28942T- T
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
OFFICE
FEE
ME
�11
• JOB DESCRIPTION
CITY OF CUPERTINO BUILDING - ELECTRICAL
CITY
C KITCHEN REMODEL
DIVISION APPLICATION/PF.RMIT - PLUMBING -MECHANICAL.
❑PLUMBING RE -PIPE
BUILDING PROJECT IDENTIFICA'1'15
x
BUILDING ADURPSS:
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owy3'g/_NJ?Z r
C INTERIOR
C CHIMNEY REPAIR
ARCHIIhUD xUINIBaK LIC NO:
par -8 UY o
PrT•l( / ikooft
D BATH REMODEUREPAIR 11 DEMOLITION
CON]'ACT: PHONE:
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❑ Consultant Fees Paid by Applicant (Initial)
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LICENSED CONTRACTORS DECLARATION
1 hereby ufrom that I ora licensed under pmvisiuns nl Chapter 9 (commend
with Sccsioula")of D,�'yision 3 for Biomass nnd Professi on/my laced is
in full force and effec// � /
Lice a.0 l— Lie #
Dam Com At
A F.CT'S DE .ARATION
I understand my plans shell be used as Public records
QTY ELCCIRIC PERMIT
PERMIT ISSUANCE
APPLIANCES—RESIDENTIAL
PANELS
UP102MAMPS
Licensed Professional
ON
that I a exempt 1'r m Ce Contractor's
I hereby . (Bra out 1 1. exempt from the festoons Co License Law for the
following reazon.IScrion]OJI,S, Bwsiness and Professions Cade: Any city or county
which noquires a permit to consumer, ahem, improve, demolish, or repair any structure
priorm its issuance, also requires the applicant for such permit to file asi,ned statement
oat he is licensed pursuant to the revision, of tire Contractor's Licenm Lar, (Chapter 9
2012000AMPS
OVER IWAMPS
SIGNS ELECTRICAL
SPECIAL CIRCUITIMISC.
TEMP. METER OR POLE INST.
OG�O
YXI Isy
'y'y
FCq
(commencing with Section 7000) of Division of the Business and Professions Code)or
thea he is exempt themfmm and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a Permit subjects the applicant o a civil penalty of
not more to.. five hundred dollen IMPEL,
❑ hmnwne of thupm try, or my employe swish wage ns oolr so le compensation.
POWER DEVICES
SWIMMING POOL ELECTRIC
ttC'C
will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business
n3 m
and Professions GNe The Comrumrs License law, does not apply to an owner of
property who builds or improves thereon, and who does such work himself or Waugh
OUTLETS -SWITCHES - FIXTURES
his own employees, provided than such improvements are not intended or offered for
NEW RESIDENTIAL ELECTR SQ Fr.
sale. If, however, the building or improvement is sold within ane yearof completion, the
-
er-baildar will have the bard,. of proving that he did not build or improve for pury
pose of
TOTAL:
1, as owner of the property, am exclusively contracting with licensed contractors to
consbuct the Project (Sec. 7044, Business and Professions Cast.:) The Cmumrars Li.
QTY. PLUMBINGPERMIT
cense Law does not apply to an owner of property who builds or improves thereon, and
who commit for such PrejwIx with a contractions) licensed pursuant to the Contractor's
PERMIT ISSUANCE
License law.
C l am exempt under Sec. ,B&PCfarthis reason
ALTER —DRAIN&VENT—WA3'HR(EA)
Owner hate
•
WORKER'S COMPENSATION DECLARATION
I hereby aRnn under Penalty of perjury one of the following declarations:
BACK FLOW PROTECT. DEVICE
DRAINS— FLOOR, ROOF, AREA, COND.
C l have and will maintain a Certificate ofConscmto self -insure for Workers Compere
s urn, Provided for by Section 37M of the Lubar Cede, far the performance of the
FIXTURES—PER TRAP
war orwhichthis Permit is issued.'
1 hav and will mainmin Worker's Compensation Insurance, as acquired by Section
3700.1' oe LaMrCade,far the perfommnceof the work far which this Permit is issued.
