S0173 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 0173
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS- SANITARY NO. APPLICATION SUBMITTAL D.
JOCe3 FL , e e f;4o Of
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OVA 'S NA E: el ' PHONE: CO 2QCTQR'S NAME: O� LIC NO:
N/C CONTROL#
ARCH ITEC /ENGINEER: LIC NO: ADDRESS: /� � ❑
$o�'1/
CONTACT: PHONE: BUILDING PERMIT INFO
.01ZA00. ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
4( ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT F1EE
I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
won Z with Section 70(0)of Division 3 of the Business and Professions Code,and my license is RESIDENTIAL:
PERMIT ISSUANCE
F in full force and effect.
a H ❑SFDWL [I KITCHEN REMODE
U
Q'U License Class— Lic.#
Q W Date Contractor APPLIANCES-RESIDENTIAL
Z ADDITION ❑PLUMBING RE-PIPE
F O ARCHITECT'S DECLARATION PANELS ❑MULTI-UNIT ]STRUCTURAL
Z O y Z I understand my plans shall be used as public records MODIFICATION
O Z. A UP TO 200 AMPS ]INTERIOR 11 CHIMNEY REPAIR
E ,�'.,_W Licensed Professional 201-10(OAMPS IMPROVEMENT
94 p `a OWNER-BUILDER DECLARATION L]SWIMMING POOLS
a Wa Q I hereby affirm that I am exempt from the Contractor's Licence Law for the OVER I0X O AMPS Z ElBATH REMODEL/REPAIR EJDEMOLITION
W 3 W following reason.(Section 7031.5,Business and Professions Code.Any city or county SIGNS FLECTRICY ❑OTH
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 CIR SC.
`4 that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 ZZ
Wa,6 (commencing with Section 7(00)of Division 3 of the Business and Professions Code)or TEMP.M El COMMERCIAL:
a 0.M w that he is exempt therefrom and the basis for the alleged exemption.Any violation oll ❑NEW BLDG/ADDITION El DEMOLITION
W.r Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POW D I S ❑TENANT El FOOD SERVICE
not more than five hundred dollars($500). IMPROVEMENT
A ❑1,as owner of the property,or my employees with wages as their sole compensation, SWIMMING POO L TRIC
17. will do the work,and the structure is not intended or offered for sale(Sec 7044,Business ❑OTHER
W W 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 �g�
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR S d'
sale.If,however,the building or improvement is sold within one year of completion,the -SQ.FT.FLOOR dR $/SQ.ET
owner-builder will have the burden of proving that he did not build or improve for pur-
poseof sale.). TOTA �Ji�i,IT9
❑1,as owner of the property,am exclusively contracting with licensed contractors to r j'
construct the project(Sec.7044.Business and Professions Code:)The Contractor's Li- �f,+
cense Law does not apply to an owner of property who builds or improves thereon,and QTY, PLUMBING PE FEE
who contracts for such projects with a contractur(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-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:
❑1 have and will maintain a Certificate of Consent to self-insure for Worker's Compen- DRAINS-FLOOR,ROOF,AREA,COND STORIES TYPE,CONSTRUCTI(
sation,as provided for by Sec' 3700 of the Labor Code,for the performance of the
work forsu ch this permit iss d. FIXTURES-PER TRAP
❑I hav n will main n W er's Com nsation Insurance.as required by SectionrN
3700 o he bot Code, or th erforma oI the work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My W r .Co sin n ra and Policy number are:
Ca y No.: GAS-EA.SYSTEM-OVER 4(EA)
IF E O XEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEANDUSTRL WASTE INTERCEPTOR
(This sec eed not he completed if the permit is for one hundred dollars($100) DIN IVISIO EEBS
less.) GREASE TRAP
PLANCHEC
I certify that in the performance of the work for which this permit is issued.I shall SEWER-SANITARY-STORM EA.200 Fr.
ft
not employ any person in any manner so as to become subject to the Workers'Compen- ENERGY F
en
sation Laws of California.Date WATER HEATER W/VENT/ELECTR
Applicant GRADIN FE
Ol
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEM/TREATING
(~ "'I
become subject to the Worker's Compensation provisions of the Labor Code,you most SOILS FEE
wQ forthwith comply with such provisions or this permit shall be deemed revoked WATER SERVICE
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
U O
t hereby affirm that there is a construction lending agency for the performance of ute Receipt#
IJrH the work for which this permit is issued(Sec.3097,Civ.C.)
O U Lender's Name TOTAL
W Lender's Address TOTAL:
I certify that I have read this application and state that the above information is BUILDI EE
r-t V] correct I agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
V 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.
m quence of the granting of .permit. PLUMBING FEE
PL! :1XT l'NDF.R STr1ND A D WILL ('UMPLl \5'I(H.AL L A'<)N-P(>IN I AIR HANDLING UNIT(TO I0,(00 CFM) MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Si at re ofAppVcar
Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
DES MATERIALS DISCLOSURE
Will the abudding occupant store or handle hazardous material HEATING UNIT(TO 100,000 BTU)
as defined by theicipal Code,Chapter 9.12.and the Health and SafetyCode,Section 25 HEATING UNIT(OVER 100,000 BTU)
-]Yes (]No
VENTILATION FAN(SINGLE RESID) PAID
Will the applicant or future building occupant use equipment or devices which Date Receipt#
emit hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(3HP OR 1(0,(00 BTU)
District? IOTA
❑Yes E]No BOILER-COMP(OVER 100,000 BTU) r
I have read the hazardous materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER
q P ISSUANCE DATE
forma Health&Safety Code.Sections 25505,25533 and 25534.I understand that if the NEW RESIDENTIAL MECH. SQ.FT.
building does not currently have a tenant.that it is my responsibility to notify the occupant
of the requirements which must he met prior to issuance of a Certificate of Occupancy.
Owner or authorized agent Date TOTAL: ISSUED BY.
OFFICE