S 0040 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - BUILDING-ELECTRICAL w .. PERMIT NO
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL Soul to
BUILDING PROJECT IDENTIFICATION •�7 pJIV/�LV
BUILDING ADDRESS: - SANITARY NO. APPLICATION SUBMI ITAL DATE
OWNE pIAMF P NE: , CONTRAC'TOR'S NAMG: LIC NO'. 5--3 NIC CONTROL#
ARCHIT7ENGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: - BUILDING PERMIT INFO
El Consultant Fees Paid by Applicant(Initial) BLDG ELE PLUMB M,.E-�Cf{�
❑ EIMJ
LICENSED COMAACTOR'S DECLARATION QTY, ELECTRIC PERMIT FEE
I hereby union that 1 atm licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
MW OZ with Section 7000)of Dlvlelon 3nfthe Business and Professions Code.and myllcensc is PERMIT ISSUANCP. RPNIDFNTIA1'
F to full foreeaad effort. OSFDWL D KITCHEN REMODEL
QUQ License Class Lie.#
yQL Date Contract., APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBINGRE-PIPE
ARCHITECTS DECLARATION PANELS El MULTI-UNIT []STRUCTURALZ O TOO Za I understand my plans shall he used as public records
y MODIFICATION
' UP T02W AMPS
N ❑INTERIOR DCHIMNEY REPAIR
F�1""t�i Lmensed Professional 201-IMOAMPS IMPROVEMENT 0SWIMMING POOLS
Sy^,<' OWNER-BUILDER DECLARATION OVER 1000 AMPS ❑BATH REMODEL/RF.PAIR D DEMOLITION
C t I hereby nRrm on 1 um exempt from the Contractors C'x License Law for me
ipyx5. L U following reason.(Section]0315.Rosiness and Professions Cale:Any city or county SIGNS ELECTRICAL ❑OTHER
t++�O 0Q which requires a permit m amuruct,slmq improve,demolish,or repute any structure
N rl prior to is counter,a) requires the applicant for such permitta file ad,rudymlemeal SPEC IAL CIRCUIT/MISC.
S y that he is licensed pursuant the provisionsof the Contractors License Law(Chapter 9
�C) (commencing with Section 7000)of Division 3 of The Business and Professions Code)or TEMP.METER OR POLE DIST. COMMERCIAL
d{y m y
that he is exempt merefmm and the basis for the alleged exemption.Any violation of "❑NEW BLDG/ADDITION D DEMOLITION
W
Section IF'L5 by any applicant for.,permit 100,111.c the applicant m a civil penalty of POWER DEVICES
y not more than five hundred dollars($500) ❑TENANT El FOOD SERVICE
�=0a ❑I,as owner ofthe property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC PROVEMENT
��. will do the work,and the snrome is not intended omRered for sale(See,7044,Business T R _
¢1 and Professions Code:The Conanemrs Liconso Lew does not apply to an owner of OUTLETS,-SWITCHES-FIXTURES
property won build,,,,improves thereon,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 withlnone yearof cnmplefitatme SQ.FT.FLOOR AREA $ISQ.Fr.
