28754%PPLICANTTO FILL-IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL
BUILDING DIVISION APPIACATION/PERMIT PLUMBING -MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: �J .� G 0,0& tT Xie
/01D/ To,� E ��I
OWN R'S NAME: PN E: I CONTRACTOR'S NAME: LIC NO:
O
AR ECI'IPNGINEER: ` LIC O' /� � DD 5
'ONTAC,.. PHONE: •' G
/M�fA9, ❑ Consultant Fees Paid by Applicant (Initial) _
LICENSED CONTRACTOR:grDECLARATION
I hereby aftirn that I am licensed under provisions of Chapter 9 (commencing
ction 7000) of Division 3 oftbe Business and Politicians Code, and my license is
ace and effect.
be
GW 6 1 hereby affirm that I um exempt from the Contmemes License Low for the
0.0 following reason. {Section 7031.5, Business and Professions Cale: Any city or county
=O which requires a permit to construct, alter, improve, demolish, or repair any structore
primmiu ismans ,alsorcsione. dre.pplicras forsuch pemti a,file asignedsu¢ment
p. that he is licensedpurmantIn the pawisionsofthe Contmcmr's License Law(Chapmr9
CSO (commencing with Section 7")of Division 3 ofhe Businessand Professions Code)or
C Nes he is exempt therefrmn and the hails for On alleged exemption. Any violation of
y Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
ZQroot more than five handled dollars ($50 0),
❑I,six owner of Ne pmpcny, or my employees with wages as their sale compensation.
will do the work, and the someone is not intended or offered for sale (Sec. 704,L Business
i� and Professions Code: The Contractors License Law dors not apply to an owner of
Y 3 property who builds or improves thereon, and who does such work himself nr through
his own employess, provided that such improvements are not intended or offered for
sale. If, however, the building or improvement is sold within one yearof completion, the
neo -builder will have the burden of proving Nat he did not build or improve for Fur -
pose classic.).
❑ 1, as owner of the pfoperty, am exclusively contracting with licensed contractors to
construct me project (Sec. 7044. Busineax and Professions Code:) The Contractor's Li-
een.se Low diva not apply to an owner of property who builds or imposes thereon, and QTY.
who contracts for such projens with a comiracrofs) licensed pursuant o the Contractors
License Law.
❑ I am exempt under Sec. ,B& P C for this masnn
Owner Don
WORKERS COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a Certificate of Consent to xelbinsure for Workers Compere
sailor, as provided for by Section 3700 .1 the Libor Cale, for Ne ped'ormance of the
work for which this permit is issued.
❑ I have and will maintain Worker's Compensation Insurance, as required by Section
37M of the Labor Cade, for the performance of the work for which this permit is issued.
My Workers Compensation Insurance canief and Policy number ore:
Comer: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
('Phis sectile aced nm hecompleted tithe permit is for onehimulmsidullana($100)
or less.)
I cenify that in the Performance of the work for which this permit is issued. I shall
not employ any person in any man subject re
manner so as to become subjeco the Workers Compe
Z seldom Laws of California; Data
zQ Applicant
Tjy NOTICE TO APPLICANT. If, after making this Cernificme of Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Code, you must
Wforthwith comply wits such provisions or this pcmmii shall he deemed revoked.
Q
CONSTRUCTION LENDING AGENCY
V Q Ifarlicachy which
thatmrthi issued(Suninn len ding agency {orbs perfmrnance of
W 1" the work for which this permit is issued (tiro. 3097, Co. C.)
ULender's N:une
Lenders AJdrcss '
04 I certify that 1 have read this application and state that the above information is
LO) correct. l agrx to comply with all city and county ordinances and state laws reining to QTY.
U building construction, and hereby ordnance reposetatives of this city to enter noun the
above-mentioned property for inspection popums.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities, judgments, coxa and expenses which may in any way ,cane against mid City
in consequence of the granting of this pemak.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NONI'OINT
SOURCE REGULATIONS.
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant stow m handle hazardous materiel
as defined by the Cupertino Municipal Code, Chapter 9.12, and the I lealth and Safety
Code, Section 25532(a)7
F] Yes [I No
Will the applicant or future building occupant use equipment or devices which
mit harallous air contaminants as defined by the Bay Area Air Quality Management
District?
C] Y. C] No
I has all the hoz rat lila reui under Chapter fi 95 of the Cali.
fomite wSafetY Cath25505' . 53J and 25534. 1 yadersmad that if the
ELECTRIC PERMIT
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL
PANELS
UPT0200AMPS
201.100AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC.
TEMP. METER OR PO
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS-SVy'(rC FS- X3
NEW RESIDENTIAL BI/CTR
PERMIT
BACK ROBACK PROT��:VICE-
DRAINS-ELO OOE ,COND.
FIXTURES -PER TRA
GAS -EA. SYSTEM -I INCA LETS
GAS- EA. SYSTEM -OVER 41EA)
GREASEANDUSTRL WASTE. INTERCEPTOR
GREASETRAP
SEWER -SANITARY -STORM EA. 200 FT.
WATER HEATER WNENT/ELECTR
WATER SYSTEM/TREATING
WATER SERVICE
NEW RESIDENTIAL PLMB. SQ. FT.
MECHANICALPERMIT
PERMIT ISSUANCE
ALTER OR ADD TO MECIL
AIR HANDLING UNIT (TO 10.000 CFM)
AIR HANDLING UNIT (OVER 10.000 CFM)
HEATING UNIT (TO 100,000 BTU)
HEATING ON] 'I(OVER 100,010 BTU)
VENTILATION FAN (SINGLE RESID)
BOILER -COMP (ME OR 1 W Ik0 BTU)
BOILER -COMP (OVER 100,(KK) BTI)
AIR CONDITIONER
NEW RESIDENTIAL MECH. SQ. FIL
OFFICE
FEE
FEE
oll 28754
ATION SUBMITTAL DK.
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JOB DESCKIVIIUN
RESIDENTIAL,
❑SFDWL ❑ KITCHEN REMODEL
❑ADDITION ❑PLUMBING RE -PIPE
❑MULTI -UNIT El STRUCTURAL
MODIFICATION
INTERIOR, ❑CHIMNEY REPAIR
IMPROVEMEREMyN:h p
OBgT�HaODEVREOR [IDEMOLITION
�
NEWBLDG%ADd❑DEMOLITION
TENANT k OFOODSERVICE
IMPROVEMENT
❑ OTHER
SQ, FT FLOOR AREA $/SQ. PC
#r941$40,
Vn ItIMIDIB
SYiI31as
BUILDING DTVI BUILDING DTVI. NkERS
PLANCHECKPLANCHECK FEE
ENERGY FEE
GRADING IEE
SOILS FEE
PAID
Data Receipt#
BUILDING FEE
PEE SEISMIC PGE
ELECTRIC FEE
PLUMBING FEE
MECHANICAL FEE
CONSTRUCTIONTAX
HOUSING MITIGATION FEE
PAID
Date Receipt
Ir