30401 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY 30401
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONMERMIT PLUMBING-MECHANICAL. �
BUILDING PROJECT'IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SSU B•MITTAL OTT
OW NAME: PHONE: CONTRACT'OR'S NAME: LIC NO:
_ �- N/C CONTROL#
SRCHI"TEC'/ENGINEER: LIC NO: ADDRESS:
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
CEJ ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATIONCZZ QTY. ELECTRIC PERMIT FEE
I hereby affirm Ihot I am liwnsed under provisions o[CM1upmr 9(commencing JOB DESCRIPTION
WC, with Section 7000)of Division 3 ofthe Business amt Professions Code,and my license is
F,Z ionllfcivemdetTecl. PERMIT ISSUANCERESIDENTIAL,
—
�Ut) License Class Lic# ❑SFDWL ❑KITCHEN REMODEL
F-ZW Date Common, APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RI?-PIPE
ARCH]I'ECT'S DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
z O y Z I understand my plans shall be used aw public records MODIIICAHON
O Z� UP TO 200 AMPS
1-4 t W Licensed Pmlessional [I INTERIOR ❑CHIMNEY REPAIR
201-1000AMPS IMPROVEMENT
�fG -a OWNER-BUILUIib tt om,C inaco OVER 1000 AMPS ❑BATH REMODIEUREPAIR (]DEMOLITION
� � I hereby affirm that I am exempt from the Convacnrza License Law for the
O a UF. following reason(Section 7031.5,Business and Professions Cade Any city errancy SIGNS ELECTRICAL - ❑OTHER $!P T^^� I.!
W O N which rctluiree a permit t.conswa,cher,improve,demolish,m repair any structure
pr o its suance,also reclaims happlicant f
res te appcant or such Permit file a signed statement
F prior tisSPECIAL CIRCUIT/MISC.
fthatheis licensed pursuunnothe provisions of he Gmnumor's License Laos lChupler9
1 (commencing with Section 7000)of Division 3 of are Business and Por inns Cos.) TEMP.METER OR POLE INST. COMMERCIAL
:
Mthat he is exempt therefrom and Ne oasis f,,,,hu Atilud c.rum ion.Any viohn n of [IN EW BLDG/ADDITION [IDEMOLITION
�nN Section 7031.5 by any applicant for apermit subjects the applicant toacivil penalty of POWER DEVICF_S Sp
not om ❑TENANT ❑FOOD SERVICE
mthan five hundred dollars IESIXB.
I,asiwner.f the pmpeny,of myemployees with wages us their sole compensation. SWIMMING POOL ELECTRIC IMPROVEMENT
=tee will da the work,and the mature is not immmdWoraRcredforsale(Sce,77, ,Business ❑OTHER
a3ro and Pmfexslmrs Codc:The Comrocmrs License Law does not apply to an owner of OUTLETS-SWITCHES-FIXT
property who builds or improves Nemon,and who dice,such work himself or through
his own employees,provided that such improvcmems are nor intended martial far NEW RESIDENTIAL ELECTR SQ FT.
sale,If.however the building or improvement is sold within one year ofcompletion,Ne SQ.FT.FLOOR AREA $/SQ.FE
owner-hudder will have the burden of proving that he did not build or improve for par-
prse of sale).
OJI-ds moser of the properly,am ewlusively contracting with licenud contmaor,to TOTA
rmtmet the project(Ste.70.14,Business and Professions Code:)The Contractor's Li-
cerise Law clues not apply in an owner of property who builds in improveuhereon,and QT-y_ PLUMBING PERMIT E
was convuns for sates pmjetb wits C comraunr(s):icenmed purxvmu io the cmarminrs
License Ira, 13
❑1 am exempt under Sec. ,B&P C for his reason PERMIT ISSUANCE
•nw.,.� A� art ALTER-DRAIN&VENT-WATER(EA) VALUATION
WORKERS COMPENSATION DECLARATION�� BACK FLOW PROTECT.DEVICE {
I herebyoffizm under penalty.fperjury ane of the following declmati.nn: GV �t
❑Ihave and will maintain a Catifc-m orCoastato sell-insure for Worker's Compen- DRAINS-rLOOR:ROOF.AREA.GOND.
