S 0739 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
r CITY OF CUPERTINO BUILDING-ELECT RICAI. PERMIT NO.
BUILDING DIVISION APPLICATIOW/PERMITPLUMBING-MECHANICAL S 0739
BUILDING PROJECT IDENTIFICATION
� SANITARY NO. APPLICATION SUBMIITE.
9L DAT
BUILDING ADDR[S5:
OWN i'SNA PHONE: C NT CTOR'S AME: LIC NO:
NIC CONTROLp
ARCHRECr/fiNGINEER: LIC NO: ADORES V�y CIwit
❑
ONTACT. - PHONL•: •Ii BUILDING PERMPf INFO
❑'Consultant Pees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CONTRA OR'S DECLARATION QTY. ELECTRIC PERMIT FEE JOB DESCRIPTION
1 hereby amlm that 1 am licensed under provisions of Charter 9(commencing
�QZ wish Section 3 of Ne Business and Professions Code,and my license is PIiNMIT ISSUANCE RESIDENTIAL;
ttyy
in full force and elle 05FDWL OKITCHIiN RF.MODEI.
�VU Lsensc Class Liwaa APPLIANCES-RESIDENTIAL ❑ADDITION OPLUMRINO RF-PIPE
N66 Dale i'—W.-_— lmchat
ARCHITECT'S DECL I PANELS ❑MULT4UNIT ❑STRUCTURAL.
F•�Z I understand my plans%hall be,used as public recnMs CHIMNEYREMODIFICATION
Oil TO 2(w AMPS ❑INTERIOR ❑CHIMNEY REPAIR
F
4I-M Licensed Rofesainnal 201-1000AMPS IMPROVEMENT ElSWIMMING POOLS
SaOWNER-BUILDER DECLARATION OVER 1(M AMPS 0 RATH REMODEL/RF.PAIR ODEMOLI ION
yy �a I hereby sift..sha!I um exempt from the Cmara tnr'x License Law for @c ❑OTHER
X�YV following lemom(Seaima 1031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL
W3 LL Pv's which requires a permit m construct,alter,improve,demolish,or repair any slmcmrc
F-�DQ prior to iu issuase,also requires the mppl'mam for such permiuo flcasigneJ antemmt SPECIAL CIRCUITIMISC.
;!I} that he is licensed pursuant m@e provisions ofshe Contractors License Lrw(Chapsar9 — COMMERCIAL
W�C 00 (commencing with Section 7")of Division 3 of Ne Business and Professions Code)or TEMP.METER OR POLEINS'L
L cy that he is exempt therefrom mad the basis for Ne alleged exemption.Any violation of ❑NEW BLDG/ADDITION El DEMOLITION
WAN Section 7031.5 by any,applicom for u permit subject the uppliewo 1.a civil penalty of POWER DEVICES []TENANT 0FOOD SERVICE
nm mare than five hundred dollars($5001. IMPROVEMENT
I. G 01..rmneroflhe property.Or my employees with wages as theirssle compensation. SWIMMING POOL ELECTRIC
will do she work,en0 the swcmre is nm intended ondfered lOr sole(ties 7044 Bmine,s ❑OTHIiR
Yat and Professions Code:The Contractor's License Law doe%not apply to:m owner of OUTLETS-SWITCHES-FI
o• — 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 RESIDENTIAL ELECT SQ FT.
sale.If,however.the building or improvement is sold within one yew of compldian.the SQ.17.I400R AREA 5/SQ.fT.
MisraFbuilder will base the huNen of proving that he did not hmld m iinpmve for par
Now of sale.).
0 I,as owner of the property,am exclusively contracting with licensed central to
construct Ne prim'IS.,70,14,Business end Profession 1pw:)'Ibe Cotnracmr's Li-
censeLaw doesnot apply to an owner of property who builds or improves thermal.and QTY. PLUMBING PE 1 EE
who contracts for such projects with a crmuacmr(s)licensed pursuant to Contractors
License Law. PERMIT ISSUANCE
0 l am exempt under Sec. .B&P C In thio reason
ALTER-DRAIN&VENT
-WATER( ) VALUATION
Owner Dow
WORKER'S COMPENSATION DECLARATION BACK FLOW FROTH .DEV ICF.
