S1720 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PE@\1tQIT NO.
BUILDING DIVISION
APPLICATION/PERMIT PLUMBING-MECHANICAL PES
1720
BUILDING PROJECT H)ENTIFICATION
DT]
ADDRESS: `i SANITARY NO. APPLICATION SUBMITTAL D
e � " , 'L'?
OWNER'S NAME: PHONE: CONTRACTOR'S NAME: LIC NO:
O 'r :N( 6 2-3 N/C CONTROL#
ARCHITECT/ENGINEER: LIC NO: ADDRESS: O ❑
'-2-110 se
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLD ELECT PLUMB MECH
LICENSED CONTRACTOR' DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
Ca a Z with Section 7000)of Division 3 of the Business and Professions Code,and my license is RESIDENTIAL:
w o O PERMIT ISSUANCE
aW F in full force and effect A 11 3 j 0'q E)SFDWL El KITCHEN REMODEL
U License`�Cl�pss �1 Lic.# O
Q U Date M Contractor e ci v Q d U r APPLIANCES-RESIDENTIAL El ADDITION El PLUMBING RE-PIPE
F U rn ARCHITECT'S DECLARATION PANELS ElMULTI-UNIT ❑STRUCTURAL
Z&nZ I understand my plans shall be used as public records MODIFICATION
UP TO 200 AMPS ❑INTERIOR IMNEY REPAIR
1_WENTLicensed Professional 201-1000 AMPS IMPROVEM ❑SWIMMING POOLS
a OWNER-BUILDEk DECLARATION OVER 1000 AMPS El BATH REMODEL/REPAIR El DEMOLITION
0.'W Q I hereby affirm that I am exempt from the Contractor's License Law for the
W0.U following reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
w0 y which requires a permit to construct,alter,improve,demolish,or repair any structure
d 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
a Q 0 (commencing with Section 7000)of Division 3 of the Business and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL:
0,c a that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
W V, Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
11
not more than five hundred dollars($500). IMPROVEMENT
"Fx,< F1I,as owner of the property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC
-�
�X n will do the work,and the structure is not intended or offered for sale(Sec.7044,Business Ctl ❑OTHER
(Rj 3and 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
sale.If,however,the building or improvement is sold within one year of completion,the 0.1
SQ.FT.FLOOR AREA $/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: ftp
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 F
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-WATER(EA) VAWATION
Owner Date
_ 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,COND. ORIES TYPE CONSTRUCTIOT
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 Workers 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 Wor�r'SCoo{ipe satiop lnsuraripe carrier and Policy nurpli% ��p Q )
Carrier: ``ff TT t�1�Q Policy No.: ` J I / GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION 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
I certify that in the performance of the work for which this permit is issued,I shall SEWER-SANITARY-STORM EA.200 Fr.
not employ any person in any manner so as to become subject to the Workers'Compen- ENERGY FEE
ZZ sation Laws of California.Date WATER HEATER WNENT/ELECTR
0 Applicant GRADING FEE
V) 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
Wrr forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE WNW
p" Q CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
V O I hereby affirm that there is a construction lending agency for the performance of Date eceipt#
w Hthe work for which this permit is issued(Sec.3097,Civ.C) TOTAL:
Lender's Name
O V Lender's Address TOTAL:
a1 certify that I have read this application and state that the above information is BUILDING FEE r�
►F.+ V) correct.I agree to comply with all city and county ordinances and state laws relating to Q'IY, 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
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.in E
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CFM) MECHANICAL F
E REGULATIONS.
�— Z GAIR HANDLING UNIT(OVER 10.000 CFM)
6. 8 CONSTRUCTION TAX
S 7g;"nMTrVApplicant/Contractor Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future budding 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)
F1 Yes F-1 No
VENTILATION FAN(SINGLE RESID) PAID
Date 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?
❑Yes ❑No BOILER-COMP(OVER 100,000 BTU)
I have read the hazardous materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
forma Health&Safety Code,Sections 25505,25533 and 25534.I understand that if the NEW RESIDENTIAL MECH. SQ.FT. �/J�
budding does not currently have a ten .that it is my responsibility to notify the occupant T
quirements w h must be t prior to issuance of a Certifica a of Occupancl.
L
Owner or authorized agent If Date TOTAL: ISSUED BY:
OFFICE