99110080APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY q q 1 in O j5 o
CITY OF CUPERTIN BUILDING - ELECTRICAL
E T O.
BUILDING APPLICATION/PERMIT PLUMBING MECHANICAL
DIVISI I
BUILDINGPROJECT IDENTIFICATION, '
BUILDINGADDRESS:
Lo
SANITARY NO. APPLIC TION SUBMITTAL DATE
' I '
O IiR'S ryAAtli:
PHONE:
IK.._
ONTRACT N E: LIC NO:
N/C
'ONTBell, p
❑
I .CT /ENGINEER: LIC O:
pDD ES
5 lS
00 ]ACT PHO NE:
BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applies/, (Initial)
BLDG ELECT PLUMB MECf
❑
LICENSED CONTRA. R' DECLARATION
I herehy adbm rh:a 1 am Beeaaea ode a arcbapler 9 maltmnenaing
r
QTY GLECTRIC PERMIT r FEE
t
_ _ _ _ .�
'
JOB DESCRIPTION
� -
PT:RMI'f ISSUANCE
with$ectian 90001 of Division 3nfthe ❑uad and Professions Code, and my license is
m full form slid ellen.
Lic.
I,ican.<Class #
Dntc omrucmr
RESIDENTIAL:
❑SPDWI. ❑ KITCHEN RIiM001iL
❑ADDITION El PLUMBING RE -PIPE
❑MULTI -UNIT [I STRUCTURAL
MODIFICATION
AI'i'LIANCES- RESIDENTIAL
A �iCTC'SDECIARATION
d amt udas public records
PANELS
UP T02W AMPS
❑INTERIOR El CHIMNEY REPAIR
IMPROVEMENT E] SWIMMING POOIS
❑ BATH RFMODEUREPAIR ❑DEMOLITION
❑OTHER'
'era 11 amna
OWNS rnifoLDER DECLARATION
erchy o(Rnn that i exempt tram the Contractors License law for the my
following Temno. (5cetion 70. .S,Business and Professions Cafe: Any oily lir county
201-IINMIAMPS
OVER IWAMPS
SIGNS ELECTRICAL.
which requires a permit to criminal alcor. improve, demolish, or repair any structure
SPECIALCIRCUIT/MISC.
primmus issuance.also requimslhe,plicam for such penniuo Elea signal storeman,
that he is licensed pursuant to the previsions of the Contractor's License law (Chapter 9
(commencing with Section 7001 of Division 3 o the Business and Professions Coca)or
TEMP. METER OR POLY NS
COMMERCIAL:
that be is exempt therefrom and the basis for the alleged exemption. Any violation of
❑ EW BLDG/ADDTDON ❑ DEMOLITION
POWER DEVICES
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
.or mora than five hundred dollars ($500).
❑ Umownerofthepmpeny,mmyemplayees with wages as their sole compensation,
d for sale (See 70 , Business
will dome work, and the wbri is not intended mcnifereW
ANT ❑ FOOD SERVICE
I PROVEMENT
[]OTHER
-
SWIMMING POOL ELECTRIC
and Professions Code: The Conlmcho's License Law does not apply mad owner of
OUTLETS - SWITCHES -FIXTURES
Property who builds or improves thereon, and who does such work himself or through
bis own employees, provided that such impnwements arc not intended m offered for
sale. IL however the building or improvement is sold within one year ol'compleion,the
NEW RESIDENTIAL ELECTR SQ PT.
SQ. FT. FLOOR AREA
$/SQ.F,
will have the hunk. of nroving that he did nm build or improve fat par.
.
perccmbnlldcr
arndc.), I
❑ [,;is owner of the Prrpedy, um exclusively centmning with Inc ewd eonanmors. m
-
'IGI'AL',
morat the project (Sec. 7044, Business ^lid Professions Coda.) The Co drsmor's Li
se Low does nolo I to an owner of t who builds or improves berva, add
apply pmlKrYw trot
h /7
i✓`yr/�
- , - � '
s
QTY. .� PLUMBING PERMIT' t FEE
who contracts for such projects with o cnnmacmr(s) lieeosed pursuant o the Contmnoh
PERMIT IV<6NCE
License Law.
❑ I am exempt under Sec. ,B& P C for this reason
^
owner Date
WORKERDECLARATION
LNT NT-WATER(EA)
VALUATION
SACK PLOW PROTF. EVICE
under Penalty
I hereby affirm under pcnuhy of perjury one of the following dedamtions:
&O`a
(J(J
DRAINS - FLOOR, ROOF, REA, COND.
