S 0438 (2) APPLICANTTO FILL IN INFORMATION WITHIN REDLINES-USE BALL POINT PEN ONLY -
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL' " S 0438
' BUILDINGPRWECTIDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMI I'll DATE
Z�8 5a iGl��1. "9 Vc r3 /
OWNER'S NAME: PHONE: CONTRACTOR'S NAME: LIC NO:
( �� N� N/C CONTROL#
t�9RCHITEC NGINEER: —• LIC NO: ADDRESS: - ❑
I
CONTACT: PHONE: BUILDING PERMIT INFO
��_p Za.3- 9// ❑ Consultant Fees Paid by Applicant(Initia 1) BLDG- ELECT PLUMB MECH
CXX�� .�Ll / / . . ❑ BX ❑ ❑
LICENSED CONTRACTOR S DECLARATION QTY `: +' ELECTRIC PERMIT FEE
1 hereby amrm the,1 an licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
with Section]000)of Dtvw nn 3 ofthe Business and Professions Code,and my been¢is
CO PERMIT ISSUANCE RESIDENTIAL'
in full force and¢fact•
4' F ❑SFDWL ❑KITCHEN REMODEL
UU License Class Lick
F�lil Date Contractor APPLIANCES-RESIDENTIAL ❑ADpITION El PLUMBING RE-PIPE
ARCHITECT'S DECLARATION PANELS El MULTI-UNIT ❑STRUCTURAL
Z C)m 7�. 1 understand my plans shall be used as public records _ - MODIFICATION
O'z" UPT0200AMP$
•�F. [ILicensed Professional INTERIOR ❑CHIMNEY REPAIR
201-IIl(I(IAMPS IMPROVEMENT SWIMMING POOLS
OWNER-BUILDER DECLARATION
1 hereby.firm,hat I am exempt from,he Connector's License Law for the OVER]"AMPS [I BATH REMODEUREPAIR El DEMOLITION
C 0R,U following reason.(Section 7031.5,Business and Professions CMe:Any city or county SIGNS ELECTRICAL _ ❑OTHER
a 41••' which requires a permit to construct,alter.improve,demolish,or repair any structure
�0 prior to its issuance,also requires Ne applicant for such permit to file a signed.statement SPECIAL CIRCUIT/MISC:
y thathe is licensed pursuant tothe provisionsofthc Contractors License Law(Chapteri)
GC (commencing with Section 7")of Division 3 elite Buxines.caird Professions Code)or TEMP.METER OR POLE INST.
4 o C dial he is exempt therefrom and the basis for the alleged exemption.Any violation of - ❑NEW BLDG/ADDITION ❑DEMOLITION
tr.
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES
❑TENANT ❑FOOD SERVICE
t more than rise hundred dollars y employees
IMPROVEMENT
❑Lo the work,the property,remyemntended with wages Bred fas0ei(See.compensation. SWIMMING POOL ELECTRIC,
will dothewonsCdethe The antis not s License
Law does of apply 9044.Business ❑OTHER
0. and Professions Cale:The Contractors License Ldw gnu not apply to if owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon,and who does such work himself or through
his own employees,building that such Wen is sold are not dummied or offered for NEW RESIDENTIAL ELECTR SQ FT "
sale.if,holder will h ve th burden
mprovement is he within one build
or
improve
the SQ.FT.FLOOR AREA .$/SQ,PT.
owner-builder will have the burden of proving that he did not build or improve for Pur-
F-1 1,a owner
t' TOTAL:
❑1,as ow c of the property,am exclusively contracting with licensed contractors i-
construct the project(Sec,o an Business and ry who
Code:)Ove Comramor's nd
cense Law docs no,apply to an owner of pmpeny who builds or improves thereon,and QTY. PLUMBING P FEE
who au.For such projects with econvnnor(s)licensed pursuant to the Contractor's
License Law. PERMIT ISSUANCE '
❑ a
Owner Date I exempt rnderS . ,B&PC for This recon
ALTER-DRAIN&VENT-WATER(EA) VALUATION
'
WORKER'S COMPENSATION DECLARATION •BACK FLOW PROTECT DEVICE
r 1 hereby affirm under penalty of Prouty one of the following declarations:
❑ I have and will maintain a Certificate of Consent to self-insure fnr Worker's Compen- DRAINS-FLOOR,ROOF,AREA,COND.
