S 0770 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE,BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PF�WIIT NO. 0770
BUILDING DIVISION APPLICATIONXERMIT PLUMBING-MECHANICAL V\
' BUILDINGPROJECTIDF.NTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
OWNE L PHONE:
.
CON1' j _ St —•
NI COMftOLN� ?P.0 _r
NGINEERLICNO. ADD7yARCHILECTE /�3
CONTACT: PHONE:
GCiGL�! BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG HLF.CT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY, ELECTRIC PERMIT FEE
1 hereby affirm that I ate licensed ander lowishou of Chapter 9(ex mmoncing JOB DESCRIPTION
QWz with Section�OOO)nfDivhlon3 of lheBusioess antl Pnsfess/iop-s1Code, dmyllemae is - PERMITISSUANCE
RESIDENTIAL:
P5CF fill force and of I. ZY l ❑SFDWL ❑KITCHEN R17MODEL
�W 1:7 in u
UU License Cl ss Lich APPLIANCES-RESIUEN'1'IAI. ❑ADDITION U BING RE-PIPE
F zz W Dme Cnntramer
.6O. ❑MULTI-UNIT STRUCTURAL
A CHITECT'Sd :0, RAf10
,Dv,
Irucenatind my,nesshall reused.,publieneemd, PANELS MODIFICATION
p z 4- UP TO 200 AMPS
Q Licensed Professional
❑INTERIOR ❑SWCHIMNEY MINGREPAIR
OOL
2111-IOW AMPS IMPROVEMENT SWIMMING POOLS
9 -� OWNER-BUILDER DECLARATION OVIiR IWO AMPS El BATH REMODEL/REPAIR El DEMOLITION
a 1 hereby affirm Thal 1 am exempt from Ne Comraemr'a License Law for the
O y U following reason.(Section 9(131.5,Business and Professions Code:Any city nr county ,g10N5 ELECTRICAL ❑OTHER
W 3 w yF which flannel a permit m constmeo alter,improve,demolish,car mgab any swcmre _
6 prior to its issuance,also remares the applicant for such permit m rile a signed statement SPECIAL CIIiCU1T/MISC
a yi1 that he inllcensW pursuam In tM10 provisions of the Contmdory Firm L.w(Choped
W �C (commencing with Section 9W0)of Division 3 of the Bualnessand Profesemne Coile)or TEMP.METER OR POLE IN ST. COMMERCIAL:
W p,2 y' that he in exempt therefrom and the basis for the alleged'exemption.Any violation of I ❑NEW BLDG/ADDITION ❑DEMOLITION
G"m Section 7031.5 by any appllaam forapermh,tic,s meappliema toe civil penally of POWER DEVICES ❑TENANT ❑FOOD SERVICE
H�6not more than five hundred dollars($500). 1 IMPROVEMENT
pit,as owner of the property,or my employees with wages as their sole compensation, SWIMMING POOL ELECT RIC
G will do the work,and the structure is not intended or offered for sale(Sec.70iL Business ❑OTHER
and Professions Cade:The Contractors License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon:and who dues such work himself or through
hi.own employees,provided that such improvement,are not intended or offered for NEW RESIDENTIAL.F.LECTR SQ Fri.
aide.If,however,the building or improvement is sold within one year of completion.the SQ. .NI9pD1 AREA S/SQ.FI'.