GAS— EA. SYSTEM. I INC. 4 OUTLETS
My W f}q'g�cynp4pya p r cyypa,t p -alley n
Carrie _Wsf Na.:
GAS — EA.SYSTEM-OVER 4(F.A)
k CERTIq AEOF X LGNFROMWORK-
COMPENSATIONINSURANCE
GREASUINDUSTRL WASTE INTERCEPTOR
or less.) (This section need not he completed ifthc .it is for one hundred dollars($ 100)
GREASE TRAP
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I canary that in the performance of the work for which nh is permit is issued, I shall
not employ any Person in any manner w 5s to become subject to the Worker,' Compen.
no. laws of California. Data
Applicant
SEWER—SANITARY—STORM RA. 200 FF.
WATER HEATER WNENTIELEM
tiNOTICE
a,
0.Q
]z
TO APPLICANT: If, cher making this Cemificnm at Exemption, you should
beco rte subject to the Workers Compensation provisions of the Lobar Cale, you most
foMwio comply with such provisions or this permit shall be deemed revokcA.
CONSTRUCTION LENDING AGENCY
WATER SYSTEM/TREATING
WATER SERVICE
NEW RESIDEM'IAL PLMB. SQ. FT.
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I hereby affirm that there is. construction lending agency for the performance of
he work for which this permit o Issued (Sea. 1097, Cr, C.)
Lender's Name
Leaders Addbass
TOTAL:
I canary that I have twit this application and state that the above information is
N
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comet. l agree to comply with all city and county ordinances and state laws relating to
barrage .nsupction. and heachy atomize oTmsenmlives of this city to inter upon the
QTY• MECHANICALPERMIT
PERMIT ISSUANCE
above mentioned property for inspection purposes.
(We) .gree m save, indemnify and keep hntmless the City of Cupertino ast
gain
ALTERORADDTOMECH.
liabilities,judgments, costs and expenses which may in any way same against said City
in consequence of the granting of this Permit.
AIR HANDLING UNIT (TO 10,0010 CFM)
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS.
AIR HANDLING UNIT (OVER W.000 CFM)
SignamreofApplicant/Cmararnr Done
EXHAUST HOOD rW/DUCO
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT CPO 100,0001 BTU)
Will the app rail or future building occupant store or handle hazardous mamrial
as defined by the Cupertino Municipal Code, Chapter 9,12, and the Health and Safety
Cade, Section 25532(0)7
HEATING UNIT (OVER 100,000 BTU)
CYcs E] No
Will the applicant or future building occupant use equipment or devices which
mit meanders air contaminants r,6 defined by the flay Area Air Quality Management
VENTILATION PAN (SINGLE RESID)
BOILER- COMP(3HP OR 100,0110 BTU)
District
❑Yes Ll No
BOILBR— COMP (OVER 100,1101 BTU)
AIR CONDITIONER
I have band the hazzNws maaninls re uiremer under Chapter 6.95 of the Cali-
lama Hca & Safay Cale, Scrioas 8525533 anali 1 undcrsm al drat if the
engd46 Tetcorrentlyhaw.'emnk N tiny re, nesihility to notify the occupant
of rc6eFn ,n .uALF roe r•.n'vG.r. nG1.n•,lX,I
NEW RESIDENTIAL MECH. SQ. ET.
OFFICE
FEE
ME
�11
• JOB DESCRIPTION
RESIDENTIAL•
❑SFDWL
C KITCHEN REMODEL
❑ADDITION
❑PLUMBING RE -PIPE
11 MULTI -UNIT
❑STRUCTURAL.
MODIFICATION
C INTERIOR
C CHIMNEY REPAIR
IMPROVEMENT
D BATH REMODEUREPAIR 11 DEMOLITION
❑OTHER IF90
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COMMERCIAL
a
CNEWBLEIG/ADDITION
CDEMOLITION
CTENANT
❑ FOOD SERVICE
IMPROVEMENT
COTHF.R
SQ. F'L FLOOR AREA $ISQ. IT..
FEE191996
e.n 111" Vk)� k.1, j Hiss)
VALUATION
BUILDING DIVISION FEES
PLANCHECK IEE
ENERGY FEE
GRADING FEE
SOILS FEE
PAID
Date --k-
Dole
BUILDING FEE
FEE SEISMIC FEE
ELECTRIC FEE
PLUMBING FEE
MECHANICAL FEE
CONSTRUCTIONTAX
HOUSING MITIGATION FEE
PAID
Data Rwciptk
BY: