28568API'LIUAN I IU TILL IN INI-UHMAI IUN WI I MIN MEU LINES - U5E BALL POINT PEN ONLY
CITY OF CUPERTINO BUELDING - ELECTRICAL
PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL
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28568 5 6 8
BUILDING PROJECT IDENTIFICATION
BUII.DING ADDRESS: � �� �
2172 r
SANITARY NO.
APPLICATION SUBMITTAL DAT
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OWNER'S NAM ON
CONTRA R'S N ME: LIC NO:
N/C
CONTROL #
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❑
ARCHITE GIN LIC NO:
ADDRESS:
CONTACT: PHO
BUII DING PERMIT INFO
❑ Consultant Fees Paid by Applicant (Initial)
BLD E� PLUMB
QTY. ELECTRIC PERMIT FEE
A a Z
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LICENSED CONTRACTOR'S DECLAtNflON
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 7000 of Division 3 of the Business and Professions Code, and m license is
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in full force and effect.
License Class Lic. #
Date Contractor
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records
JOB DESCRIPTION
RESIDENTIAL:
❑ SFDWL ❑KITCHEN REMODEL
ADDITION El PLUMBING RE -PIPE
❑ MULTI -UNIT ❑ STRUCTURAL
MODIFICATION
❑ INTERIOR ❑ CHIMNEY REPAIR
IMPROVEMENT
El BATH REMODEL/REPAIR El DEMOLITION
❑ OTHER
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL
PANELS
UP TO 200 AMPS
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Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or county
201-1000 AMPS
OVER 1000 AMPS
SIGNS ELECTRICAL
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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
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
SPECIAL CIRCUIT/MISC.
TEMP. METER OR POLE INST.
COMMERCIAL:
❑ NEW BLDG/ADDITION [I DEMOLITION
POWER DEVICES
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Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars ($500).
E]1, as owner of the property, or my employees with wages as their sole compensation,
will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business
El TENANT El FOOD SERVICE
IMPROVEMENT
❑ OTHER
SWIMMING POOL ELECTRIC
OUTLETS - SWITCHES - FIXTURES
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3 00
and Professions Code: The Contractor's License Law does not apply to an owner of
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 RESIDENTIAL ELECTR SQ FT.
SQ. FT. FLOOR AREA $/SQ. FT.
sale. If, however, the building or improvement is sold within one year of completion, the
owner -builder will have the burden of proving that he did not build or improve for put-
pose of sale.).
❑ I, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044, Business and Professions Code:) The Contractor's Li-
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SEP
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cense Law does not apply to an owner of property who builds or improves thereon, and
who contracts for such projects with a contractor(s) licensed pursuant to the Contractor's
License Law.
❑ I am exempt under Sec. , B & P C for this reason
QTY, PLUMBING PERMIT FEE
1 X99
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PERMIT ISSUANCE
ALTER - DRAIN & VENT - WATER (EA)
VAVO&ION
Owner Date
WORKER'S COMPENSATION DECLARATION
BACK FLOW P DEVICE��
I hereby affirm under penalty of perjury one of the following declarations:
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DRAINS - OR, ROOF, A A, COND.
❑ 1 have and will maintain a Certificate of Consent to self -insure for Worker's Compen-
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
STORIES
TYPE CONSTRUCTION
work for which this permit is issued.
FIXTURE/- PER TRAP
❑ I 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.
My Worker's Compensation Insurance carrier and Policy number are:
GAS - . SYSTEM -1 INC. 4 OUTNTS
OCC. GROUP
APN
Carrier: Policy No.:
GAS EA. SYSTEM -OVER 4 (EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars ($100)
or less.)
I certify that in the performance of the work for which this permit is issued, I shall
not employ any person in any manner so as to become subject to the Workers' Compen
EASFANDUS STE
GREASE
I
BUII,DING D
ION FEESFR
PLANCHECK FEE �
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SEWER - S ARY - EA. 2 FT.
ENERGY FEE 24
WATER A R W E T LECTR
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sation Laws of California. Date
Applicant
GRADING FEE
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
WA STE TING
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(~ O"t
WA
SOILS FEE
WATERS VICE
V O
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
PAID
Dat Receipt #
NEW RESIDENTIAL PLMB. SQ. FT.
w H
C) VLender's
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the work for which this permit is issued (Sec. 3097, Civ. C.)
Name
Lender's Address
TOTAL:
I certify that I have read this application and state that the above information is
correct. I agree to comply with all city and county ordinances and state laws relating to
building construction, and hereby authorize representatives of this city to enter upon the
QTY.C AL PERMIT FEE
BUILDING f• ��
SEISMIC fE
ISSUANCE
ELE C FEE r
H
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City
y of Cupertino against
liabilities, judgments, costs and expenses which may in any way accrue against said CityTER
in consequence of the anting of is permmt.
OR ADD TO MECH. 2 �'
PLUM G FEE
AIR HANDLING UNIT (TO 10,000 CFM)
MECH AL FEE
APPLICANT UNDE STAND AN IL F CVMPLY WITH ALL NON -POINT
SOURC GULA 0�8%
`
AIR HANDLING UNIT (OVER 10,000 CFM)
CONSTRUCT\N TAX
EXHAUST HOOD (W/DUCT)
HOUSING MITI ON FEE
ign licant/Con ctor Date
HAZARDOUS MATERIALS D OSURE
HEATING UNIT (TO 100,000 BTU)
Will the applicant or future building occupant ore or handle hazardous material
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 ❑ No
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
PAID
Date Receipt #
VENTILATION FAN (SINGLE RESID)
BOILER -COMP (3HP OR 100,000 BTU)
BOILER -COMP (OVER 100,000 BTU)
District?
E] Yes []No
AIR CONDITIONER
I have read the hazardous materials requirements under Chapter 6.95 of the Cali-
ISSUANCEIDATF
NEW RESIDENTIAL MECH. SQ. FT.
forma Health & Safety Code, Sections 25505, 25533 and 25534. I understand that if the
building does not currently have a tenant, that it is my responsibility to notify the occupant
of the requirements which must be met prior to issuance of a Certificate of Occupancy.
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ISSUED ,J _ �` �
Owner or authorized agent Date
OFFICE