S 0875 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
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YOIF CUPF.RTINO BUILDING-ELECTRICAL, rERMITNo'
APPLICATION/PERMIT PLUMBING-MECHANICAL S 0875
IIlILDING DIVISION BUILDINGPROIECTIDENOTIC T10 V
URDINGOADDREO/ E'er �� ` �_ /.-,/ SANITARY NO. APPLICATION SUBMII'IAL DATE
W ZNA33E:r /[J')( E: C NTRACI' R'. AME: LIC N(Y '
/ a NIC CON'1'ROLN
CHITECI'/F.NGINEER' LIC NO: ADDRESS:
CONTACT: PHONE: BUILDING PERMIT INFO
❑ ConsulWnt Feeg PBl Appli ant(initial) - BLDG ELECT PLUMB MECH
it ❑ ❑ ❑
LICENSED CONTRACTOR'S HECLARATION QTY. ELECTRIC PERMIT FEE QH DESCRIPTION
I hereby aRmm the I am licensed under provision..of Chapter 9(commencing
OW eOZ with Sectinn'BXXIIof Division lofthe BusineseaM Pmfecsions Code,andmylicenmis RESIDENTIAL•
OO PIiRMIT ISSUANCIi
CWF L ane classJeBet. ❑SFDWh OKITCHEN.REMODIiI.
<VO
License class Lick APPLIANCES—RESIDENTIAL ❑ADDITION CI PLUMBING RE-PIPE
Zip Dam Conewcmr
,isD6 [I MULTI-UNIT [I STRUCTURAL
FDy As shall ARCHITECTS DECLARATION PANELS
Z O Z 1 understand my plans shall be used as public records MODIFICATION
UP T0200 AMPS ❑INTERIOR CHIMNEY REPAIR0 ❑t3.F,LL0.41 Licensed Professional 201-1000AMPS IMPROVEMENT SWIMMING POOLS
941< OWNER-BUILDER DECLARATION OVER I"AMPS ❑BATH REMODELfREPAIR [I DEMOLITION
1 hereby affirm that I am exempt from the Contractor's License Law for the _
�y(O y V milmosing rens....(Section 7011.5,Bmmc,s and prulossinm Craft:Any city at county SIGNS ELECTRICAL OTHER
❑1 a LL F which requites v Permit to construct,alter,improve,demolish,or repair any sm¢wrc
prior to its issuance,also requires the applicant(orsuch Permit,,fileasignedatatement SPECIAL CIRCUIT'/MISC.
f N that he is licensed pursuant to the provi,mit of the Cord..ma's License Low(Chaptera COMMERCIAL:
(commencing with Scmica 7")of Division l of the Biamusand Pmfessimt Code)or TEMP.METER OR POLE INST.
a y m eG that he is exempt therefrom and the basis for the alleged exempting Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
ttXl 4• Section 7011.5 by any applicant for a permit subjects the applicant o a civil penalty of POWER DEVICES r ❑TENANT ❑FOODSERVICE
F-Z� not more than Eve hundred dollars(531X)). - IMPROVEMENT
Q ❑ Las owner ofthe property,or my employees with wages ax their sale compensation. SWIMMING POOL ELECTRIC
will do the work,and the structure is not Intended oroffered for,sale(Sec.9044.Business ❑OTHER
a 3 and Professions Cale:The Contmcmr's License law does not apply to an owner of OUTLIrS—SWITCHES—FIXTURES
property who builds or in,mi thereon,and who does such work himself or through
his own employees,provided that such imp nvemants are not intended or offered for NEW RESIDENTIAL ELECTR SQ IT.
sale.If,however,the building or improvement is sold within one year of completion.the .FT. RAREA SISQ.FT.
mvneohuilder will have the buNen of proving that he did not builder improve for Pur
to ofsalc.).
