S 0490 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDLNG-ELECTRICAL. PE§ITNO. 0490
BUILDING DIVISION . APPLICATIONIPERMIT PLUMBING MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
(�
WNER'S NAME: L� PHONE: CONT NIC C
ACTOR'S NAME: LIC O. ONTROLa
I/lwu�. V9= 5o7 a� .
ARCHITECT/ENGINEER: - LIC NO: AMR1 ❑
S• rt� �jlc�Cl
CONTACT: PHONE: BUILDING PERMIT INFO -
❑'Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ �� ❑ l
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that I am livered made,provisions of Chapter 9(commeucing JOB DESCRIPTION
(FOO with
Section 70 effect.
Sof the Businessand Professions Code,and my license is PERMIT ISSUANCE RESIDENTIAL:
aW2 in 'F1SFDWL ❑KITCHEN REMODEL
aUZt License Class I.1a.N pppLIANCES-RESIDENTIAL- ❑ADDITION $RLUMBING RE-PIPE
tF d W Date Contractor
p.Dm ARCHITECT'S DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
Z O m 7J. I undersand my plans shall he used as p colic records - MODIFICATION
Ox�O UPT02MAMPS El INTERIOR L]CHIMNEY REPAIR
r4 Licensed Professional 2014IIWAMPS - - IMPROVEMENT ❑SWIMMING POOLS
.�i OWNER-BUILDER DECLARATION OVER[Bud AMPS ❑BATH REMODEL/REPAIR ElDEMOLITION
I hereby affirm that I am exempt from the Contractor's License Law for the
ippi55,�06U following mason.(Section 7031.5,Business and Professions Code:Any city of county SIGNS ELECTRICAL ❑OTHER
u+�WO 1" which requires a permit to construct,altar,improve,demolish,or repair any structure
Poor to its issuance,also requires the applicant fimmich permit to file a signed statement SPECIAL CIRCUIT/MISC.
that he is licensed pursuant o the provisions of the Contractors License Law(Chapter 9
(commencing with Section 7")of Division 3ohe Business and Professions Cale)orTEMP.METER OR POLE INST. COMMERCIAL'
d fy eC that he is exempt therefrom and the basis for the alleged exemption.Any violation of - - .0 NEW BLDG/ADDITION ❑DEMOLITION
iLLCI n• Selliut1031.S by any applicant for a permit subjects the applicant o a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
F�y no[more than five hundred dollars($500). IMPROVEMENT
sQ
C]1,as own,,of the property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC
[..O will do the work,and the structure is not intended or offered for sale(Sea]044,Business ❑OTHER
GZC and Professions Code:no Contractor's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
.. property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such imp rvernents are not intended or offered for NEW RESIDENTIAL.ELECTS
sale.If,however,the building or improvement is sold within one year ofcompletion,the SQ FLOOORARRE^
Pace EA $/SQ.PE
mer-builder will have the burden of proving that he did not build or improve for put. A I L,+
foof sale.). -
❑1,as mune,of the pmpeny,am exclusively contracting with licensed conuanoms to TOTAL:
enamel the p,.Joe,(Sec.7044,Business and Pmfessians Cuba)The Cman ctoea Li-
canto Law does not apply to an owner of property who builds or improves thereon,and QTY PLUMBING PERMIT ' FEE
who emdo eta for such projects with a centmetodu licensed pursuant o the Contractor's I
License Law. V CITY U1
❑ I am exempt under see. ,B&P C for thPERMIT ISSUANCE is reason - _ Uut th I IND
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Owne, Date • - - m
WORKER'SCOMPENSATIONDECLARATION BACK FLOW PROTECT.DEVICE �V,
I hereby affirm under penalty of perjury one of the following deelumtiore:
S❑ te
I have and will maintain aCernficaof Commumaelf-insure for Workers Compen- DRAINS-FLOOR,ROOF.AREA,COND. STORIES TYPE CONSTRUCTION
sation,as provided for by Section 37M of the Labor Code,for the performance of the -
work for which this Permit is issued. FIXTURES-PER TRAP
E]I have and will maintain Worker's Compensate.Lisa....as required by Section
370dafthe LabarCMe,farthe performance of the work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My WorkCamp palign lnsv ancec 'er and Policy numherare: GAS-EA.SYSTEM-OVER 4(EA)
Cartier ` Policy No.:
s CERTIPI ATE OF EX PION FROM WORKERS'
COMPENSA ION INSURANCE GREASEJINDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FEES
(This sec[ionneed not becompletW ifthe permit is foram,hundred dollars($IBB) GREASE.TRAP
or leas,) PLANCHECK FEE
I certify found the Performance ofthe work forwhich this permit is issued,l shall SEWER-SANI'T'ARY-STORM EA.200 FT
not employ any person in any manner seas to become subjecno the Workers'Compen- ENERGY FEE
O ,� sation Laws of CalifomimDae WATER HEATER WNENT/ELFCTR GRADING FEE
O Applicant
y NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should WATER SYSTEMITREATING SOILS FEE
become subject o the Worker's Compensation provisions of the Labor Code,you must
Wforthwith comply with such provisions or this permit shall be deemed revoked WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY _ NEW RESIDENTIAL PLMB. SQ.FT. PAID
U Q (hereby affirm that here is acons[mdion lending agency for the performance of Dare RecciptM
(~ the work for which this Permit is issued(Sec.3197,Ci,C.) TOTAL:
O U Lender's Name -
Lender's Address TOTAL:
As 1 cenify that 1 have read this application and state that the above information is BUILDING PEE
fr to emrect.I agree an comply with all city and county ordinances and state laws miming to QTY. MECHANICAL PERMIT FEE
(� building coronation,and hereby minimize representatives ofthis city to enter upon the SEISMIC FEE
above-mentioned timpsny for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
liabilities,judgments,cams and expenses which may in any way aceme against.said City ALTER OR ADD TO MECH.
PLUMBING PEE
in consequence of the granting this permit.
APPLICANT UN ERpSTANDS AND WILL COMPLY WITH ALL NON-POINT PIR HANDLING UNIT(TO 10,0011 CFM) MECHANICAL FEE
SOURCE RNS. � // 7 -
G 4 / AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCf10N TAX-'
Signau nApplicanr/C J Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Wllthe applicant o,return huildiagocempantsmreorhandle hazardous.natena] HEATING UNIT(TO IN,"BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety -
HEATING UNIT(OVER Inn,IXN)BTU)
Code,Section25532(a)R
❑Yea ❑Nc VENTILATION PAN(SINGLE RESID) PAID —
Will the applicant or future building oecupum use equipment or devices which Dam Reeeipta
BOILER-COMP PHP OR 111(,000 BTU)
•emit hazardous air contaminants as defined by the Bay Arca Air Quality Management TOTAL:
District? BOILER-COST(OVER lffl, 0BTU) _
E]yes 7N
I have read the hazardous materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
famia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.IIT.
building does not currently have a tenant,that it is my responsibility to notify the eccupant '
of the mgcirements which must he met prior to issuance of a Certificate of Occupancy.
Owne,or emhonzed agent Data TOTAL: ISSUED .
OFFICE