The URL can be used to link to this page

28551 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 (� BUILDING PROJECT H)ENTIF'ICATION a BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DAT OWNER'S NAME: PHONE: CONTRACTOR'S NAME: LIC NO: RMI . Aw �,K 5 ON% -,-- NIC CONTROL# .ARCHITECT/ENGINEER: LI O: �7 0 ADDR� � ❑ G 5-y CONTACT: PHONE: [ BUILDING PERMIT INFO wLYV4,14o9-GJ J -11,11 ❑ Consultant Fees Paid M Applicant(Initial) LDG ELECT UM MECH LICENSED CONTRACTO 'S DECLARATION QTY. ELECTRIC PERMIT FEE LF JOB DESCRIPTION I hereby affirm that I am licensed under provisions of Chapter 9(commencing AC)z with Section 7000)of Division 3 of the Business and Professions Code,and my license is PERMIT ISSUANCE RESIDENTIAL: QW W O in full force and effect. KITCHEN REMODEL UU License Class Lic#HCn d"J I Date Contractor s APPLIANCES-RESIDENTIAL DCCION ❑ UMBING RE-PIPE F O Ln, R HITECT'S DECLARATION PANELS �FDWL ULTI-UNIT ❑STRUCTURAL Z O ti Z 1 understand my plans shall be used as public records MODIFICATION O Z Ca UP TO 200 AMPS W Licensed Professional ❑CHIMNEY REPAIR 201-1000AMPS ?�kRIOR ROVEMENT �4�a' OWNER-BUILDER DECLARATION O.0 W Q' I hereby affirm that 1 am exempt from the Contractor's License Law for the OVER 1000 AMPS [I BATH REMODEUREPAIR El DEMOLITION W0,F following reason.(Section 7031.5,Business and Professions Code'Any city or county SIGNS ELECTRICAL []OTHER V) which requires a permit to construct,alter,improve,demolish,or repair any structure rFr a prior to its issuance,also requires the applicant for such permit to file a signed statement SPECIAL CIRCUIT/MISC. X W}�. that he i,licensed pursuant to the provisions of the Contractor's Licence Law(Chapter 9 kAr Wix M 0I(commencing with Section 7000)of Division 3 of the Business and Professions Code)or TEMP. TER OR POLE INST. COMMERCIAL: a a:,,a that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION >G m Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER E CES []TENANT [I FOOD SERVICE .wH.z not more than five hundred dollars($500). ❑ 1,as owner of the property,or my employees with wages as their sole compensation, SWIM G O EC IMPROVEMENT 94( Ae will do the work,and the structure is not intended or offered for sale(Sec.7044,Business ❑OTHER W and Professions Code.The Contractor's License Law does not apply to an owner of OUTLETS-SWI - IXTURES p" -r property who builds or improves thereon,and who does such work himself or through 72A his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL CT SQ 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- I pose of sale.) ❑I,as owner of the property,am exclusively contracting with licensed contractors to ITW I 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 QI y PLUMBING PERMIT FEE ! s. who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's ' License Law. PERMIT ISSUANC ❑I am exempt under Sec. ,8&P C for this reason - ALTER-DRAIN 1w,-WATER(EA) VALUATION ,Owner Date WORKER'S COMPENSATION DECLARATION BACK FLOW PR T. E ex"d 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, STORI 5 TYPE CONSTRUCTION sation,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. FIXTURES-PER TRAP [-I1 have and will maintain Worker's 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-It;ik 4 TLETS OCC.GROUP APN My Worker's Compensation Insurance carrier and Policy number are: Carrier: Policy No.: GAS-EA.SYSTEM-OV 4 A CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE GREASE/INDUSTRL WASTE INT CE j (This section need not be completed if the permit is for one hundred dollars($100) BUILDING DIVISION FEES or less.) GREASE TRAP 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. V not employ any person in any manner so as to become subject to the Workers'ComWATER HEATER WNENT/ELECTR Pen- ENERGY FEE 0 sation Laws of California. to 0j Applicant l,� Z " of + rN !f GRADING FEE after NOTICE TO APPLICANT:If,after along this Certificate of Exemption,you should WATER SYSTEM/TREATING � become subject to the Worker's Compensation provisions of the Labor Code,you must SOILS FEE 0-0forthwith comply with such provisions or this permit shall be deemed revoked WATER SERVICE Z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID V I hereby affirm that there is a construction lending agency for the performance of Date R eipt# GLH the work for which this permit is issued(Sec.3097,Civ C.) O Lender's Name TOTAL. V Lender's Address p a 1 certify that I have read this application and state that the above information is BUILDING f/) correct.I agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE V Z budding construction,and hereby authorize representatives of this city to enter upon the SEISMIC FE -� above-mentioned property for inspection purposes. 400�PERMIT ISSUANCE (We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTR F E �� liabilities,judgments,costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECH, PLUMBING FEE 'inconsequence of the granting of this permit. vl'!'IIc AI Al\I 1()\,) Alli', ��I�»III t()A11'11 UIIII LI �� I'uIAI AIR HANDLING UNIT(TO 10,000 CFM)11 - MECHANICAL FEE til ll Kt] RI r,I I V InAti It �,q AIR HANDLING UNIT(OVER 10,000 CFM) O D CONSTRUCTION X Signature o App ant/Contractor Date EXHAUST HOOD(W/DUCT) HOUSING MITIG ION FEE HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future budding 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 oPAI ii VENTILATION FAN(SINGLE RESID) Dale Receipt# Will the applicant or future building occupant use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(3HP OR 100,000 BTU) i District? TOTAL: ! E]Yes )6No BOILER-COMP(OVER 100,000 BTU) ; I have read the hazardous materials requirements under Chapter 6.95 of the Call- AIR CONDITIONER ISSUA CE DATE forma Health&Safety Code,Sections 25505,2.5533 and 25534.I 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 of the requirements which must he met prior to issuance of a Certificate of Occupancy. LOwner or authorized agent Date _ ISSUED BY, OFFICE