99120116APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
lir no nnocomrlsrn BUILDING - ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT
e76 9
0
TOTAL:
OFFICE
❑ Consultant Fees Paid by Applicant(Initial)
BrL--D�G/� ELECT PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm that 1 am liection under provisions of Chapter 9 (commencing
with Section ]fXXI)nf Dnisi nlof the Businessml Professions Coda and my license is
p
in fullforce and eRem. 3E /noll
Lncense Cl 6 Lona ��u I
ere Cenwnor
QTY ELECTRIC PERMIT FEE
JOB DESCRIPTION
RESIDENTIAL
❑SFDWL ❑ KITCHEN REMODEL
[]ADDITION ❑PLUMBING RE -PIPE
[I MULTI -UNIT ❑STRUCTURAL.
MODIFICATION
[I INTERIOR [I CHIMNEY RI7PAIR
IMPROVEMENT E]SWIMMING POOLS
ElBATH ItEvEf kEP E C1CEIIJOLITION
(�
❑OTHER F%
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL
ARCHI'T'ECTS DECLARATION
1 malersond my plans shall be used as puhlie rceords
PANELS
UP TO 200 AMPS
Llcedard Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors License Law fnr the
following roman (Santee 7031.5, Business and Rofesaions Code: Any city or County
which requires o permil to consumer, alter, improve, demolish, or repair any saucmre
prior to its issuance, also requires the applicant for such Permit o file a signed statement
that he is license) pursuant tithe provisions of the Commnnra License Luw (Chupter9
that he is engwith heefrom 71100) of Division 3tithe Business and Professions Cade) or
that he is exempt therefrom and the basis for the e11egW exemption. Any violation of
Section 7031.5 by anyopphem! fora permit subjects the applicant In u civil penalty of
not mom then rive hundred dollars(5500). s
as rhe
Las asocrofhe property, army employees %id, wages'sulecamnpcnaotiun.
will do the work, and the stmcmmisnm imendcder o�'ereJ forsele 5a, ]1114. Business
Professions Code: The Cmarmo rs License Law due, n t apply 1Q,.. own,
201-11"AMPS
OV13R 1000 AMPS _
i
SIGNS ELECI'RICAI:
SPECIALCIRCUIT/MISC, ' a
TL•Mf. METER OR POI,UINST, r
COMMERCIAL:
❑NEW BLDG/ADDITION ❑ DEMOLITION
EI TENANT ❑ FOOD SERVICE
IMPROVEMENT
El OTHER
P0s Cfb li,
WI ING L C
T, (WITCHES - FIXTUREiS
�' .r
and
pmpeny who builds or improves thereon, and who d -, auc bins 1 hrou
his own employees, provided that such impmvernents F ad f
Bela lL however, the building., impmvemem iuold wild eycmnfc ple'i
NEW RESIDENTIAL F:LECfR SQ 1ef.
SQ. FT. FLUOR AREA
LSQ. PT.
weer -builder will have the burden of proving that he dobnildor' eforpur-
TOTAL:
ptne of sale.).
❑ 1, as Owner of Ne po pen ,tau exclusively contracting .rest commemrs to
Common, the project (See. 7044, Business add Pmfcssions Code:) The Conuucusrs Li-
ese Lvwdoes not apply m anonicr of progeny who bunds or improves Remind. add
who contracts ter such projects with u coneractorts) licensed pursuant to the Contractor's
QTY. PLUMBING PERMIT FEE
License law.
I am exempt under Sec. , B & P C for this reason
PERMIT ISSUANCE
I1
I I
ALTER - DRAIN & VENT- WATER (EA)
�i/
L2kT®NIV V V
W
Data
weer
WORKER'S COMPENSATION DECLARATION
BACK PLOW PROTECT. DEVICE
1 hereby ofiirm under Penalty of perjury one of the following declarations:
I have and will maimuin a Cenifcme of Consentto,sel Ginsure for Worker's Comped.