caner-0uildm will have the burden of proving that he did not build or improve doper- N D
owner
of lata). �� -
❑ 1,as owner of the property,aplaintively nrmmeting with licensed contractors to TOTAL'
m
0
construct the project(Seo.9fW4,Business and Profession,Code:)The Contractor's Li- = 2 p(�A
cense Law does of apply no an owner of property who build,of improv,mereon.and QTY, PLUMBING PERMIT 'E a/ ftp
who contracts for such project,with.contranar(s)licensed personal to the Contractor's t. ff
License Law. PERMIT ISSUANCE rC
❑ I am exempt under Sec. B&P C druids rearm hl
ALTER-DRAIN&VENT-WATER(EA) VAL TION3
Owner Dae
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby affirm tinder penalty of perjury ane of the I'ollawing declarations
❑ I have and will maintain a Certificate of Consent to oduinsure for Worker's Comped- DRAINS-FLOOR,ROOF.A REA,GOND. STORIED TYPE CONSTRUCTION
cation,as provided for by Section 3900 of Ore Labor Code,for thro
e permme'd of the
work for which this permit is illoned U.2TURES
❑I have end will maintain Workers Compensation Imam,,,as required by Section
3700 of the Lalsa Code,motor,performance of the work for which this permit is issued. GAS-EA.SYSTEM-I INC.40U'rLIN'S OCC GROUP APN
My Worker's Compensation Insurance carrier and Policy number are
Carrier: Policy Na, GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASGINWSTRI.WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION HER s
(This section need notbe completed Ford No mit ismoane hundmddollom,(SOT GRP.ASETRAP
or less) PLANCHECK FEE
Iecnlf thatioda performances the arkf, whic do permit, tanned,Imill SEWER-SANITARY-STORM EA.200 Fri.
not employ Fors yunhderr as bee.fie sabl 1 the Worker Crampon- ENERGY FEE
OT. smior Lawse rnia re _ WATER HEATER WNEN'I'/ELECTR GRADING FEE
z Q Applicant
NOTICE TO APPLICA 'E If,after a kin his Certificate of Exemption,you should' WATER SYSTEMCKLATING
I"t bear..,subject 10 the Workers Compensation provisions of the Labor Code,you muss SOILS FEE
forthwith comply with such provisions or this permit shall he deemed revoked. WATER SERVICE
Q
az CONSTRUCTION LENDING AGENCY NEW RESIDP.NTIALPLMB. SQ LE PAID Date Receipt#
UQ I herebyaffirmpct there iaaed(Secconstruction0 lending agency for the performance of
� the work for which this permit is issued(Sen 3099,Civ.CJ
u' Lender's Name TOTAL'
Condo's Addfesa - TOTAL:
y , 1 certify that have read this application and slate that the above information Is BUILDINGFEE
h�j correct.I agree to comply with all city and county ordinances and state laws relating to QTY. - MECHANICAL PERMIT FEE -
f, ❑ building construction,and hereby nothofze reprcsemafves of this citym entarapon the SEISMIC FEE
above-mentioned property for im"'lion purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupenlm against ELECTRIC PEE
liabilities;Judgments,uaslsandexpense,whiuhmay in anyway acerae against said City ALTER OR ADD TO MFCU
in mequenw of the gr.nting,' Phis poen PLUMBING FEE
- APPLICANT UNDERSTANDS CO 'LY WITH ALL NON-POINT AIR HANDLING UNIT(TO IO,OW CFM)
S REGO TIONS. /� MECHANICAL PEP.
. � AIR HANDLING UNIT(OVER 10,"CFM) CONSTRUCTION'TAX
Sii
Signature of ApplicanUContracmr Dme EXHAUST HOOD(W/DUCO HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future bulldingaccupanl smear handle hazardous material HEATING UNI'P(r0 I X0,000 BTU)
as defined by the Caperton.Muniaipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(.)9 HEATING UNIT(OVER 100,001 BTU)
❑Yea ON. - VENT]LAT10N FAN(SINGLE RESID) PAID -`
Date Receipt#
Will the it,dicam or(mum building occupant a,.equipment an devices which
el
BOILER-COME(3HP OR IOO,IXIO BTU)
I hodomds air contaminants as defned by the Bay Arca Air Quality Management 'TOTAL:
m ou
District? BOILER-COME(OVER 100,000[if U)
❑Yes- ❑No -
1 have read the hazardous materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
fomi,Health&Safely Code,Sections 25505,25533 and 25534.I undehaval he,if the NEW RESIDENTIAL Ill SQ.11.building does not reparry have a tenant,that it Is my responsiridity to notify the ocou.,da
of the requirements which must ad mel pdo,a issuanread.CediOeate of Occupancy.
Owner or authorized agent Date TOTAL: ISSUED DY:
OFFICE