30271 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY • q'.
.CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO. O
BUILDING DIVISION APPLICATION/PF.RMITv PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: - SANITARY NO. APPLICATIONSUBMITTALDATE
OWNER'S NAME: / P NE: 1 C TRACTOR'S NAME: LIC NO:
NIC CONTROL# - -I,
RCHITECT/ENGINEF.R: LIC NO: ADDRESS: ❑
CONTACT: PHONE- - BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG• ELECT'. PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR
under S oiskamDECLARATION QTY ELECTRIC PERMIT FEE -
IherebyarumthatIamfbeBdumderpr.vi.fessofs Cur 9 my license
JOB DESCRIPTION
e'Z withllto.and
Ofof Division 3of the Businexs and Professions Cade.and my licenu ie PERMIT ISSUANCE I
�O in full force and effect. - RESIDENTIAL• ,
U U License Class- Lic.# - ❑ FOWL [I KITCHEN REMODEL
rF�0. Date Contracmr, APPLIANCES-RESIDENTIAL ADDITION _ [I PLUMBING RE-PIPE .
psOm ARCHITECT'S DECLARATION . 'PANELS MULTI.UNIT ❑STRUCTURAL
.Z Or�'LL .I understand my plans shall be used as public records.. - t MODIFICATION
Ost=f .. 'UPT02WAMPS
[. {q Licensed Professional ❑INTERIOR '❑CHIMNEY REPAIR
L$` !aJ ✓ OWNER-BUILDER DECLARATION 201"IIXIOAMPS IMPROVEMENT -
1 hereby affirm that I am exempt from the Cormadicr's License Law for the OVER 10(1)AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
aL VFFF following reason,(Section 7031.5,Business and Prafessimis Cade:Any city or county SIGNS ELECTRICAL ❑OTHER
Owhich requires a pemat ns construct,almn improve,demolish,or repair any structure 1
prior to IN kamoce.alsoregmmamc applicant for such permit to file a signed statement 4 SPECIAL CIRCUITIMISC.
y,
that he is licensed pursuant to the......too,of the Contractor's License Law(Chapter9
(commencing with Section 7000)of Division 3 of the Business and Professions Code)., 'TEMP.METER OR POLE INST COMMERCIAL:
d y p4 that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
itXl k'
Section 7031.5 by anyapplicaut fora permit suhjens the applicant toe civil penalty of POWER DEVICES
�. not memµheeffivehundred d.11.(5500). ;' - ❑TENANT [I FOOD SERVICE
d of the property,or my employees with wages as theirsdle compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
t do thework,end theswmure is not intended oroffered for sale(Sec]044,Business
[I OTHER,
L and Professions Code:The,Contracmr's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
.. property who builds or improves thereon,and who dues such work himself or through his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SOFT. "
sale.If,however,the building or improvement is sold within one year of completion,the - SQ.FT.FLOOR AREA $ISQ.FT.
owner-builder will have the burden of proving that he did not build or improve for put,
WeofsaleJ.
L as owner of the property,am exclusively contracting with licensed contrdururs to TAL:
r
street 094,cttheponect(See.] Business and Professions CodeQThe Contractors Li- AUG
cense Law does not apply to an Owner of Property who builds or improves thereon,and QTY. PLUMBING PERMIT FEE G ���
who contracts for such pmjeets with a commemr(s)licensed pursuant to the Contracmts 5 C
�Lfi ense Law. - PERMIT ISSUANCE U
R I am�empt tide Secy ,It P C for this nma mi
!!!! W/
Dwn. 1#� 24� n'�-- ate®
ALTER-DRAIN&VE T-W ) VALUATION;
✓h Wm ander Penalty
DE CLARATION BACK PLOW PROTECT. VECE +
I hereby affirm under penahy of perjury one of the following declarations: 1000
❑ I have and will maintain a Certificate of Consent to self-insure fur Workers Compen- DRAINS-FLOOR,ROOF ARENA,,COND. STORIES TYPE CONSTRUCTION
s cation,as provided for by Section 37W of the Labor Code,for the performance of the
work for which this permit is issued,. FIXTURES-PER TRAP -
❑I have and will maintain Worker's Compensation Insurance,as requited by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued. GAS-EA.SYSTEM-1 INC.40UTLETS n,
s OCOGROUP, APN
My Worker's Compensation Insurance carticr and Policy number am:
Carries
Policy No.: 'GAS-EA.SYSTEM-OVER 9(EA) - - -
CERTIFICATEOFEXEMPTIONFROMWORKERS'
COMPENSATION INSURANCE GREASFJINDUSTRL WASTE INTERCEPTOR .
(This sect:..need not he completed iftho permit Is t'Orone hundred dollars($100) BUILDING DIVISION FE-0
or less.) GREASETRAP PLANCHECK FEE
I certify that in the performance of the work for which this permit is issued,I shall #
SEWER-SANITARY-STORM EA. FT.
any employ any person iia any manner so as m become subject the Workers'Compen- - - ENERGY FEE
12 cation Laws of California.Date
z Applicant WATER HEATER W/VENT/ELECfR GRADING FEE
NOTICE TO APPLICANT:If,after mailmgrthis Certificate of Exemption,you should WATER SYSTEM/1'REATING
became subject to the Worker's Compensation provisions of the Labor Code,you must SOILS FEE,
forthwith comply withsuch provisions.,this permee
it shall be dmed revoked. WATER SERVICE -- r
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. $Q.FT. PAI.
z �(, Thereby afium that then is oconstmeti.n lendln6 agency fonhe performance of - 'Date Receipt is
tfE••,ii the vmrk for which this permit is ISsry d(Sec.3099,Civ.C.)
O U Lervler'v Name - n TOTAL:
Lendeh Address TOTAL:
C I certify that I have read this application and state that the above information is BUILDING FEE 1.0
N isy est.I agree to comply withal]city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE -
U building c.nstmetion,and hereby authonm representatives of this city to enter upon the SEISMIC FEE
above-mentioned property for inspection puipows.
(We)agree to save,indemnify and keep harmless the City of Cupertino again. PERMIT ISSUANCE ELECTRIC FEE
liabilities,judgments,costsaad expenses which may in any wayaccrue against said City ALTER OR ADD TO MECH.
in consequence of the granting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
SOURCE REGULATIONS. MECHANICAL FEE
' AIR HANDLING UNIT(OVER 10,000 CPM) CONSTRUCTION TAX
Signature of ApplicanVConVactor Date EXHAUST HOOD ONMUCI HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE -
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(TO 100,000 BTU) +
as defined by the Criterion Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532hy? HEATING UNIT(OVER 100,000 BTU) u
❑YesONn - " • VENTILATION FAN(SINGLE RESID). PAID
Wthe applicant futurebuilding bequipment devices
eip #
mt hazardous air conttaminant,as defned by the Bay Aroa Air Quality Management
BOILER-COMP(3HPOR 100.000BTU)
District?. TOT
❑Kis �•s 7 N - BOILER-COMP(OVER 100,c00 BTU)
tI Ly
I have read the hamashm,dratedals requirements under Chapter 6.95 of the Cali- AIR CONDTTIONER - ISSUANCE DATE
forma Health&Safety Cody,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. ,SQ.FT.
building does not currently have a tenant,that it is my responsibility to notify the occupant +
of the requirements which must be'met prior to issuance Ofa Certificate of Occupancy. ' s
• Owner or authorized agent - Dme - TOTAL: ISSllED B1
1:
OFFICE