S 0587 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - BUILDING-ELECTRICAL - PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL S 0587
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICAO NSUBMITTAL DATE
G Y
OWNS A E: PHONE <_ CONTRACTOR'S NAME LIC NO:
( Y�V �`y
NIC CONTROL#
ARCHITEC- (NEER: LIC NO: ADDRESS:
42/OLS/
CONTACT. PHONE: BUILDING PERMIT INFO
���-i /�� ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB PATCH
LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm that 1 am licensed under previsions of Chapter 9(commencing QT' ELECTRIC PERMIT FEE JOB DESCRIPTION
QOC with Section 7kW)mDlvisam3.fthe Bm,m,sand Professions Cadgend my license is PERMIT ISSUANCE RESIDENTIAL'
n full fora and fe /p/
TUzE" License Class CtLie.# I"u ❑SFDWL ❑KITCHEN REMODEL
hQM Date _ Cananm„r APPLIANCES-RESIDENTIAL ❑ADDITION [I PLUMBING REPIPE
,pp, ARCHITECT'S DECLARA 10 PANELS ❑MULTI-UNIT El STRUCTURAL
Z O 4 I understand my plans shall be used as public records MODIFICATION
OZ- UP T02W AMPS
F „1'] UccnuJ Profcssionul ❑INTERIOR ❑CHIMNEY REPAIR
G W 201.1000AMPS IMPROVEMENT
y.pG�3 OWNER-BUILDER DECLARATION ID SWIMMING POOLS
a U G 1 hereby affirm that 1 am exempt from the Contractor's License Law for the OVER IIXMIAMPS ElBATH RE E 'P 1 D 'I N
'3I
VVF following reason.(Section 7(131.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL CI El
W w0 ya which requires a permit to construct,alter,improve.demolish,or repair any structure
yJ prior to its issuance,also requires the applicant for such permit to file a signed smtemem SPECIAL CIRCUIT/MISC.
�C� thatbels licensed pursuant to the provisions of the Contractor's Licence Law
(Chapm,9
��00 (commencing with Section 711M)ofDlvininn3eFthe Businesv and Professions Ceek"m TEMP.METER OR POLE INST. - l COMMERCIAL
L p,o p� that he is exempt therefzam and the basis for the alleged exemption.Any violation of
-INNEW BLDG/ADDITION ❑DEMOLITION
IN Z"
7031.5 by any applicant fora permit subjects the uppliconuo a civil penalty of POWER DEVICES
[-.Z p, not more than five hundred dollars(SSW). ❑TENANT ❑FOOD SERVICE
q^„O ❑ 1.As owner of the property,or my employees with wages as their sale compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
C2 C�Ce. will do the work,and the stmctureis not intended or offered for sale(Sec.7044,Business ❑OTHER
13 and Professions Code:The Contractor's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
progeny who builds to improves thereon,and who dues such work himself or through
his own employees,provided that such improvements are not intended or offered for%SYSTEM-OVER
SIDENTIAL ELECTR SQ ET.
sale.If,however,the building or imprecarsou is sold within one year"""PletientheSQ.FLFLOORAREA $/SQ.FT.
owner-builder will have the burden of proving that he did not build or improve for Pur- /1
pose clime). I� /1)
❑L As mvnu or the property,Am"elusively contracting with licensed comments toT
wnvtmet the project(Sec 7044.Business And Promwic as Code:)The Commetods Li-
came
i- AR I
c se Law does not apply to an owner of property who builds or improves thereon,and PLUMBING PERMIT FEE "
64
who contracts for such projects with a contraemgs)licensed pursuant the Contractor'sA/���r Adyl�
License Law. ISSUANCE , O
El,I am exempt under Sec - ,B&P C for this reasonL(✓r -
Owner Date DRAIN&VENT-WATER(EA) A AF(nN
WORKER'S COMPm imakuION DECLARATION LOW PROTECT.DEVICE V
I hereby affirm under penalty of perjury ane of the fnllcame declarations
Ihavc andwill maintain a CeniflcnteofConsenno self-insure for Worker's Compen- -FLOOR.ROOF, N STORIES TYPE CONSTRUCTION
smion,m provided for by Section 37W of the Labor Code,for the pertormanm of the
work Por which this permit is issued. S-PER TRAP
❑ 1 have and will maintain Workers Compensation Insurance,as required by Section
37M of the Labor Code,for the performance of the work for which this permit is issued. .SYSTEM- INC.4 OUTLETS OCC GROUP ANN
My Worke' Co nP cation unew carrier And Policymmbermt:
Camiee Policy No.: A.SYSTEM-OVER 4(EA)
ERT FIC TE O XEMPI'ION FROM WORKERS'
COMPENSATION INSURANCE GREASEANDUSTRL WASTE INTERCEPTOR
(This section need not beeompleted ifthe Permit is for onehundreddollats($100) BUILDING DIVISION FEES
or less.) GREASETRAP PLANCHGCK FEF.
