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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL
BUILDING PROJECT IDENTIFICATION
PE$ 117 NO. ^ `5J O
` \J
BUILDING ADDRESS: I
IR' 0 S� a5 a �,J f
SANITARY NO.
APPLICATION SUBMITTAL DAT
OWNER �ME a � , OPyFf)ZIE� <'� ' r�
r I
CONTRA R' NAME: t 7 LI�s
N/C
❑
CONTROL #
ARCHITECT/ENGINEER: LTC NO:
ADD ESS: n `V3 p � �� A
r t I�JICf ,
CONTACT /�_ f� PHONE:
`` 1
9 i �5 �� -�Q�� (�Gj- �b qq
❑ Consultant Fees Paid by Applicant (Initial)
BUILDING PERMIT INFO
BLDG ELECT > PLUMB MECH
❑ Irk ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Professions Code, and my license is
in full frce a a on �j
License Class t &Lic. # /
Date Contractor
QTY.
ELECTRIC PERMIT
FEE
JOB DESCRIPTION
RESIDENTIAL:
❑ SFDWL KITCHEN REMODEL
❑ADDITION ❑ PLUMBING RE -PIPE
❑ MULTI -UNIT ❑ STRUCTURAL
MODIFICATION
❑ INTERIOR ❑ CHIMNEY REPAIR
IMPROVEMENT ❑ SWIMMING POOLS
❑ BATH REMODEL/REPAIR ❑ DEMOLITION
❑ OTHER
(
PERMIT ISSUANCE
APPLIANCES — RESIDENTIAL
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records
PANELS
UP TO 200 AMPS
Licensed Professional
OWNER-BUILDER fr ll the Contractor's
I hereby affirm that I am exempt from the Contractor's License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or county
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
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars ($500).
❑ I, as owner of the property, or my employees with wages as their sole compensation,
will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business
and Professions Code: The Contractor's License Law does not apply to an owner of
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
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.).
❑ I, as owner of the property, am exclusively contracting with licensed contractors to
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
who contracts for such projects with a contractor(s) licensed pursuant to the Contractor's
License Law.
❑ I am exempt under Sec. , B & P C for this reason
201 -1000 AMPS
OVER 1000 AMPS
SIGNS ELECTRICAL
SPECIAL CIR 1SC.
TEMP. METER O PO
COMMERCIAL:
❑ NEW BLDG /ADDITION ❑ DEMOLITION
❑ TENANT ❑ FOOD SERVICE
IMPROVEMENT
❑ OTHER
POWER DEVICES
SWIMMING POOL
OUTLETS —SWITCHES — FI
NEW RESIDENTIAL ELECTR
SQ. FT. FLOOR AREA
VSQ. FT.
TOTAL:
QTY, PLUMBING PERMIT
FEE
PERMIT ISSUANCE
ALTER — DRAIN & VENT — WATER (EA)
Owner Date
VALUATION
WORKER'S COMPENSATION DECLARATION
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-
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
I have and will maintain Worker's Compensation Insurance, as required by Section
0 of the Labor Code, for the performance of the work for which this permit is issued.
My Worker's ComLensa �on Insurance 'er and Policy number are:
Carr -r: 6 moo•. Policy No.:
CERTIFICATE OF EXE PTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars ($ ] 00)
or less.)
I certify that in the performance of the work for which this permit is issued, l shall
not employ any person in any manner so as to become subject to the Workers' Compen-
sation Laws of California. Date
Applicant
BACK FLOW PROTECT. DEVICE
DRAINS — FLOOR, ROOF, AREA, COND.
STORIES
TYPE CONSTRUCTIOt`
FIXTURES — PER TRAP
GAS — EA. SYSTEM - I INC. 4 OUTLETS
OCC. GROUP
APN
GAS — EA. SYSTEM -OVER 4 (EA)
GREASE/INDUSTRL WASTE INTERCEPTOR
BUiiD1NG DIVISION F1�S '
GREASE TRAP
PLANCHECK FEE
. .
SEWER — SANITARY —STORM EA 200 FT
ENERGY FEE
WATER HEATER WIVENT/ELECTR
GRADING FEE
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lenders Name
WATER SYSTEMITREATING
SOILS FEE -
WATER SERVICE
PAID
Date Rec #
NEW RESIDENTIAL PLMB. SQ. FT.
OTAL:
Lender's Address
TOTAL:
BUILDING FEE
I certify that I have read this application and state that the above information is
correct. I agree to comply with all city and county ordinances and state laws relating to
building construction, and hereby authorize representatives of this city to enter upon the
above - mentioned property for inspection purposes.
(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
in conseque of the grantin this it.
APPLIC T TINT ILL S A WILL CO LY WITH ALL ON -P TNT
S U C REGULATIONS. n
i
QTY. MECHANICAL PERMIT
FEE
SEISMIC FEE
PERMIT ISSUANCE
Q
ELECTRIC FEE
ALTER OR ADD TO MECH.
Z— Q
PLUMBING FEE0
/'�
AIR HANDLING UNIT (TO 10,000 CFM)
MECHANICAL FEE
D
AIR HANDLING UNIT (OVER 10,000 CFM)
CONSTRUCTION TAX
at ppIican on rac D to
HAZA RODUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 25532(a)?
F-1 Yes F-1 No
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
District?
❑ Yes ❑ No
I have read the hazardous materials requirements under Chapter 6.95 of the Cali-
fomia Health & Safety Code, Sections 25505, 25533 and 25534. 1 understand that if the
building does not currently have a tenant, that it is my responsibility to notify the occupant
of the requirements which must be met prior to issuance of a Certificate of Occupancy.
EXHAUST HOOD (W /DUCT)
HOUSING MITIGATION FEE
HEATING UNIT (TO 100,000 BTU)
HEATING UNIT (OVER 100,000 BTU)
PAID
VENTILATION FAN (SINGLE RESID)
Date Receipt #
BOILER — COMP (3HP OR 100,000 BTU)
TOTAL:
BOILER — COMP (OVER 100,000 BTU)
21 D
AIR CONDITIONER
ISSUANCE DATE
fl
2.2
ISSUED BY:
NEW RESIDENTIAL MECH. SQ. FT.
TA
Owner or authorized agent Date
OFFICE