S 1484 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PEtTT NO.
BUILDING DIVISION APPLICATION/PERNUT PLUMBING-MECHANICAL l\
BUILDING PROJECT IDENTIFICATION 1484
LDING ADDRESS'. SANITARY NO. APPLICATION SUBMITTAL DATE
WNEW^S NAME: PHONE: CONTRACT'OR'S NAME: LIC NO: `
CONTROLM
ARCHITECT GINEEk: LICNO: ADDRESS: El
.D/CAC 4^1 C O J J
CONTACT. PHONE: I BUILDING PERMIT INFO
❑ Consultant Foes Paid by Applicant(Initial) BLDG ELECT PLUMB MUCH
tic—
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby affirm that 1 an Ilmnred under provisions of Chief 9(annnteneing _ JOB DESCRIPTION
�C, with Section 7000)aftimaon 3ofthe Business and Pmfesslnne Codgandmy licencels PERMIT ISSUANCE RESIDENTIAL
�F in full force and effect Lic. ❑SFDWL El KITCHEN REMODEL
U Licence Class Contractor
APPLIANCES-RESIDENTIAL []ADDITION ❑PLUMBING RF.-PIPE
s, F Da,c Cmntmmmr
p.pm ARCHITECTS DECLARATION PANELS []MULTI-UNIT [I STRUCTURAL
O Z 4- I understand my plans shall be used as public records MODIFICATION
QIIP TO 200 AMPS
W l Ltecnsed Pmtessronul ❑INTERIOR ❑CHIMNEY REPAIR
OWNER-BUILDER DECLARATION 201-IINIOAMPS IMPROVEMENT �S ''IM" MING POOLS
. y - I hereby alfmv that 1 am exempt from the Contractor's License Lew for the OVER 1000 AMPS ❑BATH REMODEVREPAIR' MOLITION
W3 W F billowing reason.(Section 9(131 5,Business and Profession,Cock Any city or county SIGNS ELECTRICAL ❑OTHER VA
[❑�WO ya which regards a permit to consnuet cher,improve,demolish,or repair any stmemrc
y1 prior toilissuance,also requires the applicant for such Permit to file v signed statement SPECIAL CIRCUIT/MLSC.
Alia+ that he is l icensad pursuant to the provisions of the Contraemr'x license Law(Chapter9
0 (commencing with Section 9000)of Division 3 of the Badness and Pod,ions Code)or TEMP.METER OR POLE INST. COMMERCIAL-
that he Is exempt thercfmm native basis far the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Section 703 L5 by any applicant for a permit,objects the vppliant to n civil Penalty of TOWER DEVICES
F.S>< not more than rive hundred dollars($501). ❑TENANT ❑FOOD SERVICE al E-1I,as owner of Ne properly.or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
Fo will dothewak,add lhesancturemoral intendedaroffcred fi le(See 904B
4, uslness ❑OTHER
4 a..0 and Professions Code:The Commit License Law does nod apply to an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or impmvex thereon,and who does such work himself or through
Pis own employees,provided that such impmvrments arc not intended m offered for NEW RESIDENTIAL ELEC SQ FT.
sale.IE,however,the building or improvement is sold within one year ofcomplction,the SQ.FT.FLOORAREA $/SQ.ET
owner-builder will have the burden of proving that he did not build or improve lir par- ^
pose ol',ale).
