B0614 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICALPERMIT NO
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL S00o 6 I'1 /_ 't f ' .
BUILDING PROJECT IDENTIFICATION �J CJ iP T
BUILDING ADDRESSSANITARY NO. APPLICATION SUBMITTAL DATE
su C D P_ 15Zt
OWNER'S NAME ii PHONE: CONTRACTOR'S NAME: , LIC NO:
s� IA 1�� C /� �v ,03c#�;! 6 N/C CONTROL#
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ARCHITECT/ENGINEER: LIC NO: ADDRESS: //,' a � �//� rpt
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
0 ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE JOB DESCRIPTION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing
Q CG Zwith Section 7000)of Division 3 of the Business and Professions Code,and my license is RES ENTIAL'
W p PERMIT ISSUANCE
F-W in full force and effect.2[j 3' (i ❑SFDWL
KITCHEN REMODEL
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License ass Lie.#
Q z(� .. � y - t1 APPLIANCES-RESIDENTIAL L1 ADDITION PLUMBING RE-PIPE
F W Date — Contractor '
n Q cy ❑MULTI-UNIT ❑STRUCTURAL
Z) ARCHITECT'S DECLARATION PANELS MODIFICATION
O Z v)
zcv)z I understand my plans shall be used as public records UP TO 200 AMPS
AIR
v)F A ❑IMPROVEMENT ❑SWIMMING PCHIMNEY OOLS
F.,�,..,W Licensed Professional 201-1000 AMPS ❑
OWNER-BUILDER DECLARATION OVER 1000 AMPS ❑BATH REMC!EIJ(R IR DE T l( �t N,�
049Q 1 hereby affirm that I am exempt from the Contractor's License Law for the / _
Xa V following reason.(Section 7031.5,Business and Professions Code'Any city or county SIGNS ELECTRICAL ❑OTHER _ I_�
W;.W V) which requires a permit to construct,alter,improve,demolish,or repair any structure
t 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
WR Q (commencing with Section 7000)of Division 3 of the Business and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL"
0,it, iX that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
kW Section 7031 5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
W not more than five hundred dollars($500).
IMPROVEMENT
El
ElI,as owner of the property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC
F., will do the work,and the structure is not intended or offered for sale(Sec.7044,Business [-]OTHER
a 3
0y0 and Professions Code.The Contractor's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon,and who does such work himself or through
his own employees,provided[hal such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ FT.
SQ Ff.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 pur-
pose of sale).
TOTAL
❑ 1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7041,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
who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's1990
License Law PERMIT ISSUANCE d
❑ I am exempt under Sec ,B&P C for this reason p
ALTER-DRAIN&VENT-WATER(EA) Q UATION
Owner Dale
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm under penalty of perjury one of the following declarations:
❑ 1 have and will maintain a Certificate of Consent to self-insure for Worker's Compen- DRAINS-FLOOR,ROOF,AREA,COND STOR '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
❑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. GAS-EA.SYSTEM-1 INC.4 OUTLETS OCC.GROUP ANN
My Worker's Comp nsation JRsurance carrier and Policy no herr e:
Carrier: SA O�.0 F�4 n A Policy No.: I T- 1�r-/ GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE/INDUSTRL WASTE INTERCEPTOR 1,T'
COMPENSATION INSURANCE BUILDING DIVISION FEES
(This section need not be completed if the permit is for one hundred dollars($1 W) GREASE TRAP
or less.) 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.
not employ any person in any manner so as to become subject to the Workers'Compen- ENERGY FEE
O Z sation Laws of California.Date WATER HEATER W/VENT/ELECTR
Z O Applicant GRADING FEE
r., 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
wforthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
VZ 1 hereby affirm that there is a construction lending agency for the performance of Date Receipt#
Z
the work for which this permit is issued(Sec.3097,Civ.C.) TOTAL.
0 Lender's Name
W Lender's Address TOTAL:
1 certify that I have read this application and state that the above information is BUILDING F'
correct.1 agree to comply with all city and county ordinances and state laws relating to QTY, MECHANICAL PERMIT FEE SEISMIC F
V Z building construction,and hereby authorize representatives of this city to enter upon the
~ above-mentioned property for inspection purposes.
PERMIT ISSUANCE ELECTR FEE
(We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,judgments,costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECH. PLUM NG FEE
in consequence of the granting of this permit.
IC,\NI I NDER11.1NUS ANI)\\III ('O'sl Pl.l \1'I 111 A11.1UN-1'O1\1 AIR HANDLING UNIT(TO 10,000 CFM) MEC ANICAL FEE
10ri RC F RLGI'I \f NS
r 9_ AIR HANDLING UNIT(OVER 10,000 CFM) CON TRUCTION TAX� ia� _Z —9 T.-
Signature of Applicant/Contrac r Date EXHAUST HOOD(W/DUCT) HOUSI MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building 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
HEATING UNIT(OVER 10(1,000 BTU)
Code.Section 25532(x)''
El Yes ❑No VENTILATION FAN(SINGLE RESIDI PAID Date Receipt#
Will the applicant or future building occupant use equipment or devices which BOILER-COMP f3HP OR 100,000 BTU)
emit hazardous air contaminants as defined by the Bay Area Air Quality Management T
District" BOILER-COMP(OVER 100,000 BTU)
❑Yes ❑No
[have read the hazardous materials requirements under Chapter 6.95 of the Cali-
AIR CONDITIONER ISSUANC DAT
forma Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.FT.
building does not curer have a to nt,that it is my responsibility to notify the occupant
e wrements w must twoet prior to issuance of a Certificate of Occupane.
Owner or authorized Igent Date TOTAL- ISSUED BY:
q�n
OFFICE