99110049 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL O
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO APPLICATION SUBMITTAL DA7
4`r ✓
OW';"NAME: PHONE: CONTRACTORS NAME LIC NO: r
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NIC CONTROL#
RCHITECT/ENGINEER: LIC NO: ADDRESS: CJ ❑
CONTACT PHONE: BUILDING PERMIT INFO
,��� �7-��3 J� ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
ICA / u ❑ ❑ C ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
W Z with Section 7000)of Division 3 of the Business and Professions Code,and my license is RESIDENTIAL:
W W O m full force an off i PERMIT ISSUANCE
E U D ❑SFDWL [I KITCHEN REMODEL
Q U U License Clas: Lic.# ,,,1
F- aZw Date Contractor A APPLIANCES–RESIDENTIAL ❑ADDITION EL-PfUMBINGRE-PIPE
V)U ARCHITECT'S DECLARATION l lAf6l V& PANELS El MULTI-UNIT ❑STRUCTURAI.
Z O�Z I ndnd my plans shall be used as public records MODIFICATION
--4-AF UP TO 200 AMPS L]❑INTERIOR CHIMNEYREPAIR 4�F W Licensed Professional 201-1000 AMPS
❑
IMPROVEMENT SWIMMING POOLS
OWNER-BUILDER DECLARATION
t I hereby affirm that I am exempt from the Contractor's License Law for the OVER 1000 AMPS ❑BATH REMODEL/REPAIR ❑DEMOLITION
Lai.F following reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
which requires a permit to construct,alter,improve,demolish.or repair any structure
prior to its issuance.also requires the applicant for such permit to file a signed statement SPECIAL CIRCUIT/MISC.
WQ that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9
W ZA O (commencing with Section 7000)of Division 3 of the Business and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL:
th exe t th ro th s, ort a ny on of ❑NEW BLDG/ADDITION ❑DEMOLITION
w S I y a c r e u c e a li t i e y of POWER DEVICES
Z n e h re ( ❑TENANT El FOOD SERVICE
e o ye t SWIMMING POOL ELECTRIC IMPROVEMENT
work,an the sttvc ure is not intende oro ere or sale ec.7044, usiness ❑OTHER
0.W"3 oyo and Pro ions e: ntr 'c L Onotuild
owner of OUTLETS–SWITCHES–FIXT
property, o bud o pr eon an or through
his own ploye p ided that p e ffered for NEW RESIDENTIAL ELECTR
sale.If, b so etion,the SQ.FT FLOOR AREA S/SQ FT
owner-bun et will have the urden of proving that he dor improvefor put- 7 ,1
14L
rty, Iasi
Dacito TOTAL:
( 7 ess fi-
d p n e bui d QTY. PLUMBING PERMIT FEE
who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's
License Law. PERMIT ISSUANCE
F-1I am exempt under Sec. ,B&P C for this reason
ALTER–DRAIN&VENT–WATER(EA)
OwnerDate VALUATION
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations: BACK FLOW PROTECT DEVICE
❑ I have and will maintain a Certificate of Consent to self-insure for Worker's Compen- DRAINS–FLOOR,ROOF.AREA,GOND. STORI TYPE CONSTRUCTIONsation.as provided for by Section 3700 of the Labor Code,for the performance of the
work or which this permit is issued. FIXTURES–PER TRAP
ave and will maintain Worker's Compensation Insurance,as required by Section Im
700 of the Labor Code,for the performance of the work for which this permit is issued. GAS–EA.SYSTEM-1 INC.4 OUTLETS OCC GROUP AP�Q
My Worke{�.��o ipensp)lnsurance carrier and Policy n - C�
Camey._L� a Policy No. GAS–EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROA A1ORki�R9-'V6WX1
COMPENSATION INSURANCE GREASE/INDUSTRL WASTE INTERCEPTOR
(This section need not he completed if the permit is for one hundred dollars($i 00) BUILDING DIVISION FE SGREASE TRAP
or less.) PLANCHECK FEE
1 certify that in the performance of the work for which this permit is issued.I shall
not employ an person in an manner so as to become subject to the Workers'Com en- SEWER–SANITARY–STORM EA 200 FT.
P Y P Y J P i ENERGY FEE
satO C) Applicant
Laws of California.Date WATER HEATER WNENT/ELECTR
Z 0 Apphcani GRADING FEE
Z C%) NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEMlTREATING
become subject to the Worker's Compensation provisions of the Labor Code,you must SOILS FEE
W > forthwith comply with such provisions or this permit shall be deemed revoked WATER SERVICE
� Z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
I hereby affirm that there is a construction lending agency for the performance of Date Receipt#
U
O the work for which this permit is issued(Sec.3097,Civ.C.)
O U Lender's Name
TOTAL':
W Lender's Address TOTAL.' '
P64 I certify that I have read this application and state that the above information is $UILDING FEE
V] correct.I agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE i
U Z building construction,and hereby authorize representatives of this city to enter upon the ) -SEISMIC FEE
~ above-mentioned property for inspection purposes. _
(We)agree to save,indemnify and keep harmless the City of Cupertino agar PERMIT ISSUANCEnst ELE FEE i�J
liabilities,judgments,costs and expenses which may in anyway accrue against said City ALTER OR ADD TO MECH.
in consequence of the granting of this permit. PLUMBING FEE
APPIWAN f1'V DIR.S IA.NDti,A ND N II-L('(711!'11 vb')111:UI SUN-1'(H.A1 AIR HANDLING UNIT(TO 10.000 CFM)
.tial RCH RLOI'1.%I 1ONS MECHANICAL FEE
AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCTION TAX
Signature of Applicant/Contractor Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(TO)00,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)'1 HEATING UNIT(OVER 100,000 BTU)
❑Yes ❑No PAID
VENTILATION FAN(SINGLE RESID) 1
Will the applicant or future building occupant use equipment or devices which Date Receipt#
.nit hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER–COMP(3HP OR 100,000 BTU)
District' TOTAL.
❑Yee ❑No BOILER–COMP(OVER 100,000 BTU)
I have read the hazardous materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER
9 P ISSUANCE DATE
fornia Health&Safety Code,Sections 25505.25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.FT.
building does not currently have a tenant,that it is my responsibility to notify the occupant l /r.of the requirements which must be met prior to issuance of a Certificate of Occupancy. ( �s
Owner or authorized agent Date _ TOTAL: ISSUED BY:
OFFICE JJJ