S1959 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PEtIT NO. 1959
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL `V
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DA
OWNER'S NAME:- PHONE: CONTRACTOR'S NAME. LIC NO:
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ARCHITECT/ENGINEER: LIC NO: ADDR SS: v� ❑
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CONTACT: 4 6PONE: BUILDING PERMIT INFO
ZFS 0v�,*/A''f 64 0_ S- ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ LA1 ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
O 0 O Z with Section 7000)of Division 3 of the Business and Professions Code,and my license is PERMIT ISSUANCE S Q RESIDENTIAL:
Fa w F in full force and effect,ry_I O /_7V
a 37
7 ❑SFDWL ❑KITCHEN REMODEL
Q U U License Class l Lie.# / - APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
V)Q WW Date �=T-X Contractor z c
F< ARCHITECT'S DECLARA ION PANELS ❑MULTI-UNIT ❑STRUCTURAL
p vI Z I understand my plans shall be used as public records MODIFICATION
z�.A UP TO 200 AMPS 2 ❑INTERIOR ❑CHIMNEY REPAIR
F"W Licensed Professional 201-1000 AMPS IMPROVEMENT ❑SWIMMING POOLS
a OWNER-BUILDER DECLARATION OVER 1000 AMPS ❑BATH REMODEL/REPAIR ElDEMOLITION
a 04a I hereby affirm that I am exempt from the Contractor's License Law for the
3 w F following reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL AE1HEJ Wr Ov) which requires a permit to construct,alter,improve,demolish,or repair any structure _ -
Jprior to its issuance,also requires the applicant for such permit to file a signed statement SPECIAL CIRCUIT/MISC.
COD7 W CO. that he is licensed pursuant to the provisions of the Contractors License Law(Chapter 9
GS C (commencing with Section 7000)of Division 3 of the Business and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL:
that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
W,•, Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES ❑TENANT El FOOD SERVICE
not more than five hundred dollars($500).
F z> IMPROVEyyNT j
A ❑I,as owner of the property,or my employees with wages as[heir sole compensation, SWIMMING POOL ELECTRIC
X c will do the work,and the structure is not intended or offered for sale(Sec.7044,Business []OTHER
0.3 0000 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
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 SQ.Fr.FLOOR AREA $/SQ.FT.
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 TOTAL:
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
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) ATION
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. STORIES TYPE CONSTRUCTIO
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
700 have and will maintain Worker's Compensation Insurance,as required by Section
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 Compensation Ipsu ,Q carrier and Policy number are:
Carrier: /RFfi.'.'l71 r✓i1� Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASE/INDUSTRL 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 FT.
not employ any person in any manner so as to become subject to the Workers'Compen- ENERGY FEE
Z sation Laws of California.Date WATER HEATER WNENT/ELECTR
z 0 GRADING FEE
Applicant
.. V) NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEMITREATING
(~ ; become subject to the Worker's Compensation provisions of the Labor Code,you must SOILS FEE
Wfr forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
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#
i-+ the work for which this permit is issued(Sec.3097,Civ.C.)
w Lender's Name TOTAL:
0 U Lender's Address TOTAL: BUILDING FEE
I certify that I have read this application and state that the above information is
V) 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
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
MECHANICAL FEE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signature of Applicant/Contractor Date 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)
S'D
❑Yes ❑No
VENTILATION FAN(SINGLE RESID) PA�
All 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:
Districts
F1 Yes ❑No BOILER-COMP(OVER 100,000 BTU) i
'✓
1 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. .�
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.
Owner or authorized agent DateTOTAL: ISSUED BY:
OFFICE