99110110 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL
BUILDING DIVISION APPIACATION/PERMIT PLUMBING-MECHANICAL .
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: SANITARY NO. ]CATIA AL DATE
L�q c _o �so
OWNER'SNAky PHONE: CONTRACTOR'S NAME: LIC NO:
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ARCHITECANIGINEER:
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ICN : O ADDRESS: ❑
CONTACT': PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ C2' ❑
LICENSED CONTRACT'OR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm Thal 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
wo,awz with Section 90(X1)of Division Sof the Bueines<and Professions Catm
lc. d my license is
O O PERMIT ISSUANCE RESIDENTIAL:
F in Tull force anti c0'at.
aUU License Close Lica OSFDWL El KITCHEN REMODEL
N<L Date Contractor APPLIANCES—RESIDENTIAL. [I ADDITION D PLUMBING RE-PIPE
ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT 0STRUCTURAL
,'z o n z l undcrstnnd my plans shall be axed ris publso men ds MODIFICATION
EP.Y a UP TO NNIAMPS [I INTERIOR E)CHIMNEY REPAIR
Ckz� Licensed Professional 20140MAMPS IMPROVEMENT ElSWIMMING POOLS
OWNER-BUILDER DECLARATION OVER I(NIB AMPS ❑BATH REMODEVREPAIR C1 DEMOLITION
y C Q 1 hereby affirm that I am exempt from the Contractors License Law for the
x 3 d F following reason.(Section 703 S,Business and Professions Cale:Any city or county SIGNS ELECTRICAL D OTHER
F
coor H which requires a permit to conamet,alter,improve,demolish,or repair any stmemm
prionuits itAterwe,slso requires theapplicant for such pamiuo file alignedsutement SPECIAL CIRCUIT/MISC.
that he is licensed pursuant to the provisions of the Contractor's License Law(Chaldcr9
u�1�CCa (commencing with Section 90001 of Division 3 of the Business and Professions Code)or TEMP.METER OR POLL INST.
ThR
a e LL al he is exempt rherefmm and the basis for the alleged exemptior.Any violation of D NEW BLDG/ADDITION D DEMOLET ON
�y Section 7031.5 by any applicant for a prrmit subjects the applicant its a civil penaltyof POWER DEVICES 0TENANT DFOOD SERVICE
�t�re man five hundred dollars(550% IMPROVEME
�I.asowneral the progeny,or my employees with wage.as their sole compensation, SWIMMING POOL ELECTRIC '
will dome work,and me swmure is not intended monitored for sale(Sec.96tq Business ❑OTHER
Wa and Professions Code:The Contractor's License Law does not apply m an owner of OUTLET'S—SWITCHES—FI%TU S
popery who builds 0r improes vthereon,and who dal such work himself or through
his own employees,provided that such impartment are not intended or offered for NEN'RESIDENTIAL ELECTR
sale.If.however the building or improvement is sold within one year of completion,the SQ.FT.FLOOR AREA S/SQ.FT,
ser-h rilder will have the burden of proving that he did not build or improve fm nit,
pose of sale.).
D I,as owner ol'the property,am exclusively contracting with liccuwd comracma m TOTAL:
nnstrect the Project(Sec.9044,Business and Professions Code:)The Comrvcmr's Li-
nsa Law does anti 1.mownerofpropeny who builds no imprnvesmereon,and QTY, PLUMBING PERMIT FEE
who contracts for such projects witha eoa eeorg)Ilceamd pormanl m the Conlmctors
License Lew. PERMIT ISSUANCE
I nm exempt under Sec. ,B&P C for this reason
Owner Date ALTER—DRAIN&VENT—WATER GIA) VALUATION
RK 7 S C MPENSATION DECLARATION BACK IlOW PROTECT.DEVICE
1 hereby aRrm under penalty of perjury one of the following Jcclamtions:
❑I have and will maintain a Ccnificmr of Consent mself-insure for Worker's Compen- DRAINS—FLOOR,ROOF.AREA.GOND. STORIES TYPE CONSTRUCTION
sation,as provided for by Section 37W of the Lahr Code.for the performance of the
work for which this petmll is issued, FIXTURL•S—PER TRAP
D 1 have and will maimmin Worker's Compensation Insurance,as required by Sermon
37M of the Lahr Code,for Ne performance of the work for which this permit is issued. GAS—EA.SYSTEM-I INC.J OUTLETS OCCGROUP ^l
My Worker's Compensation Insurance carrier and Policy number am: G.
Curia: Policy No: GAS—IIA.SYSTEM-OVER 4(EA)
CERTIFICATE.OF EXEMPTION FROM WORKERS'
COMPENSM ION INSURANCE GREASE/INDUSTRL WASTE INTERCEPTOR
(This cation neM not becompined if the permit is forone hundred dollars(SI WI BUILDING DIVISION FEES
nr less.) GREASETRAP PLANCHECK FEE
I terrify that in the performance ofam work for which this permit is issued,Ishell SEWER—SANITARY—STORM EA.200 PT.
not employ any Persian bec
on in any manner so as to ome subjectto me Workers'Compen- ENERGY FEE
C) swiou Lawsof Califomia.Data WATER HEATER WNENT?LEMR
Z 0 Applicant GRADING FEE
y NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should WATER SYSTIiMCREATING
become subject to me Worker's Compcnaation provisions of the Labor Cale,you must, 5'GILS 7\
0. Q forthwith comply with such provisions or tris permit shall be deemed revoked. WATER SERVICE z - I
� z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. �� Dem R
U 0 I hereby affirm that there is a concoction lending agency for the performance of
GL 1"t the work for which this permit is issued(Site3097,Civ.CJ
0 U Lenders Name TOTA
r U Lenders Address TOTAL:
1 cenily that I have read this application and state that the alive information is LDING FEE
TZRI cored.l agree to comply with all city and county ordinances aM scam laws mining to QTY MECHANICAL PERMIT FEE
U Z, build'mg construction and hereby author,.repremonaaves ufthis city menterupon the 4EIDAIC FEF.._ —�-�
alive-mentioned property for inspection proposes. PERMIT ISSUANCE J-
I We)agree Ira ave,indemnify and kttp harmless th<Ciry of Cupertino against ELECTRIC FEE
liabilities.judgments,costs and expenses which may in any way accme against said City ALTER OR ADD TO MECH.
in consequence of Ne granting of this permit. ALTER FEE
APPLICANT UNDE TANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IQ000 CEM)
SOURCE REGULA ONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER 10.(100 CFM) CONSTRUCTION TAX
Signature o[Applicamostintractor Dole EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building acupanl store or handle wounlous mumnal HEATING ON[*[(TO 100,0(01 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)'f HEATING UNIT(OVER 108000 BTU)
D Ye, ONo VENTILATION FAN(SINGLE RPSID) PAID -
Will the applicant or future building occupant use equipment or devices which Date Receipt x
emit hazvdous air contaminanu az defined by the Bay Area Air Quality Management BOILER—COMP(3HP OR 100,0011 BTU)
Dixatc6 TOTAL:
E3 yes F1 No BOILER—COME(OVER 100,000 BTU)
I have round the ha.rdous materials requirement under Chapter 6,95 of the Cali- AIR CONDITIONER ISSUANCE DATE
forme g ccslth&Safetynot
Code,have
5505.2553)end 25534.1 understand mm Bible NEW RESIDF.NTIAI.MECH. SQ.FT
building Jas not currently hove a mrwnt,that if is my respm55TL 1 to notify the acupam d
ofth irctrcm hich muss be met prior to issuance of f Occupancy.
rdamariud m air,, Date TOTAL: ISSUED BY:
OFFICE