S 0069APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
OFFICE
CITY OF CUPF.RTINO BUILDING -ELECTRICAL.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MF.CIIANICAL
BUILDING PROJECT IDENTIFICATION
PERMIT NO.
BUILDING ADDRESS:
11'3101 C\Co peri;•,o, CA
SANITARY NO.
API'LICATI(IN SUBMI7TAL DATE
�..tZ"l
OWNER'S NAME:
PHONE:
CONTRAGiOk'S AME: LICXNO:
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An
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CONTROL#
AHCrtiN : CNO:
ADDRESS: 0110 'Onb
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CON af:< PHONE:
BUILDING PERMIT INFO
BLOC ELLUMB MECH
❑ Consultant Fees Paid by Applicant (Initial)
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\31
LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm than 1 um licensed under previsions of Chapter 9 (commencing
with Section 700 Division 3 of she Business and Professionals license is
. iof
nfull farce nndeffect�. "Z �. Lie If 1 �"
Liven Clazs
Date CnnlDEC
ARCHITECT'S DECLARATION
1 understand my plain shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby action that I am exempt from the Commerce's License Law for the
following reason. (Section 7031.5, Business and Professions Cade: Any city or county
which requires o permit to construct, alcor. Improve, demolish, or repair any structure
prior to its issuance, also requires the applicant for such permit o file a signed statement
that he is licensed pvrtromi in the provisions of the Contractor's License Law (Chapter 9
(commencing with Section 7000)of Division 3 o the Business and Professions Code) or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Sound 7031.5 by any applicant fora permit subsets theapplicamca u civil penalty of
o more than five hundred dollars ($500).
as owner of the property, or my employees with wages ns their sole compensation,
will do the work, and the structure is not intended oroReml for We (Sec. 7054, Business
Professions Code: no Convector's License Law does not apply to an owner of
his iwho builds Or improves thereon, and who dreg such work himself f through
ovor wn employees, provided then such improvements arc not intended or offered for
sale. If,however, the htilJing orimprovemcm ix sold within one year of completion, the
QTY ELECTRIC PERMIT FEE
JOB DESC IPTION
RESIDENTIAL,
❑SFDWL ❑KITCHEN REMODEL
[]ADDITION UMBINGRE-PIPE
❑MULTI -UNIT STRUCTURAL
MODIFICATION
❑INTERIOR E3 CHIMNEY REPAIR
IMPROVEMENT ❑SWIMMING POOLS
U
0 BATH REMODEREPAIR ❑DEMOLITION
❑ OTHER
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PERMIT ISSUANCE
�- APPLIANCES -RESIDENTIAL
PANELS
UP TO 2W AMPS
201-1000AMPS
OVER IINq AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUITIMISC.
TEMP. METER OR POLE INST.
COMMERCIAL:
❑ NEW BLDG/ADDITION ❑ DEMOLITION
❑TENANT ❑ FOOD SERVICE
IMPROVEMENT
[3 THBR
POWERDEVICES
SWIM MING POOL ELECT RIC
OUTLETS -SWITCHES -FIXTURES
NEW RESIDENTIAL ELECTS SQ FT.
.FT. FLOOR AREA
LSQ. FT.
nen-builder will have the burden of proving thin he did am build nr toto a for em-
Sz
TOTAL:
po a of sale.).
❑ 1, as owner of the property, am exclusively convecting with licensed contractors to
Q
QTY, PLUMBING PERMIT FEE
construct the project (Sec. 7044, Business and fraternities Cade:) The Contractor's Li-
cense Law does not apply to an owner of property who huilds or improves thereon, and
/
who cumri cts far such projats with a eontmctm(s) licensed pursuant m the Conuacusrs
License Law.
❑ Iainamintander Sec. ,B&PCforihismacon
PERMIT ISSUANCE
ALTER- DRAIN & VENT- WATER RA)
VALUATION
Owner Data
WORKER'S COMPENSATION DECLARATION
BACK FLOW PROTECT. DEVICE
I hereby affirm under penalty of perjury one of the following declarations:
❑Ihave amt will mvntaineCenificam ofConsenuo self -insure for WorkeYs Compen-
DRAINS- FLOOR, ROOP, AREA, COND.
STORIES
TYPE CONSTRULTIM
section, as provided for by Section 37W of are Labor Code. On are performance of the
work for which this Permit is issued.