sation,as provided for by Section 3400 of the Labor Code,for the performance of the STORIES TYPE CONSTRUCTION
work for which this panni,is issued. FIXTURES-PER TRAP
-s E] I have and will maintain Worker's Compensation Insurance,as required by Section
3900 ofthe Labor Code,for the performance efthe work for which this permit is issued. GAS-EA.SYSTEM-1 INC.4 OUT OCC GROUP APN
My Workers Compensation Insurance carrier and Policy number are:
Center: Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEANDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FEES
(This section need not be completed lfthe perm),is forum hundmddollam($100) GREASETRAP or less.) PLANCHECK FER - -
LenifythatinNeperformanceafthe work for which this permit is issued,l shall SEWER-SANITARY-STORM EA.20(1 FT.
not employ any person in any manner so is m become subject,o the Worker.¢'Compen- ENERGY FEE
Qz sation Lawsof Califomii.Date - WATER HEATER WNENT/ELECfR
Applicant 1 GRADING FEE
G q NOTICE TO APPLICANT:If,after making this Cenifcate of Exemption,you should WATER SYSTEMOREATING
C••t become subject to the Worker's Compensation pensn provisions of the Labor Cade,you most SOILS PER
Wforthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE a
QV.
�
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PCMB. SQ.FT.
V I hereby affirm that them is a construction lending agency for the performance of Dae ' t#
F ,he work fm which this permit is issued(Sec.3099,Civ.C.)
QLender's Name \\\ TOTAL:
LUiI Lender's Address y 'TOTAL:
I certify that I have read this application and state that the above information is `� B-DING FEE
fir V) correct.I agree to comply withal)city and county motion...nd sate lawsrchair,to QTY. MECHANICAL PERMIT FEBJ<
V Z building construction,and hereby authorize represenlaniveso(this city to enteruynn the SEISMIC FEE
wr above-mentioned property for inspection proposes
(We)agree to save,indemnify and keep harmless the City of Cupertino against PERMIT ISSUANCE ELECTRIC FEE
-. liabilities,judgments,costs and expenses which may in any way accrue against said City AI.TERORADDTOMECh
inconsequence of the granting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IR"CFM) ;
SOURCE REGULATIONS. MECHANICAL FEE
" AIR HANDLING UNIT(OVER W."CFM) ICONSTRUCTION TAX
Signature of Applic.m/Contrac[or Date EXHAUST HOOD(W/UUCI•) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future Wilding occupant store or handle humnlous material HEATING UNIT(TO IOEWE BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cade,Section 25532(.)? HEATING UNIT(OVER 100,100 BTU) -
Fly es ❑No VENTILATION PAN(SINGLE RESID) PAID
Date Receipt#
Will the applicant or future Wilding occupant use equipment or devices which BOILER-COMP(3HPOR IfIO,Of,O BTU)
emit hmurdous air conmmim mts as defined by the Bay Area Air Quality Management TOTAL
District? -
[3 Yea ❑No BOILER-COME(OVER 100,000 BTU)
I have read the hazardous mammals requirements under Chapter 0.95 of AIR CONDITIONERM1e Cali- a/�1 % ISSUANCE DATE
form.Health&Safety Cade,Sections 25505,25533 end 25534.I understand that if the NEW RESIDENTIAL MECH. SQ.ET. / 7
building does not currently have atenant,that it is my responsibility to notify the occupant I /
of,he vquiremenm which must be met priortoissuancc nfa Certificate of Occupancy. - qq/r�'f
Owner or authorized agent Dam TOTAL: . ISSUED BY: V U 1` A
OFFICE