S 0860 (2) APPLICANTTO FILL.IN.INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY - - -
CITYOFCOPERTINO BUILDING-ELECTRICAL PF51T NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 0860
BUILDING PROJECT IDENTIFICATION '
BUILDING ADDRESS: SANITARY NO. - APPLICATION SUBMITTAL DATE
OWNER'S M PONE. CONMWOR'S NAME: - LICN
- ; 7 7N/C 'CONTROL# -
ARCHITECT/ENGINEER: LIC NO: y ADDRESS:. '
Cf' ZZ &10'lAteIA&.
CONTACT: PHONE: - BUILDING PERMIT INFO
❑,Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑
` - LICENSED CONTRACTORS DECLARATION QTY. ELECTRIC PERMIT FE8-
1 hereby affirm that 1 am licensed d provisions of Chapter 9(commencing JOB DESCRIPTION
aZ with Sectio ]W0)of Dt is n3of theBusinessand Professions Code,and my -license ID
DO - PERMIT ISSUANCE
in fulif once w4
QU�' Licen. C ss a �� Lia.# KITCHEN REMODEL
J 3 APPLIANCES-RESIDENTIAL' '
Da¢�• 'Comracto ❑ADDITION ElPLUMBING RE-PIPE
ARCHITECT'S DECLARATION PANELS F 5'yy� -1 MULTI '�MODIFICATION
RUCTURAL
z O N r7 1 understand my plans shall be used as public reroNs
94 wi 1' UPT00AMPS R ❑INTERIOR El CHIMNEY REPAIR
`F',� Lreensed Professional - IMPROVEMENT
9 OVER
IIIAMPS
OWNER-BUILDER DECLARATION ❑SWIMMING POOLS
y0,UtyI I hereby affirm that 1 ora exempt from the Contractor's License Law for the OVER IOW AMPS El BATH RF.MODELIREPAIR �DEMOLITION
p( following reason.(Section 7031.5,Business and Professions Cade:Any city or countySIGNS ELECTRICAL [IOTHER
�O mwhich requires a permit to oonewc', per,improve,demolish, r repair any stmcwre
_
k] a ao -
V,,J prior i is Is ey - theppl'canl forsuch permR fl amodalement SPECIAL CIRCUFOMISC.
,y
00 'hat h .licensed pursuant t thep ns of the Commences L L (Chapter 9
(cam g ithS f ]WO) fO tan 3of the Busness dpro[s Code)or TEMP.METER OR POLE INST
d p,m fB
that he is exempt therefrom and the basis for the alleged exemption.Any violas on of NEW BLDG/ADDITION El DEMOLITION
fiDt oo Section]031.5 by any applicant fora permit subjects the applicant In.civil penalty of POWER DEVICES
=z not masownore than five hundred dollars 1$50x). ANT ❑FOOD SERVICE.
=CO ❑Le.oftheproper,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT ,
+IyJ IG', will do the work;und the sWcture is not intended oroRetW for sale(Sea]1144,Business ❑OTHER-
3 and Professions Code:The Contractor's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
property who huiids 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 RESIDENTIAL ELECTR SQ FT.
sale.If,however,the building or improvement is sold within one yearnfecurplelion,the - - SQ.FT.FLOORAREA $/SQ.P..
caner-builder will have the harden of proving that he did not build or improve for puri .
-
pose of ale.).' '
❑1,as owner of Ne property,am exclusively contracting with licensed contractors to TOTAL. �} � TT.EDTom,
amwtmm the project(Sec.7044,Business and Professions Code:)The Comrecmrs Li- C�IV
cense Low does not apply to an owner of property who builds or improves thereon,anJQTY, ' - PLUMBING PERMIT' - FEE
who eamour.,fimavh projects with amr(
comracs)licensed para......the Capacities NOV O 199-#
License Law. PERMIT ISSUANCE x�y!