❑Ihave unJ will maintain aCenitim¢ofConxnno self-inmrtfm Worke(a Compen-
sation, as provided for by Section 37W of the Latin Cede, for the Performance of the
work for which this permit is issued.
Fl haveend will maintain Workers Compensation Insamnce, as required by Section
STORIES
'F`
TYPE CONS'IRUCf N
C
J
FIXTURES - PER TRAP
J7W of the Lahr Cala fonhe performance of Ne work for which this permit is issued.
GAS -EA. SYSTEM -1 INC. 40UT 'S
OCC. GROUP
APN
My Workels Compensation Insurance <nmerand Policy number arc:
Cartier. Policy No.:
GAS -F.A. SYSTF.MOVER )
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GREASE/INDUSTR ASH INTERCEPTOR
-
BUILDING DIVISION PL'&S
(This seetion need not he completed lithe Permit is forme hundred dollars ($](a))
ar less.)
RA GREASE T
PLANCHF.CK FEE
SI'W ANITARY - STORM CA. 2fM)FI'.
Icatilythat initis performance of Ne work for which this permit is issued .]shall
not ma,doy any person in any manner nn as to become subject m'he Warkerx Compere.
ENERGY I*BC
,W RI I WATER WIVENT/ELECI'R
smian Laws of California. Dare
Applicant
GRADING FEE _,�✓
.SOILS V
NOTICE TO APPLICANT: If, otter making This Cenihcme of Exemption, you fioulA
eveome insect to the Wordo', Cmi pemmion provisions of the Labor Gds, you must
ATER SYSTEM?REATING
forthwith comply with such provisions or this Permit shall he deemed revoked.
WATER SERVICE '
zf—
CONSTRUCTION LENDING AGENCY
I harebyalium that he. isoc:mswaion lending agency for the pertommoce nl
P/11D
(Ji #
NEW RESIDENTIAL PLMB. SQ. FT
the work for which this permit is issued (Sec. 3097. Civ. CJ116
Lenders Name
TOTAL:
Lcndc/s Address
TOTAL:
ILDING FEE
I certify that I have sessions happlication add site dot the above information is
QTY. MECHANICAL PERMIT FF.E
qqIIpp
-Ly 1$
correct. I agree to comply with all city and aollmy ordinances and stale laws relating m
building roe.mm�inn. and herchy amhnrize reprtuntatives o(Nis city to <mer upon the
PFRou r ISSUANCE
ELECTRIC FEE
above-mentioned prepeny for inspection purposes.
(W<) agree to save. indemnify and keep harmless the City of Cupertino against
liabilitie.s,judgments. casts and xpen:es which may in any way eccmeagainst said City
meeme of the grnmir I is permit
in ogo
ALTER OR ADDTO MECH.
PLUMBING FEE
AIR HANDLING UNIT(TO 0,"CFM)
MECHANICAL FEE
APPLIC IND .TA NO WILL COMPLY WITH LL NO POINT
SOUR s EC II S
AIR HANDLING UNIT(OVER 10,(00CFM)
CONSTRUCTION TAX
/i
Snatllrc Cpl is lit 'nnBn s Doe
I LAZA II G C MATERIALS DISCLOSU
HXHA US'T HOOD (WMUCT)
HOUSING MITIGATION FEE
HEATING UNIT (TO 100,000 BTU)
ill the oppllcum lir t <hulldingeseapndl stamorhrrele haemdnm material
us ddincd by the Cap, ticipal Cale, Chapter 9.12, and the llc:dth onrl Safety
Code, 5cetion 25532017HEATING
UNIT (OVER 100,000 BTU)
VENTILATION FAN (SINGLE RPSID)
E] Yes a
Will to,building devices
PAID
Data Receipt X
BOILER - COMP LIHP OR 1W." BTUIa
the applicant r use equipment or which
emit haxmdmair contaminantsa us definedby the the B
Bay ay ArcAir Quality Management
UismicR
❑ yes No
TOTp
BOILER -COMP (OVER 100.000 BTU)
AIR CONDITIONER
l nave reel the ha mte;ms requirements underC pmt 695 fthc Cali
NEW RESIDENTIAL. MECH. SQ. FT.
fomin Hes Saf<t C c aas 25505, M533 and 25534. mlarsty that if the
builder n c my a ton lit, that it is my responsibilimnotif he occupant
�SVj)p1CF.fF:_
e!!{p/' (T_l
t prior m ismance of yC,C c e of y.
u
ISSUED BY:
Owner II oriu n6e^t
TOTAL:
v OFFICE