99110105 (2)APPLICANTTO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING ELECTRICAL PERMIT NO. a
BUILDING
DIVISION APPLICATION/PERMIT PI.UM[SIN GMI-CHANICAI.......
PHONE:
❑ Consultant Foes Paid by Applicant (Initial)
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LICENSED CONTRACTOR'S DECLARATION
1 herchy affirm mm 1 am licensed under provisions cf Chapter 9 (commencing
with Section]0(p)nf Division3of the Business end Professions Qrde,andmylicenseis
in full force ante /
Licen I P- I Lic
Did,C
ARCHITECTS DECLARATION
1 understand my plans shall be used as public records
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PERMIT ISSUANCE.
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1 -4,1" -IA
Licensed Roressiomd
FEE
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OWNER -BUILDER DECLARATION
1 nanny from that I um exempt rrnm the Contractor's License Law for the
fallowing reason. (Section 7031.5. Business and Professions Code: Any city or county
AIR HANDLING UNIT (OVER By" CFM)
CO TRU6LIONTAX
n13 Y. F'
Fp„I�,O`3
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iX rrv,d�
which rcyuircs o permit to cnnswct, alter, improve, demolish, or repair any structure
prior to its iexmorce. also reyui res theapplicam for such permit o file a signed statement
that he is l lensed pursonnuo the. provi6msaf the Cmtochd's License Law (Clarifier 9
(commencing with Sedlnn7000)orDlvisiom3ol'the Business and Rofessions Code)nr
that he is a erola therefrom .,,it tint basis for the alleged exemption. Any violation of
HEATING UNIT LTO 100.000 BTU)
HEATING UNIT (OVER 100,000 BTU)
N
Seetinn 7031.5 by any appllcnm for a permit wM1jmte the opplwaa m a civil penalty of
Data Receipt#
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not nmre than Eve hundred dol lura (SNXW
my adntendes with wages cathed(rale compensation,
Lo the work( the
will dm the work, and the he Cma is not intended or offered for sale (Sec. ]BM, Badness
numerate
Gale: The C ,finemor, License Luo does not apply s if owner of
and Procry who
b his own who wilds m improves thenen, and who does such work himself or mroagb
his own employees, building intended or oRercd for
such num
BOILER - COMP(OVER 1110,000 BTU)
Ne ild mi ou me
rim i.s soldwithinone yearr fiawrimprove
sale. If,oilder
/1 ,aISSUANCE DATE
/ / 3 - e
ISSUED
'
ithebuildingnren(if proving
nerhuilgerwillhave the burdennfprovingthat hedid nmhuildorimprveforpur-
TOTAL:
OFFICE
pose of sale.).
❑ 1, as owner of the proper% am exclusively contracting with licensed comrac ors to
cnmwct Ne project (See. ]fed, Business and Pmm,, mos Cade:) The Consent, s la-
pselawdoesnotapplytuanownerofpropetywhobuiWsorimprovesthemose,and
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who contracts for such prjects with a conametorts) licensed Eastern to she Contrastors
License Law.
❑ I am exempt under See. , B & P C far this reason
r Date
WORKERS COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
1 have and will maintain a Cenificam of Consentto self -insure for Worke's Campen-
xation, as provided for by Section 3700 M the Labor Code, for the performance of the
wok for which his permit is issued.
�1 have and will maintain Worker's Compensation Insurance, as rcyuied by Section
3700 of the Labor Code, for the performance of the work for which this permit is issued.
My Wmm,e ptmymmylatioml 1ps�nOcepgrrier and Policy nypmberr�g:e O OD'Of
Cartier {[/f1C%L�I IJ IJ Policy No.: [J41�.1�
CERTIFICATE Olt EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This sectlnn neer) not be cnmplelW if the permit ix hxnnm hundred dollars ($1007
orlessJ
I certify that in she peromance ol'the work for which this permit is issued. I shall
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non employ any persm
on in any anner so as to become subject to the Worker: Compen-
anion Lowsof GJilincor Dam
Applicant
NGFICB TO APPLICAN'L IL after making this Cenificatc of Exemption, you should
become subject to the Worker', Cmapensation provision, of the labor Code, you most
fonhwim comply w hh such provisions or this permit shall he deemed revoked.
Cie, S Ithe ix.I.ON LENDING AGENCY
agency for rhe performance of
I far. Inch std hnnhere issued( (Sec. 3097,
he work for which mix permit is issue) (Sec. 3p9], Ci, C.)
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CA
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Lender's Name
LcndeYS Address
at that above information is
1 recify that I have mapplication wd side theov
ad this
co. I agree to Comply with all city and county o xirwmees and state laws relating to
mm
building combustion, and hereby authorizer repmumatives ofthis city m enter upon the
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above-mentioned property for inspection purposes.