❑I am exempt under Sec. ,B&P C for this reason ,
ALTER-DRAIN&VENT-WATER(EA)
Owner Dam VALUATION
} WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm under penalty of p,.,ane of the following declarations:
.� I have and will maintain a Certificate of Consent to.self-insure for Worker's Compen DRAINS-FLOOR,ROOF,AREA,COND.
senior,as provided far by Section 37W of he Latin Cede,for the perfmmonce of the STORIES TYPE CONSTRUCTION
work for which this permit iainsaed. FIXTURES-PER TRAP '
E]1 have and will maintain Worker's Compensation Insurance,as required by Section _
37W of the Labor Code,for performance of the work far which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My Worker's Compensation Insurance carrier and Policy number are:
Carrier: Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASUINDUSTR,WASTE INTERCEPTOR
(This seclionnad not IN compleied if the permit is for one hundred dollars($1 WBUILDING DMS FEES) GREASETRAP
or he's.) PLANCHECK FEE
Icertify thasochePerformance of the work forwhichthis permit isissued,I shall SEWER-SANITARY-STORM EA.2W FT.
not employ any person in any manner ao{t baycym bjecfto the Worker.'Compen-' ENERGY FEE
7. sation LewsdCall f 111.�.�1`17u
O O
Applies. I�5� -:;P*
WATER HEATER WNF.NT/ELECTR -
ra pp GRADING PEP,
NOTICE TO APPLICANT If,after making this Cediftcate of Exemption,you should WATER SYSTEMOREKRNG
abecome subject to the Worker's Compensation pmvisions of the Labor Code,you must _ SOILS FEE .
RJ forthwith comply with such pmv Bions or this permit shall be deemed revoked. WATER SERVICE -
aQ
Uz CONSTRUCTION LENDING AGENCY NEW RESIDGNTIALPLMB. SQ.FT. PAID
U O l farwhichirm'batmen issued( er.i0 lending agency for the pertormance of Dote Receipt#
ry N the work far which this permit is issued(Sec.309],Civ.C.)
O U Lender's Name'. - TOTAL:
{1a Lenders Address TOTAL:
Icertify that I have read this application and Twin that the aMve infnrmmion is - BUILDING FEE
i� W carted.l agree to comply with ell city and county ordinances and scats lows relating m QTY. MECHANICAL PERMIT FEE
UZ building construction.and hereby awhorize representatives of this city to enter upon the SEISMIC FEE
above-memianed property for inspection purpasei.
(We)agree m cave,indemnify and keep harmless fire City of Cupertino against PERMIT ISSUANCE ELECTRIC FEE
babilines,judgments,costs and expenses which may in any way acetas against said City ALTER ORADD TO MECH.
in consequence of the gmming of thio permit PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
SOURCE REGULATIONS. MECHANICAL F
x
AIR HANDLING UNIT(OVER 10,001)CFM) CONSTRUCTION TAX
Slgnamre afApplicara Comrarom - Date EXHAUST HOOD(WMUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
` Will the applicant or future building occupant store or handle hazardous materialHEATING UNIT 070,1010,000 BTU)
_ as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cade,Section 25532(a)Y - HEATING UNIT(OVER 100,000 BTU)
❑Yes - [_1 No
VENTILATION PAN(SINGLE RESID) PAIS Date Receipt#
Will the applicant or Pomre building occupant use equipment or devices which - -
I emit huzeNous air contaminants as defined by the Bay Areaa Air
r QQuuality Management BOIL ER-COMP(3HP OR IW,oW BTU) -
District? TOTAL:
'DYes ❑No , BOILER-COST(OVER IW,000 BTU) -
I have or
the hazardous an tf
AIR CONDITIONER
rer,dremems under Cbapmr 6.95 of the Cali- - ISSUANCE DATE
famin Health&Safety Code,Sections 25505,25533 and 25534.I understand that il'the NEW RESIDENTIAL MECH.' SQ.FT.
building dceanot cumn0y havicetenant.[het it is my responsibility' notifythtnecapam
of then uirememsrehich maslbe mel prior to issmna ofa Cutifl teof anoy.
w .,an o ugem am TAL: ISSUED BY:
OFFICE