h as owner of the property am exclusively contracting with licensed conumbux In TOTAL: ` ,� A
Law
to an
owner
prop Professions Caste:i Theves thereon,Li V`7yCJ
cense Inw does not apply to en owner of property who builds or improves Condam and QTY. PLUMBING PERMIT FEE
who contract for such projects with aconwetor(s)licensed pursuant to the Commdors �®� ^�
License Law. PERMIT ISSUANCE R%I Bb
Am exempt under Sec. B&P C for this reason b
ALTER—TRAIN&VENT—WATER(EA) �CI Ur LUrtk�ALU TION
mer Date V
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT'.DEVICE
I hereby affirm under Penalty of perjury one of the following declarations:
I have and will maintain a Certificate of Comento self-insure for WorFor's Compcm DRAINS—FLOOR,ROOF,AREA,GOND, STORIES TYPECONSTRUCTION
cation,as provided for by Section 3900 of the Labor Coda,for the pcRnrmance of the
work far which this permit u Issued. FIXTURES—PER TRAP
❑I have and will maintain Workers Compensation Insurance,as required by Section
39W of the Labor Code.for the performance of the work for which this Permit is issued. GAS—EA.SYSTEM-I INC,4 OUTLETS OCC.GROUP APN
My Workers Compensation Insurance carrier and Policy number art:
Cartier: Policy No.: GAS—EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASEINDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(Thisseation need not beemapleted ifthe pemdt is intone hundmldullark SHX) GREASETRAP
or less.) PLANCIiF,CK FEE
I certify that in the performance ofthe work for which this Permit is issued.l shall SEWER—SANITARY—STORM EA.201 FT.
not employ any person in any manner co as to foreman object m the Worktop Compca- ENERGY FEE
,Z whom Laws mf Califomia.Date WATER HEATER W/VENIELECf'R
z Q Applicant ' GRADING FEE
fA NOTICE TO APPLICANT IL after making this Cenificae of Exemption,you should WATER SYSTEMOREATING SOILS FEE
a F' Mcomc shire,to the Worketa Compensation provisions of the Labm Axle,you must
i�
forthwith comply with such previsions or this permit shall be deemed revoked. WATER SERVICE
iQ
CONSTRUCTION LENDING lead AGENCY NEW RESIDENI'IA1.PLMB, SQ.FI'. PAID
V 0 1 hereby affirm that there is a construction lending agency for the Performance of Date Re pt M
the work for which this permit is issued(Sec.3097.Civ.C.) TOTAL:
QU Leaders Name
{2) Lender's Address TOTAL
Iy�As I really that 1 have read this application and state that the above it is BUILDING FE
i.+V1 comet.laa.to comply with alt city Warranty thinners un it state laws misting m Q•ry, MECHANICAL PERMIT FEE
rJ building construction,and hereby authorize representatives of this city m enter upon the SEISMIC FEE
arovmmentioned property for inspection Purposes. PERMIT ISSUANCE
(Wel agree m some,indemnify anJ kap harmless the City of Cupemiam against ELECTRIC FEE
Iiabilidesjudgments,costs and expenses which may in any way averse against said City ALTER OR ADD TO MECH. PLUMBING :E
ineonseque eofthegmniingofthisp it.
APPLICANT NDERSTANDS AN 1 COMPLY WITH ALL NON-POT AIR HANDLINGUNITITO 10,00(1CFM) MECHANICA iE
SOORCER UL IONS
/ AIR HANDLING UNIT(OVER IO,OfIII CFMI CONSTRUCTION
Si u of Applicam/Comracmt Dat EXHAUST HOOD(WMUCn HOUSING MITIGATIO E
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or l'uturc building occupant store or handle hamrdnu material HEATING UNIT(TO 100.0(111 BTU)
as defined by the Cupertino Municipal Code.Chapter 9.12.and the Health d Safety
Code,Section 255321a19 HEATING UNIT(OVER 100,000 BTU)
❑Yes ❑No VENILATION PAN(SINGLE RESID) PAID
Data Receipt or
Will the applicant or future building occupant use equipment or devices which BOILER—COMP OHP OR 101,(X10 BTU)
emit hazardous air contaminants as defined by the Bay Arca Air Quality Management TOTAL:
DiouriaP BOILER—COME(OVER 100,000 BTU)
E]yes []NO
I have read the hazardom radicals requirement under Chapter 6.95 of Ne Cali- AIRCONDITIONER ISSUANCE DATE
ramie Health&Safety Cafe,Sections 25505.25533 and 25514.1 understand that if the NEW RESIDENIAL MECH, SQ.FF.
building does not currently have a tenant,that it is my responsibility to notify the occupant
of the requirement which must Ix,met prior to issuance of a Certificate of Occupancy.
Owner or uuthoczed agentDae TOTAL: ISSUED BY:
OFFICE