❑ 1 have and will maintain Workers Compensation Insurance, as required by Section
Hat Code. for the Performance of the work for which this permit is issued.
3700 of meeCe
FIXTURES - PERI 'RAP
GAS - EA. SYSTEM -1 INC. 4 OUTLMS
OCC. GROUP
APN
GAS - EA. SYSTCM-OVER4(EA)
sum
CMy rtWr:*� nce cortin send Policy n
Policy No.: rI
CERTIFICATE OF EXEMPTION FROM WORKS
COMPENSATION INSURANCE
11
GREASFIINDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
GREASETRAP
PLANCHECK FEE
(Thissatinn need not be completed ihhe pemtit is for nnehunJred Ilars (Ella)
Or Tess.)
SEWER -SANITARY -STORM IIA. 200 FT.
ENERGY FEE
I certify that in the performance of the work for which this permit is issued, l shall
Ams-
not employ any person in any manner so as to Be par, I�ri Compen-
�r
`7!ato
WATER HEATER W/VENT/ELEC R
WATER SYSTEMe BEATING
FEE
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WLender's
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sation Laws of FWomen {1[1 S 1
pplicam `
NOTICE TO APPLICANT, Tr. after making this Certificate of Exemption, you should
become subject In the Workers Compensation provisions Of the Labor Cale, you must
su
forthwith comply with such provisions Or this permit shall he deemed revoked.
CONSTRUCTION LENDING AGENCY
nstcrion lending agency for the performance Of
I hereby a17mrlhm Here isacnm
the work for which this permit is issued (Sec. XN7, Civ. C.)
Lenders Name
Address
SOUS FEE
WATER SERVICE
PAID
Dine Receiptq
NEW RESIDENTIAL PLMB. SO. FT.
TOTAL:
TOTAL"
'
BUILDING FEF.
1 certify that 1 have cam this application and stain Nut the above undetermined is
correct. l agree to comply with all city and county ordinances and mate laws relating to
building connotation, and hereby authorize representatives of this city to enter upon the
QTY. MECHANICAL PERMIT FEE
SEISMIC FEE
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
ELECTRIC FEE
ahsve-mentioned contains for inspection purposes.
(We) agree to save, indenmify ..it keep harmless the City of Cupertino against
liahilities,judgmems,cnsuand<apenses which may in any way acemc against said City
PLUMBING FEE
O
in consequence of the grunting Of this permit.
APPLICANT UNDERSTANDS ANI WILL COMPLY WITH ALL NON -POINT
AIR HANDLING UNIT TO 111,00011 CFM)
MECHANICAL FEE
SOU F,GULATIONS.
L.-ci �l
,•1 7Dme
AIR HANDLING UNI'1'(OVER IO,WOCPM)
CONSTRUCTION TAX
Signature IApplicanUCnmrnmor
HAZARDOUS MATERIALS DISCLOSURI?
EXHAUST LOGO(W/DUCG
HOUSING MITIGATION FEE
HEATING UNIT CTO 100.000 BTU)
PAID Gree j_A
Will the applicant or future Molding Occupant scare or handle hazardous material
as defined by the CUPanlna Municipal Code. Chapter 9.12, and the Health and Safety
Code, Section 25532(0)?
0 Yet
HEATING UNIT (OVER 100.000 BTU)
VENTILATION FAN (SINGLE RESIDE
Will the applicant or future building Occupant use equipment or devices which
haardous air communist, asdefined by the Boy Area Air Quality Management
BOILER-COMP(3HPOR IW.00fIBTU)emit
k
BOILER - COMP (OVER I Wp00 BTU)
District?
❑ Yes
AIR CONDITIONER
ISSUANCE Q E /jam
I hove and the htiMcpse, materials requirements under Chapterfi95 of the Coli-
NEW RESIDENTIAL MECH. SQ. ET.
forma Health & SNmy Case, Sxfiotw 25505, 25533 and 25536. 1 urdenin0nd Nat if Ne
building does inn currently have arena that it is my responsibility n notify the acumen
'1�///IT (L/tT1
a
of mere Ire is win h ut t o mreaetive of ticme Accup,�y.,
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-
TOTAL
Ah Q I� r� t
ISSUED BY:
Ownero'datim edagcnt g Data
OFFICE