S3224 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING•ELECTRICAL PER IT NO
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 3224
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS SANITARY NO. APPLICATION SUBMITTAL DATE
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OW ER'S NAME' PHONE: CONTRAC'TOR'S NAME: Y�� LIC NO. N,/C CONTROL#
ARCHITECT/ENGINEER: LIC NO. ADORESS:17 NA; 10A34-- "toc' ❑
CONTACT: PHONE: BUILDING PERMIT INFO
q� El Consultant Fees Paid b}'Applicant(initial) _ BLDG ELECT PLUMB MECH
V 1 ❑ ❑ ® ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
Q w Z with Section 7000)of Division 3 of the Business and Professions Code,and my license is RESIDENTIAL:
W Q F) PERMIT ISSUANCE
F_W= in full force and eff 't �-1 d ❑SFDWL L1 KITCHEN REMODEL
17- License Iass
Q U U _ APPLIANCES-RESIDENTIAL [:1ADDITION PLUMBING RE-PIPE
�
Q W Date Contractor
ARCHITECT'S DEC PANELS ❑MULTI-UNIT Ll STRUCTURAL
E, z 1 understand my plans shall he used asp c res s MODIFICATION
ZO OZ�„�^� UP TO 20O AMPS
n F Q 2 ❑IMPROVEMENT ❑SWIMMING POOLS
CHIMNEY REPAIR
[:.,� W Licensed Professional 01-I(�0 AMPS ❑
a$4 a' OWNER-BUILDER DECLARATION
a a¢, I hereby affirm that I am exempt from the Contractor's License Law for the OVER IOIX)AMPS ❑BATH REMODF,L/REPAIR ❑DEMOLITION
X pW.,U following reason.(Section 7031.5,Business and Professions Code.Any city or county SIGNS ELECTRICAL El OTHER
/ilii' �+F 1rtilZ,
W 3 Gi. which requires a permit to construct,alter,improve,demolish,of repair any structure
F" < 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 COMMERCIAL'
W W A Q (commencing with Section 7000)of Division 3 of the Business and Professions Code)or TEMP.METER OR POLE INST s
0.p„ that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
X Section 7031.5 by any applicant for a pernia subjects the applicant to a civil penalty of POWER DEVICES
�_' L1 TENANT [I FOOD SERVICE
W-.`� not more than five hundred dollars($500).
QQ ❑ property, j IMPROVEMENT
17- 1.as owner of theor m em Io 'es with wakes as their sole compensation, SWIMMING POOL 4RIC
❑OTHER
will do the work,and the structure is not intended or o08red for sale(Sec.7044,Business
a 3 and Professions Code.The Contractor's License Law does not apply to an owner of OUTLETS CHE$-FIX
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 NE E ENTI AI„ L R
sale.If,however,the building or improvement is sold within one year of completion,the SQ.Fr.FLOOR AREA $/SQ.FT.
owner-builder will have the burden of proving that he did not build or improve for purXV
-
pose of sale.).
TOTAL:
❑I,as owner of the property,am exclusively contracting with licensed cuntracto
construct the project(Sec.7034,Business and Professions Code:)The Contractor'V. �WBING
cense Law does not apply to an owner of property who builds or improves thereon, PERMIT FEE
who contracts for such projects with a contractor(s)licensed pursuant to the Contrac
License Law ANCE
I am exempt under Sec. ,B&P C for this reAIN&VENT-WATER(EA) VALUATION
1 Owner Date
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE /�,�'///�
1 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
ork for which this permit is issued. FIXTURES-PER TRAP
�1 have and will maintain Worker's Compensation Insurance,as required by Section
1700 of the Labor Code,for the performance of the work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My I ke'' in en.'ti 1 r nee c er and Policy nu bei a•:
Carrier d Policy No.: GAS-EA.SYSTEM-OVE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASE/INDUSTRLWAS ERC OR BUILDINGDIVtSIONFF,E.4
(This section need not be completed if the permit is for one hundred dollars($100) C,
GREASE TRAP t CHECK FEE
or less)
I certify that in the performance of the work for which this permit is issued.I shall
P SEWER-SANITARY-STO A.2 ENE Y FEE
,not employ any person in any manner so as to become subject to the Worker;Compen-
O Z cation Laws of California.Date WATER HEATER WN
TR
NG FEE
Z Applicant
,..y Ln I NOTICE TO APPLICANT If after making this Certificate of Exemption,you should WATER SYSTEM/TREATING
SOILS FEE
H ?I,become subject to the Worker's Compensation provisions of the Labor Code,you must
Wforthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
Q CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB SQ.F"r PAID
U O [hereby affirm that there is a construction lending agency for the performance of Date Receipt#
o the work for which this permit is issued(Sec.3097,Civ.C.)
0 Lender's Name TOTAL:
w
V i Lender's Address TOTAL:
'� GLI 1 certify that I have read this application and state that the above information is BUILDING FEE
E~ a
i—i correct(agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
V ,� building construction,and hereby authorize representatives of this city to enter upon the SEISMIC FEF,
above-mentioned properly for inspection purposes PERMIT ISSUANCE
ELECTRIC FEE
(We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,judgments,costs a ses which may in any way accrue against said City ALTER OR ADD TO MECH. PLUMBING FEE
in consequence c it of th permit
I( \\I 'I tiIiS \ \\I VI I 1u\-I'ul\I AIR HANDLING UNIT(TO 10,000 CFM) MECHANICAL F
tit ll R(i it, . I ti
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUC N T
Signature of Ap ant/ o or Date EXHAUST HOOD(W/DUCT) HOUSING MITI ATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(TO 1110.000 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 o VENTILATION FAN(SINGLE RESID) PAID Date 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 ORell
100,000 BTU)
District^❑Yrs BOILER-COMP(OVER 100,000 BTU)
AIR CONDITIONER ISSUANCE DATE
I have read the hazardous materr ire
ments under Chapter 6.95 of the Cali-
fornix Health&Safes C Sectio 25505, 5533 d?5534.1 understand that i(lhe Q y
Safety NEW RESIDENTIAL MECH SQ Fr. 2 ( 1
budding does n nil ave a le an�rl hal it esponsihihty to notify the occupant
of the requir s w h must be ci ior is nee of a Certif tent`C1 :ys`a
w V
Owner or authorized agent Dale TOTAL: ISSUED BY'
OFF ICE