S 3961 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY -
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO.
BUILDING DIVISION APPLICATION/PERIA'IIT PLUMBING-MECHANICAL S 3961
BUILDING PROJECT IDENTIFICATION
BUILDING w Al g/Q N �d' ��-er�/N O SANITARY NO. APPLr ATION SUBMITTAL DATE
l J'^ �l
CONTRACTORS NAME: LIC NO:
N/C C NTR LN
CHITECT NGINEER: LIC NO: ADDRESS: �- ❑
CONTACT: PHON9F BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
01 ❑ ❑ ❑
LICENSED CONTRACTORS DECLARATION QTY. ELECTRIC PERMIT FEE
p 1 hereby affirm rant I am licensed under provisions of Chapter 9(commencing ]OB DESCRIPTION
G a'Z with Section 70pit.f Division 3ofthe Businessand Professions Code,and my license is
C O PERMIT ISSUANCE RESIDENTIAL:
F Licenfulse
aClassconcerto effect.
�zV License Class Lic.# ❑ADWL ❑KITCHEN
yQa Date Contractor - APPLIANCES-RESIDEM'IAL El ADDITION ❑PLUMBING RE-PIPE
ARCHITECTS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
z O o Z 1 understand my plans shall be used as public records PANELS
O z 4 UP TO 200 AMPS MODIFICATION
l..,fa ❑INTERIOR El CHIMNEY POOL
Licensed Professional 2(11-1000 AMPS - IMPROVEMENT
OWNER-BUILDER DECLARATION
' ❑SWIMMING POOLS
yy CG W¢ I hereby spent that 1 am exempt from the Contracmrs License Law for the OVER I010 AMPS ❑HATH REMODEUREPAIR [I DEMOLITION
X 3 LL F following reason.(Section q031 5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
which requires a permit to consumer,alter,improve,demolish,or repair any structure
ti prim to its issuance,also requires the applicant for such permit to file a signedsmtement SPECIAL CIRCUIT/MISC. yy
dthat he is licensed purmartmind provisions ofthe Comments License Law(Chapter 9 —
^QO (commencing with Section 7000)of Division 3 offie Business and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL:
d{y m yv that he is exempt therefrom and the basis for the alleged exemption.Any violation of El NEW BLDG/ADDITION ❑DEMOLITION
ad Iy Section 7031.5 by any applicant for a permit subjects me applicant to a civil penalty of POWER DEVICES
r more than five hundred dollars(5500). ❑TENANT ❑FOOD SERVICE
S as owner of the tett,or m employees with wages as their sole cora IMPROVEMENT
prop y yemp y g compensation, SWIMMING POOL ELECTRIC
II oche work,and NesWcwre is at intended or offered for salt(SecJ044,Business ❑OTHER
1 m and Professions Cale:The Contractors License Law does not apply m an owner of OUTLETS-SWITCHES
-FIXTU S
property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDHNTIAL ELE SQ ET.
sale.IL however0e bulldimgor improvement is sold within no year ofcompleavir the SQ.FT.FLOOR AREA $/$Q.Fr.
owner-builder will have the burden of proving that he did not build or improve for pur-
pass of'rR.f
❑ 1,as owner of the Property,am exclusively contracting with licensed contractors to T
constructive preject(Sex.'IM4,Business and Professions Code:)The Contractors Li-
cense Law does not apply to an owner of pmpeny who builds or improves thereon,and QTY PLUMBING PERMIT E
who contracts for such projects with a contractor(s)licensed pursuatu m the Controemrs s
License Law. PERMIT ISSUANCE
❑Ia.exams mnder Sao ,B&PCforthisroe on
4P y n _ / ALTER-DRAIN&VENT-WATER(EA) VALUATION
mer \\ KER'S COMPENSATION DECL RATIO09VN— BACK FLOW PROTECT.DEVICE
1 hereby affirm under penalty of perjury one of the following declarations: CJ
❑I have and will maintain a Certificate of Cousetn to self-instrre for Workers Compen- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCTIONsmiom,as provided for by Section 37W of the Labor Code,for the peffornence of the
work for which thi s pemtit is issued. FIXTURES-PER TRAP
❑I have and will maintain Workers Compensation Ina ufanc.as required by Section 6
11016-1
3](r,of the Labor Code,for the performance of the work for which this permit is issued GAS-EA.SYSTEM-I INC.4 OUTLETS - OCC.G UP /� APN
My Workers Compensation Insurance calla and Policy number are: •N O
Carrier: Policy No.: GAS-FLA.SYSTEM-OVER 4(EA) / �/
CERTIFICATE OF EXEMPTION FROM WORKERS' /Q Gi
COMPENSATION INSURANCE GREASFIINDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FEES
(This section neednot becomplmod ifthe pemtit is forone hundred dollarsSIM)
m less) GREASE TRAP
PLANCHECK FEE
I certify that in the performance ofthe work for which this pemtit is issued,)shall
not employ any person in an SEWER-SANITARY-STORM EA.200 FT.
y manner so as to become subject m the Workers'Camper. ENERGY FEE
�
C) Minn Laws of California.Data O Applicant t WATER HEATER WNENTIELECTft GRADING FEE
h NOTICE TO APPLICANT:If,after making this Cenificafo of Exemption,you should WATER SYSTEM?BEATING
ay" become subject to the Worker's Compensation provisions of the Labor Code,you must SOILS FEE
LII forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
0. Q
CONSTRUCTION LENDING NEW RESIDENTIAL PLMB. $Q.FT. PAID
U
I herebyoptionnn thattherei is ac ed Stretionlending agency for performance of Det Reuipt#
(A the work for which this permit is issued(Sec.3097,Civ,CJ
Q U Lenders Name TOTAL:
GU Lenders Address TOTAL:
y that f have read his application end state that me above info anon is BUILDIN
sF-1 fn coram.I agreetncomply withal]city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
V ,2, haddingconsimetion,and hereby antcannodpresentatives ofthis city menterupon the SEISMIC E
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep That the City of Cupertino against ELECpRI FEE
liabilities,judgments,costs and expenses which may in any way accrue against said City ALTER OR ADD TO MEC . A 1
in asequence at the granting of this permit. P UMBIN E
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT PIR HANDLING UNIT( CFM) CHAN AN EE
SOURC REGULATIONS. ftl
AIR HANDLING UNIT(0 Q INSTRUCTION TAX
;a,
nawren plmarm Contercmr l� I �l EXHAUST HOOD OODU ) USING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(TO LOQ U) _
efined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
e.Seedon 25532(a)? HEATING UNIT(OVER IgD,(100 BTU)Li❑Yes 0No VENTILATION FAN(SINGLE RESID) PAIDDate Receipt#
Will the applicant or future huilding occupant use equlpmem or devices which BOILER-COMP(3HP OR 100,1100BN)t lmzardnus an contaminants as defned by the Bay Area Air Quality Management TOTAL:
Dstrict?
`!
❑Yes 7 N BOILHR-COMP(OVER 100,0110 BTU)
77
hazardous I have read the matelots requirements under Chapter 6.95 of the Cal4 AIR CONDITIONER ISSUANCE DATE
Farm Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.FT
building does not currently have a tenant,that it is my responsibility to notify the occupant l /�
of the Ornaments which most be mea prio o issuance a Carl at f 0c anoy.
nr au 'zed id mead /p ate Z TOTAL: ISSUED BY:
OFFICE