20309 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. j Q
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL S()��1 0 3 0 J
BUILDING PROJECT IDENTIFICATION LX
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DAT
/020 �rL� rye ��/ Ift
OWNER'S NAME: PHONE: CO R'S E: LIC NO: N/C CONTROL#
7- I y - -
ARCHITECT/ENGINEER: LIC NO: ADD$ES ❑
CONTACT: PHONE: !/�!/ BUILDING PERMIT INFO
931-Aq-V33 ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMLT FEE
I hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
Z with Section 7000)of Division 3 of the Business and Professions Code,and my license is RESIDENTIAL:
W 0 O PERMIT ISSUANCE
F .4 in full force and eff
a W F„ E)SFDWL El KITCHEN REMODEL
d U U License CI Lic.# 12Z 1
WP. Date Contractor APPLIANCES—RESIDENTIAL El ADDITION El PLUMBING RE-PIPE
I..U ARCHITECT'S DECLARATION' PANELS ❑MULTI-UNIT El STRUCTURAL
0 Z I understand my plans shall be used as public records MODIFICATION
UP TO 200 AMPS
F W El INTERIOR El CHIMNEY REPAIR
Licensed Professional
201-1000 AMPS IMPROVEMENT ❑SWIMMING POOLS
a OWNER-BUILDER DECLARATION OVER 1000 AMPS ❑BATH REMODEL/REPAIR ❑DEMOLITION
Ri W Q I hereby affirm that I am exempt from the Contractor's License Law for the
w0 L4 U following reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
O rj which requires a permit to construct,alter,improve,demolish,or repair any structure
aprior to its issuance,also requires the applicant for such permit to file a signed statement SPECIAL CIRCUIT/MISC.
�. that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9
A0 (commencing with Section 7000)of Division 3 of the Business and Professions Code)or TEMP.METER OR POLE INST. ER IAL:
that he is exempt therefrom and the basis for the alleged exemption.Any violation of BLDG/ADDITION El DEMOLITION
WSection 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES TENANT [I FOOD SERVICE
Z not more than five hundred dollars($500). IMPROVEMENT
Q ❑I,as owner of the property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC a
x Ca will do the work,and the structure is not intended or offered for sale(Sec.7044,Business ❑OTHER
W-0 and Professions Code:The Contractor's License Law does not apply to an owner of OUTLETS—SWITCHES—FIjCtINRE
property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDE E• I FT.
sale.If,however,the building or improvement is sold within one year of completion,the SQ.FT.FLOOR AREA $/SQ.FT.
owner-builder will have the burden of proving that he did not build or improve for pur-
pose of sale.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to TOTAL:
construct the project(Sec.7044,Business and Professions Code:)The Contractor's Li-
cense Law does not apply to an owner of property who builds or improves thereon,and Q PL FEE
who contracts for such projects with a contractor(s)licensed pursuant to the Contractors �y
License Law. P SUANC IJV
❑I am exempt under Sec. ,B&P C for this reason
Owner Date ALTE VENT—WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FL PROTECT.DEVICE (Arny
I hereby affirm under penalty of perjury one of the following declarations: �' `� ,!
❑I have and will maintain a Certificate of Consent to self-insure for Worker's Compen- DRAINS—FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
sation,as provided for by Section 3700 of the Labor Code,for the performance of the
work f hick this permit is issued. FIXTURES—PER TRAP
ave and will maintain Workers Compensation Insurance,as required by Section
3700 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 34 AP .�
My Wor5js�J�psa "�s�r�p�ec er and PolicX
Carrier. iVl l(�l4 Policy No.Mr 1?W GAS—EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' G'
COMPENSATION INSURANCE GREASEIINDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
(This section need not be completed if the permit is for one hundred dollars($100) GREASE TRAP
or less.) PLANCHECK FEE
I certify that in the performance of the work for which this permit is issued,I shall SEWER—SANITARY—STORM EA.200 FT.
not employ any person in any manner so as to become subject to the Workers'Compen- ENERGY FEE
Z sation Laws of California.Date N
WATER HEATER WENT/ELECTR O
z 0 Applicant GRADING FEE
..i V) NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEM/I'REATING
E"+ ? become subject to the Worker's Compensation provisions of the Labor Code,you must SOILS FEE
wA forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
p" CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
U C) I hereby affirm that there is a construction lending agency for the performance of Date Receipt#
"o Hthe work for which this permit is issued(Sec.3097,Civ.C.) TOTAL
Lender's Name
U Lender's Address TOTAL.
a1 certify that I have read this application and state that the above information is BUILDING FEE
t-i rA correct.I agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
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 against PERMIT ISSUANCE ELECTRIC FEE
liabilities,judgments,costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECH.
in consequence of the granting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) MECHANICAL FEE
SOURCE REGULATIONS.
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 100,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? HEATING UNIT(OVER 100,000 BTU)
❑Yes
VENTILATION FAN(SINGLE RESID)
Date Receipt#
Will the applicant or future building occupant use equipment or devices which 1
emit hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER—COMP(3HP OR 100,000 BTU) T
MAY 201999
�+
,e
District? BOILER—COMP(OVER 100,000 BTU)
E]Yes
I have read the hazardous materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
fomia Health&Safe Code,Section 5505.25533 and 25534.I understand that if the NEW RESIDENTIAL MECH. SQ FT. Y
building does no rent h v a nan that it is my responsibility to notify the occupant
of the requireme whi s me 'or to issuance of a Certificate 1',
Owner or authori agen• e' `—�••— Dire TOTAL: I y.
nF-irp