S0782 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PF�v11T NO. A
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL ``J U 2
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBBMMITTAL DATI
6-6 Ar//)&
OWNS 'S NAME: PHONE:(_tfOy CONTR TO 'S NA LIC NO: NIC CONTROL#
41
ARCHITECT/ENGINEER: LIC NO: ADDRES LJ
5-M km/-11 Rkele
CONTACT': PHONE: J BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE 0 1:1 X Ei
I hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
A a Z with Section 7000)of Division 3 of the Business and Professions Code,and my
license is
WOO PERMIT ISSUANCE RESIDENTIAL:
F W Z in full force and eff
d U U License Class — Lic.# 51 - ❑SFDWL [_1 KITCHEN REMODEL
�d W4 Date Contractor APPLIANCES-RESIDENTIAL ❑ADDITION -1 PLUMBING RF.-PIPE.
F O ARCHITECT'S DECL TON PANELS ❑MULTI-UNIT ❑STRUCTURAL
Z O 0 Z I understand my plans shall be used as public records MODIFICATION
O
_4 G UP TO 200 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
[-+4 iF".,LU Licensed Professional
Q .7 01-I(HH)AMPS IMPROVEMENT ❑SWIMMING POOLS
�14 .a OWNER-BUILDER DECLARATION OVER 1000 AMPS ❑BATH REMODEL/REPAIR ❑DEMOLITION
0.'04 9X Q I hereby affirm that I am exempt from the Contractor's License Law for the
X wF following reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
y 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 CIRCUIT/MISC.
that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9
11114 A 5 (commencing with Section 7000)of Division 3 of the Business and Professions Code)or TEMP METER OR POLE INST. COMMERCIAL:
0.0.o a that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
y('wo GL Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES
W., not more than five hundred dollars($500). ❑TENANT ❑FOOD SERVICE
AI,as owner of the property,or m employees with wa es as their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
❑ P P Y• Yg P'
F. will do the work,and the structure is not intended or offered for sale(Sec.7044,Business ❑OTHER
W3and Professions Code:The Contractor's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
0. 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 Soft T. OYR eg EA $/SQ FT.
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: p{ �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 v !S }J
who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's
License Law. PERMIT ISSUANCE •� ,,., ';n:f�
❑I am exempt under Sec. ,B&P C for this reason
Owner Date ALTER-DRAIN&VENT-WATER(EA) VALUATION
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
❑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-I INC.4 OUTLETS OCC GROUP APN
My Worker's fcynpeasat'pp Ins ranee carrier and Policyn bei are:y
Carrier. Policy No.:7Z7 /5 Tj�S GAS-EA.SYSTEM-OVER 4(EA)
CERT, XEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASERNDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
(This section need not be completed if the permit is for one hundred dollars($100) GREASE TRAP
or less.) PLANCHECK FEE
1 certify that in the performance of the work for which this permit is issued,I shall SEWER-SANITARY-STORM EA.200 FT
Z
not employ any person in any manner so as to become subject to the Workers Compen- ENERGY FEE
sation Laws of California.Date WATER HEATER WENT/ELECTR
Z 0 /VApplicant GRADING FEE
pr V) NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEMITREATING
I"t 0-4
become subject to the Worker's Compensation provisions of the Labor Code,you must SOILS FEE
wA forthwith comply with such provisions or this permit shall he deemed revoked. WATER SERVICE
Z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
U 0 1 hereby affirm that there is a construction lending agency for the performance of Date Receipt#
w H the work for which this permit is issued(Sec.3097,Civ.C.)
0 U Lender's Name TOTAL:
U Lender's Address TOTAL.
a 1 certify that I have read this application and state that the above information is BUILDING FEE
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.
in consequence of the granting of this permit. PLUMBING FEE
',PPI(CANT UNDERSl ANUS AND%N ILL CONIPL'i NVI fit ALL VON-P0lNf AIR HANDLING UNIT(TO 10,000 CFM)
tiJR(T RE ULA'I IONS MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
:z� z
Signa6. of pphcan Contractor ate EXHAUST HOOD(W/DUCT) HOUSING 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
Code,Section 25532(a)" HEATING UNIT(OVER 100,000 BTU)
❑Yes ❑No
VENTILATION FAN(SINGLE RESID) PAID
Dale 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 OR 100,000 BTU)
TOTAL:
District's
❑Yes ❑No BOILER-COMP(OVER 100,000 BTU)
1 have read the hazardous materials requirements under Chapter 6.95 of the Cah- AIR CONDITIONER ISSUANCE DATE
fomia 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 m wreme is which must be et prior t`nuance of a Certificate of Occu ncY.
Owne a rized agent DTdte — TOTAL. ISSUED BY: - -
OFFICE