DRAINS- FLOOR, ROOF, AREA, GOND.
e¢ ORIELS
TYPECON 'ION
cation, as provided for by Section 3700 of the labor Cale, for the Performance of the
work for which Nis permit is wand.
FIXTURES -PER TRAP
1 have and will maintain Workers Compensation Insurance, as required by Section
M(X)of the Lougr Code, fur Ne performance of the work for whiti��nn-s .sued
My Workler�.Jomj�r/c tion lnsu and Policya 8 99
Cormier: 'cy No
OCGGROUP
APN
gy�,S'7 0
GAS -EA. SYSTEM -OVER
GREASIVINDUSTRL WASTE INTERCEPTOR
CERTIFICATE OF EXEMPT ION FROM WORKERS'
COMPENSATION INSURANCE
BUILDING DIVISION FEES
GREASETRAP
PLANCHECK FEC
Z
r~Ns
a >
0s
V C)
pr
Q V
it res
(,)
ed not he completed if the Padi is forms, hundred dollars CS 100)
(Thisseca. Mro
or less)
I certify that in the performance .fine work far which his permit is issued, [,hall
not employ any person in any manner so as M become subject to the Workers' Compen-
sotto. laws Of California. Date
Applicnm t
SEWER -SANITARY -STORM CA. 200 IT.
ENERGY PEE
WATER HEATER WNENDELECTR
GRADING FEE
NOTICE TO APPLICANT: If, after making this Cer ificme of Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Code, you must
forthwith comply with such previsions or this permit shall be deamd rtvokrd.
CONSTRUCTION LENDING ACIiNCY
I hereby affirm that there is a construction lending agency for the performance of
the work for which this penial is issued (See. 3097. Civ. C.)
Lenders Name
WAI ER SYS'11CMITREATING
WATER SERVICE
SOILS FEE
PAID Date Receipt
NI3W RESIDENTIAL PLMB. so 11
TOTAL:
TOTAL:
Lenders Address
I ,edify that I base mead this application and stat, hs, he above information is
Correct. l agree t. comply with all city and county ordinances and sore lees miming W
building constmetion, and hereby structure mpmscrativcsofhis city mernerupnn the
BUILDING FEF.
QTY, MECHANICAL PERMIT FEE
SEISMIC FEE
FZ-t
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 again. said City
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
ELECTRIC FEE
PLUMB I NO FEE
in Consequence of he granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON4YHNT
SOURCE REGULATIONS.
/;t L.AIR
AIR HANDLING UNIT G'01(1,01X1 CPM)
MECHANICAL FETE
HANDLING UNIT (OVER 10.000 CFM)
CONSTRUCTION TAX
Signature UTA IicvnuContractor Da
HAZARDOUS MATERIALS DISCLOSURE
Will heepplicant or future building occupant stnmnrhmdle Inuumbus material
e, derided by the Cupertino Municipal Cale, Chapor 9.12, and the [Icahn and Safety
Cade, Section 25532(a)'I
EXHAUST HOOD(W/DUC)
HOUSING MITIGATION FEE
HEAPING UNIT(TO 100,000 BTU)
HEATING UNIT (OVER I(NI,IXX1 BTUI
VENTILATION FAN (SINGLE RESID)
❑Yes (]No
PAID
Dote Receipt#
BOILER -COMP IMP OR 100,000 BTU)
Will the applicant or future building occupant use equipment or devices which
at instructions air contaminants as defined by the Bay Area Air Quality Management
TOTAL:
BOILER -COMP (OVER IW." B'TU)
isn't]
E] Yes ❑No
AIR CONDITIONER
ISSUANCE DATE:
Cali-
I have read the tanneries materials requircmenH under Chapter 6.95 of the Cali-
NEW RESIDENTIAL. MECH. SQ. FE
haresHealth & Safety Cale, Sections 25505, 25531 sad 25514.1 understand that if the
building JOex not contently have a tenant thatjtjs my rcspmsihility m notify the acupant
TOTAL:
OFFICE