I trinity that in the performance oRhe work for which this permit is issued,l shall SEWER-SANITARY-STORM EA. PI'.
not employ any person in any manner so as to become subject to the Workers'Compen- - ENERGY FEF.
z smion Laws of California.Date
7 Applicant
- WATER HEATER WNF,NT/ELECTR GRADING FEE
r'7 0 NOTICE TO APPLICANT:If,atter making this Cur ifcate of Exemption,you should WATER SYSTEM/1'REATING
abecame subject to the Worker's Compensation provision,of the Labor Code,you most SOILS PGE
f4J forthwith comply with such provisions or this permit shall he deemed revoked. WATER SERV ICE
M A
� z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.PC PAID
I hereby affirm that hen is a construction lending agency for the performance of _ pole Receipt#
the work for which this permit is issued(Sea 3097,Civ.C)
0
Lender's Name U L:
W Levderls Address TOTAL: TOTAL
Pt 1 certify that 1 have read this application and state that the those information is - gBUILDINGEUJ correct.I agree to comply with A11 city and county mi inane,and state laws rlating to QTY. MECHANICAL PERMIT FEE
Z building convection,and hereby authorize representatives orchis city to enter upon the above-mentioned property for inspection purposes. PERh11l'ISSUANCE(We)agree to save,indemnify and keep tandem the City of Cupertino against Eliabilities,judgments,costs andexpenses which may in any way acerae against said Cityg1.TER OR ADD TO MECH. 'in asequence of the granting of Nis permit. EAPPLICANT UNDERSTANDS AND LL WITH ALL ON-POI T AIR HANDLING UNIT(TO 10.0f10CPM)SOURCE RE ATION.. FEEN\ I AIR HANDLING UNIT(OVER 111,1NI(I CFM) ON TAX
Signature ofA ph ✓ nntmctar Dalt EXHAUST HOOD(W/DUCT)
HAZARDOUS MA RIALS DISCLOSURE HOUSING MITIGATION FEE
Will a applicant or future building occupant.store or handle hazardous material, HEATING UNI r UO 100,00h BTU)
as defined A the Cupertino Municipal Code.Chapter 9.12,and the Health and Solely IL
Code,Sectio 5532(a17 HEATING UNIT(OVER 100,0011 BTU)
El Yes Fl No
VENTILATION PAN(SINGLE RESID) PAID
Will the applicant or future defined y the Bay
equipment or devices which Date Receipt#
emit hazardous air contaminants n defined by the Boy Arco AR Quality Management BOILER-COMP(3HP OR 100,000 BTU)
D
istrict? TOTAL:
s ❑No BOILER-COMA(OVER UMOWBTU)
read the hazarous matumb requirements under Chapter695 of the Cali- AIR CONpITIONERISSUANCE DATE
&Safmy Code,Sections 255” 25533 and 25514.1 ondcrstanA that if the NEW RESIDENTIAL MECH. SQ.FT.
not currently have s Icnant,that itisityresponsibilitytonotifytheoccupantments which must be met I norm Aeon.ofaCenlBcaleofOcetpaocy.
horiud goal' TOTAL: ISSUED BY:
OFFICE