S 2295 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHArvICAL S 2 2 9 5
BUILDING PROJECT IDEN'PIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
"L C - 3
R'
OWNEME: P NE: CON TRAC'I'OR:S NAME: LIC NO:
NIC CONTROL#
ARCHITECT/ENOINEER: I LIC NO: ADDRESS ` ❑
CONTACT: - - PHONEILDING PERMIT INFO
• ❑ Consultant Feca Paid by Applicant(Initial) BLDG ELECT PLUMB MUCH
❑ 14 ❑
LICENSED CONTRACTORS DECLARAGON QTY. ELECTRIC PERMIT FEE
I bunch,afamt mal I am licensed ander pericions ofChapter 9(eommenrldg JOB DESCRIPTION
AaZ with Section 7000)of Division 3 nftha Busdnelstad Profesidre Codeand toy license le
CDO _ PERMIT ISSUANCE RESIDENTIAL
UF Lfullfmwand of ❑SPDWL Ll KITCHEN REMODEL
aUU 4cereClasr Lic.p APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE
DECLARATION
asilL
ANCHI'fECTS ULCLARATION ❑MULTI-UNIT ❑S'1'RUCfURAL
ZOy ZZ I understand my plansshall he used as public records PANELS MODIFICATION
OZ- �
UP PO 200 AMPS El INTERIOR C:1 CHIMNEY REPAIR
Q,�FLL� Licensed Professionall201-1000AMPS IMPROVEMENT 0SWIMMING POOLS
..I OWNER-BUILDER DECLARATION OVER 1000AMPS El BATH REMODUUREPAIR DEMOLITION
C
6I hereby of0rm that 1 am exempt from the Comae ar'a License Law for the
7qq74� y U following lesson.(Section 7031.5,Rosiness and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
t's'3 as y which requires a permit to construct,alter.Improve,dernnlish,or repair any srruemw 1Q p
d,al prio t . .. a tc,els r y e the appli tt p htmilt 11 g eJ statement SPECIAL CIRCUITIMISC. Gl IA I C,
y that he licensed Promisor 0th previsions of the Contractor's L Lw(Chapter9 4
(son g with Sect 700(h fDvid 3 fm Business dP 1 :ions Cadder TEMP.METER OR POLE INST. COMMERCIAL:
Ihm he Is exempt therefrom and the basis for IM1c alleged exemption.Any violation of ❑NEW 6LDG/ADDITION ❑DEMOLITION
W^m Section 7031.5 by any op,lican(for a ermil,ubject,the applicant I...N 'realtynf POWER DEVICES ]TENANT ❑FOOD SERVICE
Zda more than five hundred dollars($500). IMPROVEMENT
Q Lasownet of the property,or my employees with words se Meir sole compcosetion, SWIMMING POOL ELECTRIC
will dome wnrk andthe'Mdure is not intendedom0'ered Unsold(Sea 7044,Beside, El OTHER
and Professions Code: the Con seer m's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
property who had Ids or imprnves thereon,and who asci such work himself or through
his own employees,providad that such improvements are net intended or ofrecrul for NEW RESIDENTIAL ELECPR SQ ET
sale.If,however,the building or improvement is sold within one ycarrfeumpletion,the SQ,I FLOOR AREA $/SQ.Fr.
owner-halide,will he.the harden of proving that he did nal build nr improve forpur-
gase of sold.).