(We) agree m sa' , indemnify and keep harmless the City of Cupertino egaimt
liabilities, judgments. mend expenses which may in any way accroe against said Ciry
A canuyuNT of gut 'N StAIs prono.
APPIJCANT 1F ND W1M. COMPLY WITH ALL NON -POINT
.gTMim of ApplicaMC,4,,Wi —1 - - Data
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hasallous material
as deputed by he Cupertino Municipal Cade. Chapter 9,12, and she Health add Safety
Cade, Section M532m)'t
❑Yea bNn
Will the applicant or future building occupant use equipment or devices which
mit hazardous air contaminants as defined by the Bay Area Air Quality Management
District?
❑ Yes %dNo
I hove reed hunt snvnerinLs rcyuirenmms under Chapter h95 of the brain Health ,fee la : bio 25. and 25536. 1 unJersmnJ mm if the
builm�ftgJre n ly earn utf ncihilitymnmtiry the mcupant
ELECTRIC PERMIT
PERMIT ISSUANCE
APPLIANCF_S - RESIDENTIAL
PANELS
UP TO 200 AMPS
SIGNS ELECTRICAL
SPECIAL. CIRCUITIMISC.
TEMP. METER OR POLE INST.
POWER DEVICES
SWIMMING POOL (ELECTRIC
OUTLETS - SWITCHES -FIX]
NEW RESIDENTIAL EI.
SQ En
PLUMBING P�;RM
PERMIT ISSUANCE
ALTER - DRAIN & VENT - WATER (EAP
BACK FLOW PROTEC'E DEVICE
DRAINS- FLOOR, ROOF. AREA, COND.
FIXTURES - PER TRAP
GAS - EA. SYSTEM -I INC.4 OUTLETS
GAS - EA. SYSTEM -OVER 4 (EA)
OREASETNDUSTRL WASTE. INTERCEPTOR
GREASETRAP
SEWER -SANITARY -STORM IEA. 200 FT.
WATER HEATER W/VENT'/BLECTR
WATER SYSIHMO EATING
WATER SERVICE
NEW RESIDENTIAL PLMH. SQ. PT
�9
SQ. FT FLOOR AREA
FEE
VALUATION
1� 0(09, o It
STORIES TYPECC
OCC. GROUP
BUILDING DIVISION FOES
PLANCHECK FEE
ENERGY FEE
GRADING FEE
SOILS FEE
PAID
Data Receipt#
MECHANICAL PERMIT FEE
SE II HE
PERMIT ISSUANCE.
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
❑ Ely74 ❑
PL
FEE
JOB DESCRIPTION
R .cIF_, _D_ NE TIA1
❑SFDWL El KITCHEN REMODEL
❑ADDITION ❑PLUMBING RE -PIPE
❑MULTI -UNIT El STRUCTURAL
MODIFICATION
C3 INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT E] SWIMMING POOLS
❑ BATH REMODEL/REPAIR ❑ EMOLITION
HE q, AfKR
��4l6P �.tY
ME HANICAL FEE
AIR HANDLING UNIT (OVER By" CFM)
CO TRU6LIONTAX
EXHAUST HOOD I W/DUCT)
HOUSING MITIGATION FEE
HEATING UNIT LTO 100.000 BTU)
HEATING UNIT (OVER 100,000 BTU)
PAID -
COMMERCIAL:
❑NEWBLDG/ADDITION ❑DEMOLITION
❑TENANT ❑ FOOD SERVICE
IMPROVEMENT
❑ OTHER
Data Receipt#
BOILER - COMP QHP OR 100,(1(111 BTU)
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TOTAL: V
SQ. FT FLOOR AREA
FEE
VALUATION
1� 0(09, o It
STORIES TYPECC
OCC. GROUP
BUILDING DIVISION FOES
PLANCHECK FEE
ENERGY FEE
GRADING FEE
SOILS FEE
PAID
Data Receipt#
MECHANICAL PERMIT FEE
SE II HE
PERMIT ISSUANCE.
EL .DUCUnV 18 9
ALTERORADDTOMECH.
PL
GING FEE
AIR HANDLING UNIT TO By" CFM)
ME HANICAL FEE
AIR HANDLING UNIT (OVER By" CFM)
CO TRU6LIONTAX
EXHAUST HOOD I W/DUCT)
HOUSING MITIGATION FEE
HEATING UNIT LTO 100.000 BTU)
HEATING UNIT (OVER 100,000 BTU)
PAID -
VENTILATION FAN (SINGER RESID)
Data Receipt#
BOILER - COMP QHP OR 100,(1(111 BTU)
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TOTAL: V
BOILER - COMP(OVER 1110,000 BTU)
AIR CONDITIONER
/1 ,aISSUANCE DATE
/ / 3 - e
ISSUED
NEW RESIDENTIAL MUCH. SQ. FT.
TOTAL:
OFFICE