99110187 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. ER
CAL
BUILDING DIVISION APPLICATION/PERMIT DNGPRPLUMBING.CTIDENTIFIC
t BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: _ SANITARY NO. APPLICATION SUBMITTAL DATE
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RCHfrECT/ENGINEER: LIC NO: ADDRESS' ❑,
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CONTACT: PHONE: - BUILDING PERMIT INFO
c` �C QOj ❑ Consultant Fees Paid by Applicant(initial) BLDG - ELECT PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT EEE JOB DESCRIPTION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing
O�,Z with Section 700fpofDivision 3ofthe Business and Professions Code,and my license is - ,RESIDENTIAL'
tsl O e PERMIT ISSUANCE
FF in toll force and effect. ❑SFDW L El KITCHEN REMODEL.
�UV License Clas Z Lic.N APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
F R Yl Dae — Convector_
.or,< , ❑MULTI-UNIT ]STRUCTURAL
,D V, ARCHITECT'S DF.CLARATI N PANELS
I understand my plans shall be used as public records UPT0MODIFICATION
GZ neO OVER 200 MPSAMP ❑INTERIOR El CHIMNEY REPAIR
r4: M License.)Pmfessinnal 201-100JAMPS IMPROVEMENT ❑SWIMMING POOLS
+y+�� .4 OWNER-BUILDER DECLARATION OVER iqx AMPS ❑BATH REMODELREPAIR ❑DEMOLITION
C W sp I hereby affirm that 1 am exempt from the Contractor's License Law fm the ❑OTHER
C U following reason.(Section 70315,Business and Professions Code:Any city.r county SIGNS ELECTRICAL `
W W O F- which requires a permit to construct,viten,improve,demolish,or repair any structure
prior to its issuance,also requires the applicant for such permit o file a signed statement SPECIAL CIRCUITIM1SC.
6 that he is licensed pursuant to the provisions of the Contractor's License Law(Chapau 9
W CC (commencing,with Section 701 of Division 3 ofthe Business and Professions Code)or TEMP.ME'I'ER OR POE B SCOMMERCIAL,
F L c¢ that he in exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION - ❑DEMOLITION
' mo,, Section 10,IS by any applicant for apermitsubjectstheapplicanttoa civilpealty of PO WEE DEVICES []TENANT ❑FOOD SERVICE
F+ not mare than rive hundred dollars($5fq). IMPROVEMENT
p C O D L as owner of the property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC lie,
21C'. will do the work,and the structure is not intended oroffered forsale(See 70kEBusiness OTHER
¢l 0 and Professions Code:The Contractor's License Law does not apply to an owner ofMPERMU
ITCHES-MIXTURES
3 property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements are not intendedoroffered forTIAL ELECTR SQ ET.
sale.If,however,the building or Improvement is sold within one year of completion,me SQ.FT.FLOOR AREA VSQ,FT.
ownerbuilder will have the burden of pmving that Ice did not hard or improve for par-
pmc.f sale.).
I,as owner of We property,am exclusively contracting with licensed contractors to TOTAL'
onsweuhe project(Sec.7044,Business and porE,non Code:)The Contmcmr's Li-
crass
i- -
nssLawdoesnotapplytoanownerorpropertywhobuildsorimprovesthereon,and UMBING PERMIT FEE
who contracts for such projects with a contactors)licensed pursuant to the Contractors -
License Law. NCE
❑I am exempt under Sec. ,B&P C for this reason
DoleALTER-DRAIN&VENT-WATER(EA) VALUATION
Owner O
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE: nGROUP 1 hereby a1Arm under penalty of perjury one of the following declarations:
I have and will maitain a Cenificene ofConrrom,elf-inure for Workers Compen- DRAINS-FLODR.ROOF,AREA,CONE. STYPE CONSTRUCTION
737W
ilor,as provided for by Section 37M of the Labor Code,for the performance of the
ork for which this permit is issued. FIXTURES-PERTRAP
1 have and will maintain Workers Compensation Insurance,as required by Section oftheLaLorCode,for the performance of the work for which this return is issued. GAS-EA.SYSTEM-I INC.40UTLETSOCC. Aryl`
y Worker's ompensali.n Insuranceartier and Policy nu gg wwaniec ' SI��t� Policy No.Mb-2-0n GASB-EA.SYSTEM-OVER4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERSGREASFJINDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FRES
(His section need notbe completed ifthe permit is for one hundreddollats($100) GREASE TRAP
nr PLANCHECK FEE
less.)
I certify that in theperfmarmate.fthe walk for which this permit is issued,Ideal SEWER-SANITARY-STORM EA.200 FT.
nm employ any person in any manner so as to become subject to the Workers'Compen- ENERGY FEE
Z sation Laws of Cahmmia.Dam WATER HEATER WNENTMLECTR GRA
O rA Applicata
GNOTICE TO APPLICANT If,after making this Certificate of Exemption,you should WATER SYS'I'EMOREATING SO"-FE
F became subject to the Worker,Compensation provisions of the Label Code,you most
Wforthwith comply with such.,,his pe at shall he deemed re'colwe. WATER SERVICE
Q O
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT.Q (hereby affum thauhere is aconswdion lending agency for Ne performance of ec p
V
Ne work for which this permit is Issued(Sec.3097,Civ.C.)
IL F+ Lenders Name AL.
finders Address TOTAL: -BUILDING FEE
y 1 cenify that I have read,his application and state that the above information is
i.h c.rccl.l agree to comply with all city and county ordinances and state laws minting to QTY MECHANICAL PERMIT FEE SEISMIC FEE
U Z building construction,and hereby authmite representatives of this city to enter upon the
above-mentioned property for inspection purposes. PERMIT ISSUANCE - ELECTRIC FEE
(We)agree to save.Indemnify and keep harmless the City of Cupertino against
liabilities,judgments,costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECH. PLUMBING FEE
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NONPOINTAIR HANDLING UNIT(TO 10,000 CFM) MECHANICAL FEE
SOURCER�qE`GUlLATIONS. �s
Y AIR HANDLING UNIT(OVER 10,IXN)CFM) CONSTRUCTION TAX
Signatureef ApplicardUContractor� /( Dale/ / EXHAUST RUDD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIAL DISCLOSURE
Will the applicant or future building occupant slum or handle hazardous material HEATING UNIT(TO 101000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(al? / HEATING UNIT(OVER 100,000 BTU)
E]Vote No VENTILATION FAN(SINGLE RESID) PAID Doc ReceiptM
Will the applicant or future building occupant use equipment or devices which BOILER-COMP(3HP OR 100,(x0 BTU)
emit hazardous air contaminants as refund by the Bay Area Air Quality Management 'OT L.
District? // c BOILER-COMP(OVER 100,000 BTU)
E]Yes ANO I
I have mad the hazurdous materials requirements under Chapter 6.95 of ton Call- AIR CONDITIONER / ISSUANCE DATE
f.mia Health&Safety Code,Sections 25505,25533 and 25534.I understand Wal if the NEW RESIDENTIAL MECIL SQ.ET. /r ,� 2- 9- 90
building does net currently have a tenant,that it is my responsibility to notify the Occupant ( /
oft gmrements which m t prior to is a of.Cerf¢me of
owner or autho� riudagenl Do,, - TOTAL: ISSUED BY
OFFICE