satiun.as provided for by Section 3700 of the labor Cale,for the performance of the STORIES TYPE.CONSTRUCIOt
work for which chis permit is issued. FIXTURES-PER TRAP
❑I have and will maintain Worker's Compensation Insurance,as required by Section
37M ofne Labor Cale,for the Infarmancedue work for which this permit is issued, GAS-EA.SYSTEM-]INC.4 OUTLETS OCC.GROUP APN
My Worker's Compensation Insurance carrier and Policy number me:
Canner. Policy No.: GAS-EA.SYSTEM-OVER4 PA) -
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASERNDUS RL WASTE INTERCEPTOR
(Thissen ion need not be completed if the pernal idor one hundred dol tan is I(o) BUILDING DIVISION FEES
or Its,.) - GREASETRAP PIANCHECK FEE
Loy mythatinthe perfornamy
work for subjech ct
to one it Workers
Comical] SEWER-SANITARY-STORM EA.200 ET.
not employ any person in any manneno as to become subject to one Workeri Compen- ENERGY FEE
zz sainnLaws ofCClifomia.Dam WATER HEALER WNIiN'f/ELECTR
0 Applicata
Z r. GRADING FEE
res
NOTICE TO APPLICANT:If,Cher making this Certificate of Exemption.on,you should RgT{iR SYSTEM/BEA'TINC
a bmnme nuomt y it Wuvkcr's Cnrnpcnsnt is provision of he Labor Codc,you most
� 0 forthwith comply with such pmvisionx or this permit shall be deemed mvokcd WATER SERVICE, SOILS FEE
� z CONSTRUCTION LENDING AGENCY NEW RESIDE.NTIALPLMB. SQ.FL PAID
U p I hereby alarm that Nem is a construction lending agency for the performance of Date Receipt#
iL l-' the work for which this permit is issued(See.RED,Civ.C)
Lenders Name
O V Lenders Addmsa TOTAL:
F. y 1 certify that I have mal this application and state that the abswe information is TOTAL:
.I"-s-s (A cancer.I agree m comply will,all city and caunly ordinances and sw¢laws relating to BUILDING FEE
U ,Z buildingsuction,and here# anthonmm b QTY. MECHANICAL PERMIT FEE
com y pmsematives of Nis city to upon the SEISMIC IEE
n-i above-mentioned properly far inspection pumoscs. C77
(We)agree t.ave,indemnifyd keep hmmlemm the Cit f Cu vino against PERMIT ISSUANCE
an P Y o Pe g ELECTRIC FEF,
inr0it picidgmenhegraaind ex pens es which may in any way aremu against said City ALTER OR ADD TO MECH.
muynvnce of Nc granting of This perosit. PLUMBING FEF,
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNITOD 10,"CPM)
SOURCE REGULATIONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signaunol Applmant/Contmclor Dam EXHAUST HOOD OMMUCl7
HAZARDOUS MATERIALS DISCLOSURE 1 SING MITIGATE tI i
Will the applicant or future building occup-nt.vom or handle hazardous material HEATING UNIT(TO 100.000 BTU)
m defnW by Ne Cupertino Municipal Cale,Chapter 9,12,and the Hmllh and Safety ; 1
Code,Section 25532(0)'! HEA9'ING UNIT(OVER 11003)00 BTU) LI
❑Vex ❑No
-
VENTILATION FAN(SINGLERESID) PAID
Will the applicant or future building ove-pun use equipment or devices which Date Reccipt#
mit hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(3HP OR 1(1(1,000 BTU)
Discoid^ s_1�
❑Yes 1 No BOILGR-COMP(OVER 100,000 BTU) TOTAL: �7
I have and the hocnda s mamdals rcquirerdems under Chapter 6,95 of the Cali- AIR CONDITIONER
rami-Health&Satiny Cala Sections 25505,25533 and 25534.1 uralm,mod Nal if the ISSUANCE DATE
building does not cmready have a tiant.that it is my aspomibilitY to Modify the occupant NEW RESIDENTIAL MECH. SQ,FT.
of Ne resmrements whichnand lc met prm,1. sonnet of.Cenilicate.f Oceupmcy. �(- (•
Ownerormbomed.gent Dam TOTAL: 1
OFFICE