❑ 1,as owner of the properly,am exclusively contracting with licensed commands an TOTAL:
instruct the project(Sec.7044,Business and Professions Code:)The Central Li-
cause Law ideas'lot apply to an owner of property who builds or improves thereon,and QTY. PLUMBING P RMIT FEE
who Contracts for such projects with a amhador(a)licensed pursuant to the Coromandel,
pp��
License Law. PHHM IT ISSUANCE p- t
- ' --I ad1-mv. and ,B A,P C for this gF OR re�Sco
70 1ALTER-DRAIN&VENT-WATF;R QiA) ��� AMID
Dale
K COMP ION DECL RATION BACK FLOW PROTECT.DEVICE
I hereby affirm un of perjury one of following dedamtinns
❑Ihnve and will meimaina Cert roof 'If
in far Workers Co.,.- DRAINS-FLOOR,ROOF,AREA.COND. a I TVPG CONSTRUCTION
svdon,as provided far by Section 3700 of the Labor Code,far the performance of the IllrgjF L Uh"C 1 ln13
weak for which this permit is issued. FIXTURES-PER TRAP
have and will mvimain Worker's Compencmlon Insurers as required by Section
3700 ofthe Labor Cnde.for the perfomndnce of the work for which this permit is issued. GAS-GA.SYSTEM-I INC.40UTLETS OCC GROUP APN
My Workers Compensation Insurance artier and Policy number are:
Cartier Policy Na.: GAS-EA.SYSTEM-OVER 4(RA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASMNDUSTRL WASTE INTERCEPTOR
(Thissedimn needootbecompleted irthe permit is Formed hundred dollars($100) BUI D)kISIONFIR
or less.) GREASE'FRAP PLANCHECK FEE
1 certify that o the anyperformance o as t work for which this permit is issued,)shall ��-
not em In an SEWER-SANITARY-STORM EA.2110 FT.
employ y person in any manner so as m become subject to the Workers'Compen- ENERGYFEE IF
,z sedum Laws of California.Date
O WATER HEATER WNENT/UL[CTR
Applicant i GRADING PEE
rj1 NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEMO RF.AI'ING
abecame subject k the Workers Cnmpensetion ow,inme of the Labor Code,you most SOILS FEE
Q forthwith comply with such provisions or this permit shall he deemed revoked. WATER SERVICE
'az CONST RUCTION LENDING AGENCY NEW RESIDENTIAL.PLMB. SQ.IT PAID
UO T hereby affirm that hem is a construction lending agency for the Performance of O Receipt to
fL P the work far which this pemlit is Issued(Ree.3097,Civ.C)
Q Lenders Name TOTAL:
U Lenders Address TOTAL
a I candy that I have read this application and state that the above information is - BUILDIN F kE
Fay correct l agree to comply with all city and county nationalists and state lawn relating m QTY MECHANICAL PERMIT FEE
U building armhudimnand hereby authorize representatives or learn,n,parr,upon the SEISMIC FEE
above-mentioned properly for inspection pwPases.
(We)agree to rove,indemnify and keep hamddas the City of Cupertino against PERMIT ISSUANCE ELECTRIC FEE
liabilities,judgments,costs and expenses which may in any way accrue against said City ALTER OR ADD 10 MHCfI.
inconsequence mf the granting of this Permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10o")CPM)
SOURCE REGULA'1'10 MECHANICALFEE
Q' AIR HANDLING UNIT(OVER I0.Of10 CFM) CONSTRUCTION TAX
Signature of Ap I U «odor Data EX14AUST HOLD(W/DUCT) HOUSING MITIGATION FEH
'LIAR S MATERIALS .CLOSURE
Will thati'licvntnrf mrelandiingreau t store or handle hazardous material HEATING UNIT(TO 100,000 BTU)
as defined brittle Cape nioo L hapter 9.12,and the Health and Safety
Code,Section 25532(a)P HEATING UNIT(OVER 100,000 BTU)
❑Yes ❑No VENTILATION FAN(SINGLE RESID) PAID
Date Reorip It
Will the applicant infurore building by the Bt useapartmentAirQuordeviceswhich BOILER-COMP(3HP OR 100,000 BTU)
emit hazardous air contaminants as defined by the Buy Area Air Quality Management TOTAL:
District?
F7 Ye, - 7 N BOILER-COMP(OVER 100,000 BTU)
AIRCONDITIONER I have read the h ode.S x materials requirements under .1 ad 6.la of the Cali- ISSUANCE DATE
forma Health&Safety Code.eedian,t,that i 25533 and 25534.1I nder,mnd that if the NEW RESIDENTIAL MUCH. SQ.Pr.
building doesnotcurrently must Ni,cactpthatit is er idofa apfia ratify thnmerty.
of Ne requirements which man:w met prior m issuena mf o Cenifievre of fkcvpanoy.
Owner or nmhorized agem - Date TOTAL: ISSUED BY: _
OFFICE `\