31150 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 y
BUILDING PROJECT IDENTIFICATION50
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
OWN NAME. 'n- ONE: CONTRACTOR' NAME LIC NO:
(7 f (I , 7 ' N/C CONTROL#
ARCHITECT/ENGINEER: LIC NO: l I AADD(DJR•ES . ❑
'L u-th.�• a� 9`�1 Z)
'CONTACT PHONE: BUILDING PERMIT INFO
❑ Consultant lees Paid by Applicant(initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
A a z with Section 7000)of Division 3 oQhe BUysmess and Professions Code,and my license is RESIDENTIAL:
W O O �, C' PERMIT ISSUANCE
H W in full force an l S ElSFDWL El KITCHEN REMODEL
Licens C ass' Lic.#
- APPLIANCES-RESIDENTIAL El ADDITION ❑PLUMBING RE-PIPE
F Z W Date Contractor vp
ARCHITECT'S DECLAR ION PANELS L1MULTI-UNIT ❑STRUCTURAL
ti Z I understand my plans shall be used as public records MODIFICATION
O Z 4 A UP TO 200 AMPS ❑INTERIOR ^HIMNEY REPAIR
(•:„�„.F.w Licensed Professional 201-1000 AMPS IMPROVEMENT
OWNER-BUILDER DECLARATION
LISOVER 1000 AMPS ❑BATH REMODEL/REPAIR F1DEMOLITION
C4 I hereby affirm that I am exempt from the Contractor's License Law for the
XC a U following reason.(Section 703 1.5,Business and Professions Code Any city or county SIGNS ELECTRICAL ❑OTHER
W W V) 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.
that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9
W U] Q (commencing with Section 7000)of Division 3 of the Business and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL:
.,q0
91,A, that he is exempt therefrom and the basis for the alleged exemption.Any violation of El NEW BLDG/ADDITION ❑DEMOLITION
W Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES [-]TENANT ❑FOOD SERVICE
Z y, not more than five hundred dollars($500). rZ IMPROVEMENT
F A ❑1,as owner of the property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC
will do the work,and the structure is not intended or offered for sale(Sec 7044,Business -]OTHER
Lail 3 and Professions Code:The Contractor's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURE
0. 1 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 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.). TOTAL:,
..t
❑ I,as owner of the property,am exclusively contracting with licensed contractors to
t
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 QTY, PLUMBING PERMIT FEE
who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's d
License Law. PERMIT ISSUANCE •e
❑ I am exempt under Sec. .B&P C for this reason �'t�
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Owner Date
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
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.GOND. STORIES 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
:�-'Ihave 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-1 INC.4 OUTLETS OCC.GROUP APN
My Worker's ComTp�en�a ion Incur ce carrier and Policy number
Carrier 'CL1M- Policy No. I �L' I U a GAS-EA.SYSTEM-OVER A(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' 1
COMPENSATION INSURANCE GREASE/1NDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FEES
(This section need not be completed if the permit is for one hundred dollars($100) GREASE TRAP
1 or less.) PLANCHECK FEE
I certify that in the performance of the work for which this permit is issued,l shall SEWER-SANITARY-STORM EA.200 FF.
not employ any person in any manner so as to become subject to the Workers'Compen- ENERGY FEE
Z sation Laws of California.Date WATER HEATER WNENT/ELECTR
0 Applicant GRADING FEE
Z � NOTICE TO APPLICANT:If,after making 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
WQ forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
Z 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 Re ipt#
i--i the work for which this permit is issued(Sec.3097,Civ.C 1
u" Lender's Name TOTAL.
ULender's Address TOTAL
a I certify that I have read this application and state that the above information is BUILDING FEE
V 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. PLUMBING FEE
in consequence of the granting of this permit.
\I'I'I I( \�I 1 �Iil lal\\P" \\I)\\[II (I)NIN) \\1111 \II \ii\ l'In\l AIR HANDLING UNIT(TO 10,000 CFM)
MECHANICAL F
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signature of Applicant/Contractor Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(TO 100,000 BTU)
l as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
I Code,Section 25532(a)° HEATING UNIT(OVER 100,000 BTU)
❑Yes ❑No PAID
VENTILATION FAN(SINGLE RESID)
Date Recei #
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)
TAL:
District'? BOILER-COMP(OVER 100.000 BTU)
❑Yes ❑No
I have read the hazardous materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ! ISSUANCE DATE
forma Health&Safety Code,Sections 25505,25533 and 25534 1 understand that if the NEW RESIDENTIAL MECH. SQ.FT
building d s not currently have a tenant,that it is my responsibility to notify the occupant
of the irements which mus et to issu e of a Certificate f Occs anc
��' l
Muth zed ag rt ate'r- TOTAL: ISSUED BY:
OFFICE