S1944 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PE18IT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL LJ 1944
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
OWNER'S NAii� E: PHONE: � CTOR'S N E: y. C NO:
av-di H)6 CIA.
`' �� )��` Q� NIC CONTROL#
A CHITECT/ENGI EER: LIC NO: qpD SOS. N'C�T�M �r'�• P7`Z ❑ 3 2-
CONTACT PHONE: Il BUILDING PERMIT INFO
Cuntiultant Fees Paid b) Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION f� QTY. ELECTRIC PERMIT FEE LJ CrJ/
I herebv affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
Cacd z with Section 7000)of Drvisum 3 of the Business and Professions Code,and my license is /'� RESIDENTIAL:
W O p PERM IT ISSUANCE I `,J
W F in full force and effec r ❑SFDWL ❑KITCHEN REMODEL
U License CI .s Lie.# j
Q U APPLIANCES-RESIDENTIAL. El ADDITION ❑PLUMBING RE-PIPE
Z W Datc Contractor
Q C ❑MULTI-UNIT ElSTRUCTURAL
ARCHITECT'S DECLARA ON
F,�v)� PANELS MODIFICATION
Z I under and plans shall be used as Mi re ords
O z 4 , t i � UP TO?UO AMPS TERIOR ❑CHIMNEY REPAIR
Licensed Proles. nal 201-IOIH)AMPS IMP VEMENT ❑SWIMMING POOLS
OWNER-BUILDER DECLARATION TH REMODEUREPAIR ❑DEMOLITION
CG W Q
OVER 1000 AMPS
K>a.U I hrreby alfimm 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 SIGNS ELECTRICAL ❑OTHER
W-w O� 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.
.1
W�, that he is licensed pursuant to the provision,of the Contractor's License Law(Chapter 9
W a 0� (commencing with Section 7000)of Division 3 of the Business and Professions Code)or TEMP.METER OR POLE INST. ! COMMERCIAL:
P.a.c a that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Section 7031 5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES
W tn� ❑TENANT El FOOD SERVICE
not more than Ove hundred dollar+($500).
F z Q L as owner of theproperty,or m employees with wages as their sole compensation. SWIMMING POOL ELECTRIC IMPROVEMENT
W t O ❑ tYg P ❑OTHER
will du the work,and the structure is not intended or offered for sale(Sec.701-3.Business
LW'�WI and Professions Code:The Contractor's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
LL 3~iI property who builds of improves thereon,and who docs such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELEC'TR SQ FT
sale If,however,the building or improvement is sold within one year of completion,the
SQ.FT.FLOOR $/SQ Ff.
I owner-builder will have the burden of proving that he did not build or improve for pur-
poseof sale.)
❑ 1,as owner of the property,am exclusively contracting with licensed contractors to TOTA
construct the project(Sec.7011,Business and Professions Code:)The Contractor's Lr
cense Law docs not apply to an owner of property who builds or improves thereon,and QT}'_
UNWING PERMIT FEE
who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's
License Law. PERMIT UA
❑ I am exempt under Sec ,B&P C for this reason t
ALTER-DRA VENT-WATER(EA) VALUATION
I Owner Date �i
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTE DEVICE 2 O .�
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 CONSTRUCTION
It
I61t, m,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued. 41 FIXTURES-PER TRAP
❑I have and will maintain Worker's Compensation Insurance,as required hy�Section ^
37(X)of the Labor Code,for the performance of the work for which this permit is issued. GAS-EA SYSTEM-I INC.1 OUTLETS 0 OCC-GROUP APN
My Wo is Com n Ins ance carrier and Polis n b arse
Carrie. PolicvNoY �-`� GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICA OF EXEMPTION FROM WORKERS'It GREASE/INllUSTR1.WASTE INTERCEPTOR
COMPENSATION INSURANCE r BUILDING DIVISION FEES
(This section need not be completed if the permit is for one hundred dollars($1(X)) GREASE TRAP
or less.) PI. ECK FEE �7 /�
I certifythat in the performance of the work for which this permit is issued,I shall w
P p SEWER-SANITARY-STORM EA.200 FT. L NERGY FEE O
I not employ any person in any manner so as to become subject to the Worker'Compen-
sation Laws of California.Date WATER HEATER W/VENT/ELEC'
Z Q Applicant GRADING FF.E
NOTICE TO APPLICANT:It,after making this Certificate of Exemption,you should WATER SYSTEM/TREATING SOILS FEE
become subject to the Worker's Compensation provisions of the Labor Code,you mus[
La forthwith comply with such provisions or this permit shall be deemed revoked WATER SERVICE Of
Z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ FT PAID
t hereby affirm that there is a construction lending agency for the performance of. Dae Receipt#
U O I the work for which this permit i�issue ec.3097,Crvr.C.)
C) H Lender's Name ��WWI V- OTA TOTAL:
U Lender's Address �
QWr 1 certify that I have read this application and state that(he above information is RUILDI E
rA correct.1 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
PERMIT ISSUANCE ELECTRIC E
(We)agree to save,mdemnif d keep harmless the City of Cupertino against
liabilities.judgments,costs and exp uses hich nmay m any w,ay accrue against said C'ty ALTER OR ADD TO MECH.
PLUMBING F
in consequence of the granting oft is pen 1.
\I'I'I Id \\I �lil Ktil\�Imti 1'1)\\ L0AIN) III \1I \UX 'OI\I AIR HANDLING UNIT(TO 10,000 CFM) MECHANICALF E in
+� AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signature of Applicant/Contractor Date EXHAUSTHOOD(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
�
HEATING UNIT(OVER IOO,IX)O BTU)Code.Section 25532(a)"
`�-
❑Ycs im PAID
VENTILATION FAN(SINGLE RESID)
Date Receipt#
Will the applicant or future budding 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)
District'? BOILER-COMP(OVER I00,OOO BTU)
❑Yes YI No
//�1 AIR CONDITIONER ISSUANCE,DATE
1 have �d the hazardous materials requirements under Chapter 6.95 of the Cali-
to is Health& •fety Code,Sections 25505 5533 and 25531.1 understand that if the NEW RESIDENTIAL MECH SQ.FT
bin i g dots not rrently have a tenant h i is my responsibility[n not the o upant g '"'1
of the iremen h n it e et o t iasu a Certificate o Occup nc. /
a � _
Owner o ut .z ent V Dat AL: it ISSUED BY.
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OFFICE