31048 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES,USE BALL POINT PEN ONLY -
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO,
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDING ADDREgS: - SANITARY NO. APPLICATION SUBMITTAL DATE
O R'SNAME:^ - PHON : CO RACTOR'SNAME: LIC NO:
UL 1k&15/ CONTROL#
s CHITECVENGINEER: - LIC ADDRESS:
.,.'CONTACT: _ PHONE BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial), BLDG ELECT PLUMB MECH
LICENSED CONTRACTORS DECLARATION TY ELECTRIC PERMIT FEE ' ❑ ❑
1 hereby.affirm that I am licensed under provisions of Chapter 9(commencing' JOB DESCRIPTION
Woo with Section 7")of Division 3ofthe Business and Professions Cale,and my license is
F w p in full force and effect. PERMIT ISSUANCE - RESIDENTIAL
�UU License Class Lic.# O SFDWL ❑KITCHEN REMODEL
rF � Date Contmotor APPLIANCES-RESIDENTIAL El ADDITION ❑PLUMBING RE-PIPE
g,D on¢ ARCHITECI"S DECLARATION
,x O E q 1 understand my plans shell be used as public records PANELS �❑MULTI-UNIT 0 STRUCTURAL
OZ 0 UP TO 201)AMPS MODIFICATION
tl] Ucensed Professtonnl, INTERIOR - El CHIMNEY REPAIR
CCC777 +a',
OWNER-BUILDER'DECLARATION 20I-IINxIAMPS IMPROVEMENT
1 hereby affirm that I am exempt from the Contractor's License Law fur the OVER 1000 AMPS ❑BATH REMODEL/REPAIR 0 DEMOLITION
>(a F following reazon.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL OOTHER
lic
tv Q which requires a permit to vacation,alter,improve,demolish,or repair any structure
h prior to its issuance,atm requ on,the applicant for such Permit to file a signed statementSPECIAL CIRCUIT/MISS.
thatheis licensed pursuanlm the provisions ofthe Contractor's License Law(Chapter 9 ,
y� d (commencing with Seelion 9000)cf Divi,ion 3 ofthe Business and Profession Code)or TEMP.METER OR POLE INST. COMMFRyLAI -
0.y e C that he is exempt therefrom and the basis for the alleged exemption.Any violation of _ ,. ❑NEW BLDG/ADDITION ❑DEMOLITION
i� Y. Seninn 7031.5 6y any apPlicamfor.permit subjects the applicant toacivil penalty of POWER DEVICES
Z j not more than five hundred dollars(SSW). 0 TENANT 0 FOOD SERVICE
01.asownerofthe propeny,nr my employees with wages as their Sole compensation, SWIMMING POOL C ELECTRIC IMPROVEMENT'will do the work;and the structure is not inlendedorottiered fnrsale(Sce.7044,Business ❑OTHER
and Professions Code:The Contractors License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURE
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 ELECfR SQ
kala.If,however the building or improvement is sold within one year ofcompletion,the -SQ.FT.FLOOR AREA $/SQ.FT.
wner-builder will have the burden of proving that he did not build or improve for pur-
pose of sale.). t
Ell.as owner of the property,am exclusive) nilvetiu -
y co g with lioensod contractors to TOTAL:
cause uctLa the poles not (Sec. r no Business and Professions ds or
Theves thecmr's and
#y,
cense Lawdoesfors apply man Ownerofpropeny who builds or improves thereon,end QTY. PLUMBINGPERMIT FEE 1_
who contracts for such pro ems wi sacontmmor(s sed Pur mthe Counaturs
License Law.
❑1 am exam t d c. ,B&P C for this aeon PERMIT ISSUANCE
Owner Dote ALTER-DRAIN&VENT-WATER(EA) b N
WOR ER'S COMPENSATION DEC RATIO u/.
