S1855 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PE IT NO.
BUILDING DIVISION APPLICATION/PERMITPLUMBING-MECHANICAL 1855
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DA'
OWNER'S NAME: PHONE: CONT[tACTOR'S NAME: LIC NO:
_'1 4..G' / ?� .\ -.e�_L VA ie C u Z-9 Ai� N/C CONTROL#
ARCHITECT/ENGI EER: LIC NO: ADDRESS: 1 1 ❑
ZL LG l ti 4-A.' Z
CONTACT: PHONE: BUILDING P RMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG EV PLUMB MECH
LICENSE CONTRACTOR'S DECLARATION QTY, ELECTRIC PERMIT FEE
I hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
FOA a Z with Section 7000)of Division 3 of the Business and Professio s Code,and my license is RESIDENTIAL:
O in full force and of PERMIT ISSUANCE
a W H i o Z r ❑SFDWL El KITCHEN REMODEL
Q U U DatLicass- Con# APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
¢W0. Date Contractor od
in ARCHITECT-S DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
pV)Z I understand my plans shall be used as public records PANELS MODIFICATION
Z 4— UP TO 200 AMPS
q ❑INTERIOR ❑CHIMNEY REPAIR
F a Licensed Professional 201-1000AMPS IMPROVEMENT ❑SWIMMING POOLS
}� .a OWNER-BUILDER DECLARATION OVER 1000 AMPS BATH REM L/REPAIR ❑D OLITION
a W d I hereby affirm that I am exempt from the Contractor's License Law for the
'O P.U following reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
Cde
WWO y which requires a permit to construct,alter,improve,demolish,or repair any structure
aprior to its issuance,also requires the applicant for such permit to file a signed statement SPECIAL CIRCUIT/MISC.
�. that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9
CL A C) (commencing with Section 7000)of Division 3 of the Business and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL:
0.o p that he is exempt therefrom and the basis for the alleged exemption.Any violation of El NEW BLDG/ADDITION ❑DEMOLITION
W uw�. Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES []TENANT ❑FOOD SERVICE
not more than five hundred dollars($500).
H z>
�x A ❑I,as owner of the property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
a e will do the work,and the structure is not intended or offered for sale(Sec.7044,Business ❑OTHER
W 3 m and Professions Code:The Contractor's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
p" property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELEC`rR SQ FT.
sale.If,however,the building or improvement is sold within one year of completion,the SQ.FT.FLOOR AREA $/SQ.Fr.
owner-builder will have the burden of proving that he did not build or improve for pur-
pose of sale.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to TO
construct the project(Sec.7044,Business and Professions Code:)The Contractor's Li-
cense Law does not apply to an owner of property who builds or improves thereon,and QTY, PLUMBING PERMIT FEE
who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's
License Law. PERMIT ISSUANCE
❑I am exempt under Sec. ,B&P C for this reason
OwneDate ALTER-DRAIN&VENT-WATER(EA) VALUATION
r
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEV42E
I hereby affirm under penalty of perjury one of the following declarations:
have and will maintain a Certificate of Consent to self-insure for Worker's Compen- DRAINS-FLOOR,ROOF,A A,COND. STORIES TYPE CONSTRUCTIOt
ation,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued. FIXTURES-PER TRA
❑I have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued. GAS-EA.SYSTEM-I f11C.4 O TS OCC GROUP APN
My Worker's C mpen ation Ins}gynce c err and Policy number are: C�
Carrier: " +J(� Policy No.:�13�i���L�4 GAS-EA.SYSTEM-OVER 4(EA) 00,
CERTIFICATE OF EX MPTION FROM WORKERS' it
COMPENSATION INSURANCE GREASE/INDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
(This section need not be completed if the permit is for one hundred dollars($100) GREASE TRAP
or less.) PLANCHECK FEE
I certify that in the performance of the work for which this permit is issued,I shall SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any manner so as to become subject to the Workers'Compen- ENERGY FEE
2 Z sation Laws of California.Date WATER HEATER WIVENT/ELECTR
C) Applicant GRADING FEE
i-� NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEM/rREATING
I—+ -- become subject to the Worker's Compensation provisions of the Labor Code,you must SOILS FEE
wH forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
U C) I hereby affirm that there is a construction lending agency for the performance of Date Receipt#
w the work for which this permit is issued(Sec.3097,Civ.C.) cl TOTAL
0U
Lender's Name Is
W Lender's Address TOTAL:
a I certify that I have read this application and state that the above information is B FEE
V] correct.I agree to comply with all city and county ordinances and state laws relating to QTy_ MECHANICAL PERMIT
U rZ building construction,and hereby authorize representatives of this city to enter upon the SEISMIC,
~ above-mentioned property for inspection purposes.
PERMIT ISSUANCELtCTRIC FEE
(W a ee to save,indemnify and keep harmless the City of Cupertino against �
liabilitie,judg encs,costs and expenses which may m any way accrue against said Qty 't
ALTER OR ADD TO MECH. V` PLUMBING FEE
in copse uenc of the granting of this permit.
APPLI N UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) MECHANICAL FEE
SOURC GULATIONS.
t 5—_O U HANDLING UNIT(OVER 10,000 CFM)
CONSTRUCTION TAX
74)
rg ature f Applica Cont etor Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
A DOUS MATERIALS DISCLOSURE
W the applicant future building occupant store or handle hazardous material HEATING UNIT(TO 100,000 BTU)
as defined by the Cuperti o Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? HEATING UNIT(OVER 100,000 BTU)
❑Yes ❑No
VENTILATION FAN(SINGLE RESID) PAID
Date Receipt#
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(3HP OR 1(H1.000 BTU)
TOTAL:
District? J (
❑Yes ❑No BOILER-COMP(OVER 100,000 BTU)
I have read the hazardous materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATF�
forma Health&Safety Code.Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH SQ FT —7
building does not currently have a tenant,that it is my responsibility to notify the occupant / (�
of the requirements which must be met prior to issuance of a Certificate of Occupancy.
Owner or authorized agent Date TOTAL: ISSUED
OFFICE