupant use equipment or devices which
emit htzerdous air contaminants as defined by the Bay Area Air Quality Management BOILER—COMP(JHP OR 100,000 BTU) -
TOTAL:
Dlsulc.7
E]Yes C]No BOILER—COMP(OVER 100,000 BTU)
I have read the hazardous materials requirements under Chapter 6,95 of the CA- AIR CONDITIONER ISSUANCE DATE
from Health&Safety Code,Sections 25505,25533 and 25534.1 underswnd that find, NEW RESIDENTIAL MECH. SQ.!T.
building doe,mol awardy have a levan.,Nat it is my rcspmsibility Initially the wcapmnl
ofthe requirements which must he me,prior to issuance of a Certificate of occupancy.
Ownermauthnrizedagenl Date TOTAL ISSUED BY:
OFFICE