B0413 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY DI CUPVISION BUILDING-ELECTRICAL •QV VIlZ � PERMIT NO. 0-r
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING PROJECT IDENTIFICATION
6 09 Z67
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DA
10+0 3 hlo� PV_-
O 'S NAME: PHONE: COACTOR'S NAME: LIC NO: N/C CONTROL#
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ARCHITECT/ENGINEER: LIC NO: ADDRESS:_ C"t4 10 � ❑
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CONTACT: PHONE: BUILDING PERMIT INFO
C.
4s.,tq 4q1 Consultant Fees Paid by Applicant(Initial) BLD ELECT' Z_ Y
C 7rLICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE a--I hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
G C4 Z with Section 7000)of Division 3 of the Business and Professions Code,and m license is .�►
W a en y PERMIT ISSUANCE a • V RESIDENTIAL: ,��//
F.W F in full force and effect. 54 TS Z� ❑SFDWL LKKITCHEN REMODEL
U License Class Lic.#
P ZZ WW. Date Contractor APPLIANCES—RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
ARCHITECT'S DECLARATION1:1MULTI-UNIT ❑STRUCTI rRAL
•p tn Z I understand my plans shall be used as public records PANELS MODIFIC',TION
F Ca UP TO 200 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
W Licensed Professional 201-1000 AMPS IMPROVEMENT
E]SWIMMING POOLS
7��.4 OWNER-BUILDER DECLARATION
0.'W Q I hereby affirm that I am exempt from the Contractor's License Law for the OVER 1000 AMPS ❑BATH REMODEL/REPAIR El DEMOLITION
3 0. following reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL El OTHER
+ O to which requires a permit to construct,alter,improve,demolish,or repair any structure
Q prior to its issuance,also requires the applicant for such permit to file a signed statement SPECIAL CD2CUIT/MISC.
}� that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9
a A 0 (commencing with Section 7000)of Division 3 of the Business and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL:
that he is exempt therefrom and the basis for the alleged exemption.Any violation of
[I NEW BLDG/ADDITION F-1 DEMOLITION
WSection 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES ❑TENANT El FOOD SERVICE
F
not more than five hundred dollars($500).d ❑ I,as owner of the property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
will do the work,and the structure is not intended or offered for sale(Sec.7044,Business ❑OTHER
W0.3 oyo and Professions Code:The Contractor's License Law does not apply to an owner of OUTLETS—SWITCHES—FIXTURES O
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.
sale.If,however,the building or improvement is sold within one year of completion,the FLOOR ftA
owner-builder will have the burden of proving that he did not build or improve for pur-
pose of sale.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to TOTAL: . A
construct the project(Sec.7044,Business and Professions Code:)The Contractor's Li-
cense MAY
Law does not apply to an owner of property who builds or improves thereon,and QTY_ PLUMBING PERMIT FEE ,I A 1 v J
who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's
License Law. PERMIT ISSUANCE �.
❑ I am exempt under Sec. ,B&P C for this reason
ALTER—DRAIN&VENT— R
Owner Date A)
WORKER'S COMPENSATION DECLARATION affirm BACK FLOW PROTECT.D CE !gr Odv
I hereby arm under penalty of perjury one of the following declarations: 1J
I I have and will maintain a Certificate of Consent to self-insure for Worker's Compen- DRAINS—FLOOR,RO A O STORIES TYPE CONSTRUCTIOI
!tion,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 V
❑ I have and will maintain Worker's Compensation Insurance,as required by Section ��11
3700 of the Labor Code,for the performance of the work for which this permit is issued. GAS—EA.SYSTEM-1 INC.4 OUTLETS • V OCC.GROUP
My WorCker's�C mp nsa Ins ranee carrier and Policy number are:
Carrier:!S Policy No.. GAS—EA.SYSTEM-OVER 4(EA) e
C RTIF CA E OF EXEMPTION FRO WO MER '
COMPENSATION INSURANCE GREASEQNDUSTRL WASTE INTERCEPTOR
(This section need not be completed if the permit is for one hundred dollars($100) BUILDING DIVISION ES
GREASE TRAP
or less.) PLANCHECK FEEO.
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 WATER HEATER WNENT/ELECTR
ZFEk
0_4 V) NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEMITREATING
H ; become subject to the Worker's Compensation provisions of the Labor Code,you must SOILSFtV
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 affom that there is a construction lending agency for the performance of Dat Receipt#
L>~ H the work for which this permit is issued(Sec.3097,Civ.C.)
Q
Lender's Name TOTAL:
Lender's Address 1 144 TOTAL: Q
a I certify that I have read this application and state that the above information is BUILDING FEE
P-4 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 •d
H above-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against PERMIT ISSUANCE .S� ELECTRIC FEE
AAPPLICU
ts,costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECH.
PLUMBING FEE ,6.Zb
he granting of this permit.
STANDS AND ILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) GYONS. MECHANICAL FEE o f.§ AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX for Date EXHAUST HOOD(W/DUCT) k-30
HA OUS MATERIALS DISCLOSURE HOUSING MITIGATION E
Will a applicant or future building occupant store or handle hazardous material HEATING UNIT(TO 100,000 BTU)
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
VENTILATION FAN(SINGLE RESID) PAID
eipt
Will the applicant or future building occupant use equipment or devices which Date Rec
iit hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER—COMP(3HP OR 100,000 BTU)
rstrict? TOT
❑Yes ❑No BOILER—COMP(OVER 100,000 BTU)
I have re the hazardous materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
fomia Health afery Code,Sections 25505,25533 and 25534.1:understand that if the NEW RESIDENTIAL MECH. SQ.FT,
building doe Moymave a tenant,that it is my resposib'b to otify the occupantof the re ust be met o issuance of a Cert a of096upancy.
O ern or au agent S Date TOTAL: b ISSUED BY:
OFFICE