99090063 (2)APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY O
CITY OF CUPERTINO BUILDING - ELECTRICAL
PeR
BUILDING 131VISION APPLICATION/PERMIT PLUMBING - MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDsNG ADDRESS:
-
SANITARY NO. APPLICATION SUBMITTAL DATE
a a
r
OWNERS NAME PHONE:
ONTR CTOR'S NAME'. LIC NO:
N/C
CONTROL#
.1 _ 135
❑
RCHITELT/EN INEER: LIC NO:
ADDRESS:
CONTACT: PHONE:
BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant (Initial)
BLDG ELECT PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
1 herion 7 affirm mat I am f he Bu under and
with Section ndaffecDivisinn3oFthe Business and Pm(esslons Code, and mylicemeis
Podrns of Chapter 9 mylicense is
in full force and arrest.
License Class Lick
Dam Cootrector
Qom, ELECTRIC PERMIT FEE
Wore,
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JOB DESCRIPTION
RESIDENTIAL:
❑SFDWL ❑KITCHEN REMODEL
El ADDITION ❑PLUMBING RE -PIPE
❑ MULTI -UNIT ❑ STRUCTURAL
MODIFICATION
[I INTERIOR ❑ CHIMNEY REPAIR
IMPROVEMENT SWIMMING POOLS
❑ BATH REMODEL/REPAIR ❑ DEMOLITION
❑OTHER
PERMIT ISSUANCE
APPLIANCES—RESIDENTIAL
ARCHITECTS DECLARATION
1 understand m y p urs shall be used as public records
PANELS
UP TO 200 AMPS
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Comment's License Law for the
following musom. (Section 20315, Business and Professions Cade: Any city or county
which requires a permit to inalto, improve, demolish, or repair any spuctere
prior m its issuance, also requires the applicant for such permit to file a signed statement
2U1-IOAMPS
201-1000AMPS
OVER 1000 AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC.
3a0a �0
Goy'
m W
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CZO
that he is licensed pursuanuo the provisions fine Centauri License Law (Chapter 9
(commencing with Section 2000) ofpickiest 3 of the Business and Professions Code)or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 2031.5 by any applicant fora pomdt sub,,m d e 0p,li.aI to n civil Penalty of
tmore man five hundred dollars )8500).Fair
❑hesowner of the property, nr my employees with wages as their sole compensmion,
TEMP. METER OR POLE INST.
COMMERCIAL:
❑NEW BLDG/ADDITION El DEMOLITION
❑ TENANT [I FOOD SERVICE
IMPROVEMENT
OTHER
POWER DEVICES
SWIMMING POOL ELECJ'RI
dd
will clothe work,and thesvucmoar,ut imeudedmafiered heroism (So,, 7044, Business
OUTLETS—SWITCHES —FIXTU S
^
1 m
and Professions Cade: The Contractor's License Law does not apply to an owner of
property who builds or improves thereon, and who does such work himself or through
his awn employees, provided that such improvement, are not intended or offered for
NEW RESIDENTIAL ELECTR SQ FT
si,iaSQ.
FT. FLOOR AREA
$/SQ. FT.
sale. If,however, the building or improvement is sold within one year ofecmpletion,the
oa
her -builder will have the burden of proving that he did not build or improve for pur-
Ms 're.
TOTAL:
esr of the pmpeny, am exclusively competing with licensed convectors m
consumer theepocact (See. 2044, Business and Professions 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 c ourecter(s) licensed pursuant to the Contractor's
PERMIT ISSUANCE
License Law.
❑ lamexemptunder Sec. ,B&PCfmthisreawn
ALTER— DRAIN & VENT — WATER (EA)
wrier Dale
VALUATION
BACK FLOW PROTECT. DEVICE
W S COMM NSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
DRAINS— FLOOR, ROOF, AREA, COND.
❑ I have and will maintain a Certificate of Consent o self -insure for Worker's Compen-
sation, as provided for by Section 37M of the Labor Code, for the performance of the
STORIES TYPE CONSTRUCTION
FIXTURES —PER TRAP
work for which this permit is issued.
El 1 have and will maintain Worker's Compensation Insurance, as required by Section
37M of the Labor Code, far the perforromme.( the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number are:
GAS—EA. SYSTEM -1 INC. 4 OUTLETS
OCCGROUP �APNO/
10
CarrierToday No
. .'.
GAS — EA. SYSTEM -OVER 4 (EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed iFthe permit is forone hundred dollars
mless)
GREASE/INDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION
GREASETRAP
PLANCHECK FEE
I certify that lathe performance ofthew.rk for whichthispermitisisaued,(shall
not employ any such in any manner so as to become subjem to the Workers' Compact -ENERGY
SEWER — SANITARY — STORM EA 200 FT.
FEE
l7 Z
O
action Laws of California. )late
Applicant
WATER HEATER W/VF.NT/ELECTR
GRADING FEE
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject to the Weakels Compensation provisions of the Labor Code, you not
forthwith comply with such pmvisionsor thispermit shall he deemW revoked.
CONSTRUCTION LENDING AGENCY
(hereby affirm that construction hem is a coction lending agency for the performance of
WATER SYSTENUTREATING
WATER SERVICE
y
h
W�'•r
6t ❑
Uo
SOILS FEE
.v
>
�D
NEW RESIDENTIAL PLM#. SQ. FT.o ('PAi
" e O Reeefp
b+
O f^
the work for which this permit is issued (See. 3092, Civ. C.)
Lender's Name
\\•' p TOTAL.
Address
WLender's
>a1
N
L) Z
TOTAL:so
HViI DING FEE
certify that 1 have read this application and state that the above information is
correct. I agree to comply with all city and county ordinances and state laws reining to
building construction, and hereby authorize representatives of this city to enter upenthe
- -
QTY. MECHANICAL PERMIT
kil
SMIC PEE
above-mentioned property for inspection purposes.
(We) agree m save, indemnify end keep harmless the City of Cupertim against
PERMIT ISSUANCE
ALTERORADDTOMECH.in
FEE
liabilities, judgments,costs and expenses which may in any way accrue against.said City
con.sequcnce ofthe granting of this permit.MBING
AIR HANDLING UNIT(TO IO,000 CFM)SOUS,�GULATIONS. IMECHANICAL
.E
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
AIR HANDLING UNIT (OVER IU,00) CFM)NSTRUCT(
X
Sigmafim ofApp1m Vonuacan"Dow
ZARDOUS MATERIALS DISCLOSURE
EXHAUST HOOD(W/DUCI•)USING
MITI TION FEE
Will the applicant or future building occupant store or handle hazardous material
HEATING U N IT( TO 100,000 BTU)
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
-
Code. Section 25532(0)!
HEATING UNIT (OVER 101600) BTU)
❑Yea ON.
PAID
VENTILATION PAN (SINGLE RESID)
Dole Remi
BOILER—COMP(JHPOR IW,IXI00TU)
Will the applicant or future building occupant use equipment or devices which
mit hazardous air contaminants as definul by the Bay Area Air Quality Management
District?
❑Yes ON.
T
BOILER— COME (OVER 100.100 BTU)
AIR CONDITIONER
I have read the hazardous materials requirements under Chapter 6.95 of the Cali-
ISSUANCE DATE
NEW RESIDENTIAL SUCH. SQ. Fr.
forms Health & Safety Core, Sources 25505, 25533 and 25534. 1 understand mat if the
building does not currently have a tenant that it is my responsibility to notify the oeeupant
C7J
of the re - mems which must met p'or m issuance of u Canificam of Occupeuey.
CC
ncr or authorized or Data
TOTAL:
ISSUED BY:
OFFICE