❑I,as owner of the property,um exclusively amlnating with licensed conlraetora Ir TOTAL:
tdoisfool,he project(Sce.704,Business add Professions Cale:)The Contractor's Li- -
se Law does not apply to an owner or property who builds or improves[human,and QTY PLUMBING PERMIT PEE
who contracts for such projects with a communists)licensed paramount to the Commemfs
License Law. PERMIT ISSUANCE
Q 1 am exempt under See. ,R&P C for this rozsnn
Owner Dore ALTER-DRAIN&VENT-WATER(EA) VALUATION
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby afford under penalty of perjury Ane of the following declarations:
❑ IhaveandwillmaintainaCenifcaleof Consent(oself-insurefor WorkersGrmpe- DRAINS-FLOOR,ROOF,AREA, 'OND. s STOR .. TV PE CONSTRUCTION
serum,as provided for by Section 3700 of[he Labor Code,for me petiommnce of[he
W�k fir which this permit is issued. FIXTURES-PER TRAP
1171 have and will maintain Worker's mpensation Insurance,as required by Section _
0ofthe Labor Cale,for the pa',o are of the work fm which this permit is issued. GAS-EA.SYSTEM-]INC.4 OUTLETS OCC.GROUP APN
My W -,G rvmti a 1 s a artier and Policy h
Care' Policy No.:.�t / GAS-I.A.SYSTEM-OVER 4(EA)
CERTI.ICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASOINDUSTRI.WASTE INTERCEPTOR BUILDING DIVISION FEES
(This section need not be completedHthe permit is heron hundred dollars S100)
nr Icss.) GREASETRAP PLANCf1ECK PRE
Icenifythvtimhepednrmvnceofthework forwhich lhi ,armltis issued,l shall SEWER-SANITARY-STORM EA.200 PT.
not employ any persvni in any manner sees to become subject to the Workers Cooper- ENERGY FEE
soloed Laws of Califnmia.Date WATER HEA NENT/F. k
Q Applicant GRADING FEE
NOTICE TO APPLICANT:IL alter making Ills Certificate of Exemption,you should WATER SYS REA
become sobjes,to the Worker's Compensation provisions of the Leon,Coale,you must - SOILS FEE
frchwom comply with suchprnvirtuoso,his permit.hall M deemed worked. WATER SER
Cls Q
Z CONSTRUCTION LUNDINGng ENCYagency NEW RESID IAL PL PAID pate cei t#
U I affirm thew lssue (Sea3nlanding agency for the performanceof p
rs the work for which this permit is issued(See 3097,Civ.C)
QLender's Name TOTAL:
LeadcFs Address I Y TOTAL: �•
I certify that 1 have read this application and state that the above information is BUILDING FEE
F-t V) eompet.Iagree to comply with all any and county ordinances and state lawsrelatlngw QTY. MECHANICAL PERMIT FEE
U 4 building concoction,and hereby authorize representatives of this city'.emerupon the SEISMIC FEE
abovementioned pmpedy for inspection Purposes
(We)agree to save,indemnify and keep harmless the City(if Cupertino again PERMIT ISSUANCE5. ELECTRIC FEE / �-
lishirliesjudgment,costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECH. /
in nseaan
gce of the granting of this permit. PLUMBING FF.F.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,(S10CFM) MECHANICALFEE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 10,00)CFM) CONSTRUCl10N TAX
Signature of ApplicanUContmcmr Date EXHAUST HOOD(W/DUCT) tHOUSINGGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous amount HEATING UNIT(TO 103,000 BTU) i onas defined by the Cape I Mumcl I Codd.,Chap,a,9.12,and the Health and Safety
Code,Section 25532()p UEATING UNIT(OVER I W,000 H'fU)
El Yet VP.NTILATIONPAN(SINCLRRESID) e Receipt#
Will the applicant or future building occupant use equipment or devices whichBOILP.R-COMP(3HP OR IIXI,IlOU RTU)
emit hazardue,air contaminants as defined by did Bay Area Air Quality Management TOTALDistrict? BOILER-COMP(OVER 100,000BTU)❑YesI have mod the hazaNuus materils requirement under Chapter G95 of the Coli- AIRCANDITIONERISSUANCE DATE
forme Heal[h Safely Cale,Sections 25505,25533 and 25534.1 undarvtwd mal If m° NEW RESIDENTIAI.MUCH. SQ.FT.
buildings m Ally heves enant.that itEmy responsibilitym Auto then ape
of there h mast met prior m issuance of n CeniF a c !
14
O D e TOTAL: ISSUED BY: /
OFFICE �/