mictun-laildec will have the burden of provimg that he did a.[build or improve far per,
or sale.),
of the propary,um exclusively concealing with licensed emonoetars m TOTAL
14torn the project(Seo.7044,Business and Professions Cndep The Cnntmetor's Li- F
couse Law does not apply to an owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT FEE
who contracts for such projects with a contractor(&)licensed pursuant to the Convector's
I'ens.Law. PERMIT ISSUANCE
Ism exempt undfaer Sec. ,B&PC dn'rcamn
Owner Da � _ AUfER-DRAIN&VENT-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm under penalty of perjury one of the following declarations:
❑ I have and will mandern a Cenificate ofComcenua self-insure for Worker's Compen- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
sation,as provided for by Section 3700 of the Labor Code,for the performance of the
work fo,which this permit is issued. FIXTURES-PER TRAP
❑I have and will maintain Workees Compensation Insurance,as required by Section
37W of tlm Labor Code,for the folomnonce of the work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS
OCC GROUP APN
My Worker's Compensation Insurance caniez and Policy ovmher are:
Cvraer: Policy No.: OAS-EA.SYSTEM-OV ER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' Aot
COMPENSATION INSURANCE GREASE/INDUSTRI.WASTE INTERCEPTOR
(This section need not he wmple¢dif thepermit is[ar ane hundreddellers($1(10) ING DI 1�1DN PEES
or less.) GREASETRAP PI ANCHECRR FEE `
I Certify that in theperformur,caflhe weak forwhich thispenmit is issued,l shall SEWER-SANITARY-STORM EA.2110 FT is
net employ any person in any manner so tem hecome maject o the Workers'Compen- ENERGY FEE (,
Z .cation Laws of California.Date WATER HEATER WNENT/F.LF.CTR O
Q C) Applicant t GRADING FEE C7
tiNOTICE TO APPLICANT.If,after making this Comfiaae of Exemption,you should WATER SYSTEMPMEATING
became subject to the Worker's Compensation provisions of the Labor Code,you must SOILS FEE
fonovilh comply with such Provisions ,,his pogra,bell be deemed revoked. WATER SERVICE
C6
Q
oz CONSTRUCTION LENDING AGENCY NEWRESIDENTIALPLMB, SQ.FT. PAID
V I hereby affirm that here is a construction lending agency for the performance of Date Receipt it
LL the work for which this permit is issued(Sec.3097,Cie.C.) -
o U Lender's Name O' L:
Lender's Address TOTAL:
r y I certify that 1 have read this upplieation and sate that the above informmiou is BUILDING FEE
U h correct.1 agree to comply with all city and county ordinances and stats laws relating to QTY, MECHANICAL PERMIT FEE I.
G Z building construction,and hereby authorize repreeenacives of his city to enterupon the SEISMIC FEE
above-mentioned property for inspection purpoces.
(We)agree to save,indemnify p y o R g PERMIT ISSUANCE
g y and which
harmless the Cit fp a nine i otic z �/� ELECTRIC FEE
me..ties,j repoftheSummand expenses smil. may in any way accrue against said City ALTER OR ADD TO MECIL ,kV PLUMBING FEE
onsequcnce of the groming of this pumic.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON.POINT AIR HANDLING UNIT(TO 10,000 CFM)
SOURCE REGULATIONS,
MECHANICAL FEF.
AIR HANDLING UNIT(OVER 14000 CFM) CONSTRUCTION TAX
Signature of AppllcanUCemracter Date EXHAUST HOOD ONMUCT) CONSTRUCTION
NTAXNFP.E
HAZARDOUS MATERIALS DISCLOSURE
Wlllthe applicant or future bulldiagnecupamsmrear handle hahroous mutenal HEATING UNIT(To 100,000 BTU)
ax defined by me Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? HEATING UNIT(OVER 1040()0 BTU)
❑Yes ❑Nn VENTILATION FAN(SINGLE RESID) PAID
Dale Receipt#
Will
rd the applicant arfurore building by The nt BuseaAirtent Quordeviceswhich BOILER-COMP(THPOR 104000BTU)
emit hazardous air contaminants as defined by the Bay Arca Air Quality Management TOT
Distract?
❑Yes DNo BOILER-COME(OVER 100,000 BTU)
I have read the hazmdons marededs recommend,under Chapter 6.95 of Ne Cali- AIR CONDITIONER
9 P ISSUANCE DATE
fmmia Health&SafetyCode,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH, SQ.FE ^/
building does not currently have a tenam,Fiat it is my resprmsibility inactivate ioccupant
of the requirements which must ed met prior to issuance of a Certificate of 0ceuwtncy. . 7
Owner ar authorazetragin Ilene TO ISSUED BY. "' -" - 14
OFFICE