99080146 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY q ag 0/L1 45P
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION ;
BLT,LDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
OWN R'S NA PHONE: CO RACTOR'S AME: LIC NO: NIC CONTROL#
Q✓t rrlS — /'i9
ARCHITECTIENGINEER', LIC NO'. ADDR S: ❑
0 9 7 r.Qc 6+2 c
oNTACT: PHONE. BUILDING PERMIT INFO '
FnH 5 3—rX,/E4 El Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ L ❑
LICENSED CONTRACTORS DECLARATION QTY, ELECTRIC PERMIT, FEE
1 hereby firm tot 1 m licensed d under previsions of Chapter 9(commencing - _ JOB DESCRIPTION
�OZ with Section 7000y.fEnlilich 3 flhe Bnirassand Profess'ane Cede and myliceseis RESIDENTIAL:
Or
in full f d effect PERMIT ISSUANCE
oUVLicense Clan. Lica DSFDWL D KITCHEN REMODEL
ti�a Dare Cnmmctor APPLIANCES—RESIDENTIAL []ADDITION RTMMBINGRE-PIPE
ARCHITECT'S DECLARATION D MULTIUNIT D STRUCTURAL
Z O raj rZr I understand my plans sM1a11 be used as public recorPANELS ds MODIFICATION
O Z"0 UP'T0200 AMPS ❑INTERIOR ED CHIMNEY REPAIR
F im.,Fq Licensed Professional 201-1000AMPS IMPROVEMENT
Oat I ma exempt
to DECLARATION ❑SWIMMING POOLS
pp,, ffLL< I hereby affirm that I am exempt from the Commdor's License Law for the OVER I000AMP5 ❑BATH REMODEI/REPAIR D DEMOLITION
W3F following reason.(Section 7031.5.Business and Professions Code:Any city or county SIGNS ELECTRICAL D OTHER
F O which requires a permit to construct,alter,improve,demolish,m repair any structure
prim to its issuance,also requires the applicant for such permit to file a signed statement SPECIAL CIRCUIT/MISC.
6� that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9
Iy Commencing with Sulion]000)of Divisiou3 ofthe Business and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL:
that he is exempt Iherefrnm and the basis for Ne alleged exemption.Any violation of D NEW BLDGIADDITION D DEMOLITION
iC t�wZSuedon]03L1 hyany applicant forapermitsuhjects theamducant too civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE�s not more than five hundred dollars($500). IMPROVEMENT
560 ❑ Lus owner of the propetty,nr my employees wiN wages as their sole compensmion, SWIMMING POOL ELECTRI
F wdl do the work,anJ the saucwre is notlmended orofferedfor sale(Sec]044,Business El OTHER
aim and Professions Code:The Contractor's License Law does not apply to an owner of OUTLETS—SWITCHES—F TU
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 ELECTS S150
sale.If,however,the building or improvement is sold within one yearofcompletion,the SQ.IT FLOOR AREA $/SQ,FL
owner-builder will have the burden of proving that he did not build or improve for pur-
pose of sale].
D I,as owner of the properly,an exclusively contracting with licensed contractors to TOTAL:
constrvct the project(Sec.7044,Business and Pmfeceiens Code)The Contractor's Li-
cense Law does not apply to an owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT' - FEE
who contracts for such projects with a eontraetuds)licensed pursuant to the Contractor's
License Law. PERMIT ISSUANCE
❑ I am exempt under Sec. ,B&PCferthisreamn
Owner Date ALTER—DRAIN&VENT—WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK PLOW PROTECT.DEVICE
1 hereby alarm under penally of perjury one of the fallowing declarations:
I have and will maimain aCertifese of Consent to self-insuro for Worker's Compete DRAINS—FLOOR,ROOF,AREA,COND.
STORIES TYPE CONSTRUCTION
as provided for by Section 3700 at the Lahnr Grde,for the performance of the
work for which this permit is issued. PIXTURP;S—PER TRAP
@00 ofth L will maintain Worker's Compensation Insurance,h required by Section
My eche Labor Cade,for a I Formandame for whichthis permit isissued, GAS—EA.SYSTEM-I INC.40UTf.ETS
My We 9Cotcase f9n h�furunce urrier and Palicyn Wye OCC GROUP APN
Carrier a Policy No.: S 3l(ti I GAS—EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF E)'•MPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEANDUSTRL WASTE INTERCEPTOR
(This seclion need sol be completed If the Females forone hundred dollars($1 W) 41UIL151NQ DIVISION'M
or loo.) GREASE TRAP PLANCHECK FEE
I certify that in the performance oftlte work for which this permit is issued,l shall SEWER—SANITARY—STORM EA.200 FT.
not employ any person in any manner so an to lecture subjectto the Workers'Common- ENERGY FEE
Z sation Laws of California.Date WATER HEATER WNENUELECTR
7Q O Applicant GRADING FEE
q y NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEMITREATING
become subject m the Worker's Compensation provisions of me Labor Cede,you mon SOILS FEB
04 DJ forthwith comply with such previsions or this permit shall be deemed revoked, WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
V l for
thatpermit i is.nd(Seeti30 len ding agency for the performance of Date ReoeiptN
L4 NC work for which this permit is issued(Sec 309],Gv.CJ
O Lenders Name TOTAL:
V Lender's Address TOTAL:
I certify that 1 have read this application and state Nut the above information is BUILDING FEE
�.h7 correct.1 agree m comply with all city and county ordinances and state laws slating m QTY. - MECHANICALPERMIT " FEE
V Z building construction,and hereby authorize representatives ofthis city to enter upon the a - SEISMIC FELE
above-mentioned property for inspection pmposea' PERMIT ISSUANCE
(We)agree reship,indemnify and keep hnrmlass the City of Cupertino against ELECTRIC FEE
liabilities,judgments,costs and expenses which may in any way terms against said City ALTER OR ADD TO MECH.
in consequence of the granting for,permit PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IQOOOCFM) MECHANICAL FEE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signature of ApplicardCumnatcmr Date EXHAUST HOOD(WMUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(TO I00,000 BTU)
as defined by the Cupertino Municipal Cede,Chapter 9.12,and the Health and Safety
Chile,Section 25532(0'I HEATING UNIT(OVER 100.(100 BTU)
El Yes ❑No VENTILATION PAN(SINGLE RESID) PAID
Date Receipt#
Will Neat,cor nlorfutureonsas building by apart the
A.Aiequipment ot Micagement BOILER—COMEQHPOR OLOWBTU)
t hawNnm air conmminunts as JefineJ by Ne Bay Arca Air Quality Management .I'O'LAL.
dctp Ely. C]No BOILER—COME(OVER 100.000 BTU)
I have read the hazardous materials requirement under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
forma Health&Safety Cede,Sections 25505,25533 and 25Y L I understand Ihat if Ne NEW RESIDENTIAL MECH. SQ,FT
building does not currently have a levant that it is my responsibility to notify the occupant
of the requirements which In rat be met prior m Issuance of a Cediftcule of Occupancy.
Owner an authorized agent Date TOTALISSUED BY:
OFFICE