S 0190 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL,POINT.PEN'ONLY
CITY OF CUPER.TINO BUILDING'-ELECTRICAL PE§IT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL, 0190
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
OW 'R'S NAME: .PHONE: C TRACTO ' NAMEs rLTC NO:
N/C CONTROL#
i I - O3 .� 2n Or 16 '
ARCHITECOENGINE R: LIC NO: ADDRESS. /I 1 S(' ❑
S •VI
CONTACT: PHONE: BUILDING PERMIT INFO
_ ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MEC
❑ ❑ ❑ r
LICENSED CONTRACTOR'SDECLARATION QTY, 'ELECTRIC PERMIT ( FEE
Zw 1 hereby affirm that lam licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
Ih Section 9000)of Division 3 of the Business and Professions Gds,and my license is REW(DE TIAL'
O O PERMIT ISSUANCE
U�. in full fo ea t. b DWI. El KITCHEN REMODEL
�U Liccns Li0.N APPLIANCES-RESIDENTIAL. ❑ADDITION El PLUMBING RE-PIPE -
y Date TSITCimbL
Da c ARCHITECT'S IT El MULTI-UNIT ❑STRUCTURAL
Z O v� 1 understand my plana shall be used as public records PANELS ,' MODIFICATION
:.1 UP TO 200 AMPS El INTERIOR El CHIMNEY REPAIR
rrs Lam.I'"u0] Licensed Professional - 201-]"AMPS IMPROVEMENT E]SWIMMING POOLS
GOWNER-BUILDER DECLARATION OVER]"AMPS - - El BATH REMODEL/REPAIR El DEMOLITION
Q I hereby offom that 1 nmxem
ept from the Contractor's License Law for the
O 0.0 following reason.(Section 7031.5.Business and Professions Cade:Any city or county SIGNS ELECTRICAL ❑OTHER �a�/-—
which requires a permit to cmon.O.than improve,demolish,or repair any'stmM cture j
F�Or3 Norm its ismance,ins.requires the applicant forsuchpermitm file.signed statement SPECIAL CIRCUIT/MISC. 5 -
6� teat he is licensed pursuant to The provisiaasofthe Contractor's License Law(Chapter 9
E500 Commencing with Section]000)of Division 3 ofthe Business and Professions Code)or TEMP.METER OR POLE INST, - COMMERCIAL'
y M N that he is exempt therefrom and the basis for the alleged exemption.Any violation of - [I NEW BLDG/ADDITION El DEMOLITION
so Section103LSby any applicant for a permitsubjcets the applicant o a civil penalty of POWER DEVICES []TENANT - ❑FOOD SERVICE
yy ]m are thanfive hundred d.11.m($500). - - IMPROVEMENT ,
9FQ ❑Las owner of the property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC
.H.❑ will do the work,and mearmoure is not intended orofrered foreale(Sec,9044.Business ❑OTHF,R
W 3 and Professions Code:The Contractors License Law does not apply m agawner of OUTLETS-SWITCHES-FIXTURES
property who builds of improves thereon;and who does such work himself ar through
his own employees,provides)that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ FT.
sale.If,however the building lir improvement is sold within one year acompletion,the SQ.Pf.FLOOR E _ $ISQ.FT.
er-builder will have the burden of proving that he did not build or Improve for por- -
❑ Imi net of the property,,B exclusively contracting with licensed contractors in TOTAL: ,o Vtl zC
conswcl the project(Sec.]146,Business and Professions Code)The Contractors Lianswer, - - y
cense Law does not apply to an owner of property who builds or improves and QTY PLUMBING PERMIT + •r FEE C17/ U
who contracts for such projects with a contractors)licensed pursuant to the Contractor's —� f L�N t'I/AI
ISI License Law. PERMIT ISSUANCE 0
❑I am exempt under Sec. .B&P C for]his reason AL
Owner - Date ALTER-DRAIN&VENT-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE '
I hereby tiff rte under penalty of perjury one of the following deelafmi...:
❑ Ibaveand will maintain aCertificaaof Consent]u sciNnxumfor Worker's Compen- DRAINS-FLOOR,ROOF,AREA:COND. STORIES TYPE CONSTRUCTION
sari..,as,provided for by Section 3900 of the Labor Code,for the performance of the
work for which this permit is issued. FIXTURES-PER TRAP.
have and will maintain Worker's Compensation Insurance,as inquired by Section -
3700 of the Labor Cole,for the performance of the work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS - OCCGROUP APN
�ydWor ICuce carrier ad
NGAS-EA:SYSTEM-OVER4(EA)
EXEMPTION FROM WORKERS' -
COMPENSATION INSURANCE GREASMNDUSTRL WASTE INTERCEPTOR
BUDDING DMSION PEE$
(This seadon need nolbe completed if Ue pumit is f.nmehundrW dollme(SI W) GREASETRAP
or less) � � PLANCHECK FEE
I certify that in the performance ofthe work for which This permit is issued,l shall SEWER-SANITARY-STORM EA.200 Ff.
not employ any person in any manner sm as to become subject to the Workers'Compeo- ENERGY FEE
O Z. smidn Laws of .1ifomie.Date - WATER HEATER WNENTMLECfR FEE
O Applicant GRADING
h NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEMaREATING
become subject in the Worker's Compensation provisions of the Labor Cole,you mus] SOILS FEE
forthwith comply'with such provisions or this permit shall be deemed revoked. ' WATER SERVICE
a �
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMR.. SQ.FT - PAID
,'7. Dom Receipt#
-V work
w'effthi thauhere issued(Sec.30 trading agency for Ile performance of
the work for which this Permit is issued(Sec.309],Cie CJ '
Lks FsLeaders Name TOTAL'
O V Leader.Address TOTAL: .
Liz BUILDING FEE
1 certify that I have real this application y o site that the above information is
U h
correct.I agree to comply with all city and county ntative of and Stam laws relating upt e QTY. MECHANICAL PERMIT . 'FEE
G 7 building construction,and hereby authorize representatives of this city to enter upon the SEISMIC PEE
above-mentioned property for inspection purposes. PERM IT ISSUANCE -
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC NEE
liabilities,judgmems,costs and expenses which may in anyway acme against said City ALTER GRACE,TO MECH. -
inconsequenceofthe granting ofThis permit. - PLUMBING FEE IT
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALV NON-POINT AIR HANDLING UNIT CFO 10,000 CFM)
S URCE REGULATIONS � � � MECHANICAL FEE
` { AIR HANDLING UNIT(OVER 10,"CFM) CONSTRUCTION TAX
Si,miume of teaWContmw.1 Duty I EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the.pplismumfor..building occupant store or handle M1azatdous mammIl HEATING GNU(TO 100,0017)BTU) '
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code,Section 25532(x)? HEAPING UNIT(OVER 100,00)BTU),'
❑Yes XNo VENTILATION FAN(SINGLE RESID) PAID '-
Date Receipt#
C Y -
Will the applicant or future building occupant use equipment or devices which
I emit hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMPt3HP OR 100,000 BTU)
s TOTAL'
District? -
C]Yes - �No � � BOILER-COMP(OVER 100,0100 BTU)
haad the h..H.s materialsrequirem is under Chapter 6.95 of the Cali- AIR CONDITIONER
Ive re - ISSUANCE DATE
mania Health&Safely Code Sections 25505.25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.PT.
building does nor cuirenlly k,e a tenant.That it is my responsibility to notify the occupant
of tM1 o.irememe which n , met priori nuance of ace nIfi rinfoce'pancy. - -
Owns r utho gentOwne gent Ole TOTAL: ISSUED BY. TOTAL: ISSUED BY:
OFFICE