BACK FLOW PROTECT.DEVICE
I hereby affirm under penalty of pedury one otrue Ilowing declarations; LUr'4LL++)) -
01have and will maintain.Ceniftcate of Consent to self-insure for Workers Compeer DRAINS-FLOORROOPAREA,COND. nll�
sation,as provided for by Section 37M of the labor Code,for the,pconsomme Of the , , STORIES - TYPE CONSTRUCTION
work for which this permit is issued. FIXTURES-PER'rRAP "
0 I have and will maintain Workers Compensation Insurance,as required by Section
377 Of the labor Code,forthe Performance ofthe work for which this permit is issued. GAS-EA.SYSTEM-1 INC.4 OUTLETS
My Worker's Compensation Iasumnce carrier sad Policy number urn. OCC.GROUP APN
Carrier: Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROMWORKERS'
'COMPENSATION INSURANCE GREASPIINDUSTRL WASTE INTERCEPTOR
(Thee section need nm he completed if the permit is I'carcne hundred dol lan,1$100) BUILDING DIVISION FEES
Or loco.) GREASE TRAP r
i - loenlfy that in the perfortnanca ofthe work for which thio � PLANCHHCK PEB
pertnimkaok C,lshall SEWER-SANITARY-STORM EA.200 FL
not employ any person in any nomination,m become subject m the Workers'Compen-
Z cation Laws of California.Dam 'ENERGY FEE O Applicata WATER HEATER WNENVELECTR
-• GRADING PEE
ti NOTICE TO APPLICANT.If,after making this Cenifcate of Exemption you should -
becomesubjectmtheWorkersCompenation provisions of the labor Code,you must WATER SYSTENATREATING
(Yt SOILS FEE
forthwith comply with such provisions or this permit shall be deemed revoked.
a Q - DWATER SERVICE
� z CONSTRUCTION LENDING AGENCYNE WRESIDENTIALPLMB. SQ.FT: PAID
V Q t .I hereby affirm that there is a construction lending agency for the performance of ..Date Receipt#
Wt the work for which this Permit is issued(Sec.3097,Civ,C.)
C Lender's Name _
Lenders Address r - TOTAL:
TOTAL:y I certify that 1 have rein this application and stain that the above information relating is BUILDING FEE
UVl cumin.l agree to comply with all city and county ordinances of and citta laws relating to QTY, MECHANICAL PERMIT FEE
`� above-ng mentioned
hereby impaction
purporesenmtives of this city memer upon the SEISMIC FEE
above-mentioned property for inspection pnirposes. � ,
(We)agree to save,indemnify and keep harmle a Cit of Cu nium a PERMIT ISSUANCE pe against ELECTRIC FEE
liabiliA
nde sw ch ma any wu c meagain. id City ALTFRORADDTOMECH.
m conof Nix p' it. c PLUMBING FEE
APPLNDSA WIL. COMP WITH AI N-POINT AIR HANDLING UNIT90IO,OW CFM)
SOURMECHANICAL FEE
AIR HANDLING UNIT(OVER 10,000 CFM), CONSTRULTIONTAX
Sign .amr Datc EXHAUST HOOD(W/DUCfJ
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Will the applicant or future building occupant store or handle hazandous material HEATING UNIT(TO 100,000 BTU)
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code,Sxtion 25532(e)7 HEATING UNIT(OVER 100,000 RTU)
Yea ON.
VENTILATION FAN(SINOLH RBSID) PAID
-Will the applicant or future buildin am me a Dam Receipt#
g accop equipment or devices which BOILER-COMP )
mit hazardous air contaminants as JefinC by the Bay Area Air Quality Management (3HP OR 100,000 RTU r
Distract? - D
❑Yes- ONO- BOILER-COME(OVER 100,000 BTU)
I have re e hazard s materials require der Ch 5 of the Cali- AIR CONDITIONER f
fomes Healt S ,S tions 25505, 3 a 255 un rood that if the t ISSUANCE DATE
building mntly ha atetmn6N ism spo iliry notify the occupant NEW RESIDENTIAL ME CH. SQ.FT.
of there no tswhich stbemet rte' aCe ' camof Occupancy. -
Ow roraunan" gent Date TOTAL: ISSUED BY: I..
OFFICE"
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