I hereby affirm under penhy of perjury one of the folhswing Jedamrianx:
Ihavc
van Maw
Imalka¢of Cansenvn tel Ginsure for Wnrkds Comp:n- DRAINS-Ff.OfIR,ROOF,AREA.GOND. STORIES TYPE CONSTRUCTION
as provided for by Section 3700 of the Labor Corte,for the performance of the
rk for which Nix permit is issued. FIXTURES-PER TRAP
res 1 have and will maintain Workers Compensation Insurance,as required by Section
37fUof Ne Labor Code,for Nc pafornrance of the work for which this permit is issued. GAS-EA.SYSTEM-I INC.40UT S1 OCC.GROUP APN
MY Wr'rkfr%C9n'Iensatin sunm cwria nnJ PoliaY GAS-EA.SVS7F.M-OVER4(EA
Carrier:(�Q,IQ Policy No.:
CERTIFICAT P EXEMPTION FROM WORKEkS' GRGASFJINDUSTRL WAS'T'E INTERCEPT' R
COMPENSATION INSURANCE
BUILDING DIVISION FIiF.S
(This section need notWcnmpleteJ if the permit is fmrone hunJmlJ011ors(41110) GREASE TRAP
Or less.) PLANCHECK PEG
Icenify that in she perfommnce ofthe work for whichthispennit isisnued,IsM1all SI?WIiR-SANITARY-STORM LA.206 FT.
, notcmplmy any person in any mannermus m�ecome suhjecnothe WOrkeri Cnmpen- ENERGY FEE
Z cation Laws OI Culifomin.Date WATIiR HEATER WNFNTIELECI'R GRADING PER
zQ Applicant
r.y gl NOTICE TO APPLICANT.IL after making this Cenifcete of Exnnption,you should WATER SYSTEMRREATING SOILS FEE
rl bmome subject m the Workers Compenrutinn pmvisions of the LahOr Cadc,you run
{aE1 O forthwith comply with such pr�visionsrnthio permit shnllWJmmW rvokeJ. WATER SERVICE ..
U O CONSTRUCTION LENDING AGENCY NEW R17SIDENTIAL PLMB. SQ.FT. PAID
I hereby difrmthat there is.cowflowlion lending agency for the performance s( Dae RmeiptM
H the walk far which this permit is issued(Sec.3097.Civ.C) 'TOTAL.:
O U Lender's Name
Lenders Address TOTAL:
'bks WCL. I certify that I have read this application and state that the above information is BUILDING FEE
IrA coect.l agree to comply with all city and county ordinances and stun laws relating m QTy. MECHANICAL PERMIT FEE , SEISMIC FEE
U Z holdingcnnuucrion.and herebyauthmile rpmumaives'If this city or enter upon the
r above.roadi ara property for inspection puryaes. PERMIT ISSUANCE ELECTRIC FILE
(We)agree m save,indemnify and keep him less the City of Cupertino against
liabilities,judgments,costs and expenses which may in any way acaearsimnst Maid City ALTF.RORADDTOMECH. PLUMBING FEE
in consequence Of the gmming of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CFM) MECHANICAL FEE
SOl'RCE REGULATIONS.
\ 'A"��\, AIR HANDLING UNIT(OVER if(ml CFM) CONSTRUCTION TAX
Signa ApplAppl enU o—on, J / i/ Dae EXHAUST HOOD(W/DUCT) RE
ON FEE
(/ HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant stow or handle becommus material HEATING UNIT LTO 100.000 BTU)
ns defncd by the Cupertino ManiciPsl Code.Chapter 9.12.and[lie Health and Safely HEATING UNIT(OVER I W.Iglll BTU)
Code.Steps.25532(a)^
O Ycs ON. VENTILATION FAN(SINGLE RESID)
Receipt X
Will the applicant m fear.Wilding occupant use equipment or device,which 601LER-COMPIJIIP OR I(q,glU 111 U)
•mit Wrardous air contaminants as def nal by the Bay Ara Air Quality Management TOTAL:
i,Mcrt BOILER-COMP(OVER 1(10,1X10 BTU)
❑Yea MNo
I have toad the haempus materials rtquiremenls under Chapter 695 of the Cali. AIR CONDI9'IONER SUANCE DATE
fond.Health&Safety Cade,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDP.NTIAL MECH. SQ.IT.
building does nor currently haveatenanLthat it is my msponxihilirymrwufy the occupom
of the '¢teen which st meted n issuartccofa Cenif¢aeof urea y.
Owner Rud agent Dae 'TOTAL: ISSUED BY:
OFFICE