S2536 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL S 2536
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DAT
OWNER'S NAME: PHO . CONTRACTOR'S NAME. LIC NO:
NIC CONTROL#
-�Cll /ENGINEER: 1 LIC NO: n ADDRESS: LiVI r Z zf►
CO TACT: PHONE: BUILDINb PERMIT INFO
5/'"JLN6 is /ya ��s�� ❑ Consultant Fees Paid by Applicant(Initial) B- fl EL —
PLUMBt— ME l�
Y.
LICENSED CONTRACTOR'S DECLARATION QTELECTRIC PERMIT FEE LJ
I hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
Q W Z with Section 7000)of Division 3 of the Business and Professions Code,and my license is RESIDENTIAL:
W O p PERMIT ISSUANCE
F W in full force and effect. ❑SFDWL ❑KITCHEN REMODEL
Q U U license Class Lic.# APPLIANCES-RESIDENTIAL Ekl)DITION ❑PLUMBING RE-PIPE
F Z W Date Contractor
v Q aElMULTI-UNIT ❑STRUCTURAL
ARCHITECT'S DECLARATION
]h PANELS
b MODIFICATION
p tq z 1 understand my plans shall be used as public records
Z4'-' UP TO 200 AMPS
❑
Q INTERIOR [_1 CHIMNEY REPAIR
I W Licensed Professional201-IOOOAMPS IMPROVEMENT ❑SWIMMING POOLS
W;4
a OWNER-BUILDER DECLARATION ` " OVER 1000 AMPS ❑BATH REMODELIREPAIR ❑DEMOLITION
d I hereby affirm that I am exempt from the Contractor's License Law for the
O W U following reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
3 O l" which requires a permit to construct,alter,improve,demolish,or repair any structure
W. a for to its issuance,also requires the applicant for such permit to file a signed statement
pr eq pp pe g SPECIAL CIRCUIT/MISC.
Wp. that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9
A O (commencing with Section 7000)of Division 3 of the Business and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL:
p„c y� that he is exempt therefrom and the basis for the alleged exemption.Any violation of El NEW BLDG/ADDITION ❑DEMOLITION
M
LL Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
z� not more than five hundred dollars($500). _ IMPROVEMENT
A ❑I,as owner of the property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC ❑OTHER
c will do the work,and the structure is not intended or offered for sale(Sec.7044,Business
a 3 00 and Professions Code:The Contractors License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
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 ELECTR SQ FT.
r SQ.FT.FLOOR AREA $/SQ.FT.
sale.If,however,the building or improvement is sold within one year of completion,the
owner-builder will have the burden of proving that he did not build or improve for pur-
pos sale.). r 0
as owner of the property,am exclusively contracting with licensed contractors to r Q "
construct the project(Sec.7044,Business and Professions Code:)The Contractor's Li- Z 0
cense Law does not apply to an owner of property who builds or improves thereon,and QTY, PLUMBING PERMIT FEE j�
who contracts for such prects with a contractor(s)licensed pursuant to the Contractor's
License Law. PERMIT ISSUANCE
❑I am exempt un ,B&P C for this reason
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Ow Date
WOR 's COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm under penalty of perjury one of the following declarations:
-1 I have and will maintain a Certificate of Consent to self-insure for Worker's Compen- DRAINS-FLOOR,RO STORIES TYP CONSTRUC ION
cation,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued. XTURES TRAP '� / (///
❑I have and will maintain Worker's Compensation Insurance,as required by Section v
3700 of the Labor Code,for the performance of the work for which this permit is issued. S-E YSTEM-1 INC.4 OUTL S OCC.GROUP PN
My Worker's Compensation Insurance carrier and Policy number are:
Carrier: Policy No.: 11b14S- T -
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE REASE/INDUSTRL WASTE INTER R 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 S
not employ any person in any manner so as to become subject to the Workers'Compen- ENERGY FEE
O Z sation Laws of California.Date WATER HEATER W/VENT/ELECTR GRADING FEE
Z 0 Applicant
H V) NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEMrFREATING SOILS FEE�Y i
become subject to the Worker's Compensation provisions of the Labor Code,you must v
forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE ^
Z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
U 0 1 hereby affirm that there is a construction lending agency for the performance of ate Rec pt 11
j1
L1~ H the work for which this permit is issued(Sec.3097,Civ.C.) TOTAL- V
C)ULender's Name
Lender's Address TOTAL t
W
I certify that I have read this application and state that the above information is BU I FEE Q
V) correct.I agree to comply with all city and county ordinances and state laws relating to QTY SE FEE
MECHANICAL PERMIT FEE d�D
U Z building construction,and hereby authorize representatives of this city to enter upon the
~ above-mentioned property for inspection purposes
(We)agree to save,indemnify and keep harmless the City of Cupertino against PERMIT ISSUANCE ELE RIC FEE I 0
liabilities,judgments,costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECH.
PL B1NG FEE
in consequence of he granting of this permit.
APPLICANT UN ERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) CHANICAL FEE
SOURCE R
AIR HANDLING UNIT(OVER 10,000 CFM) CO TRUCTION TAX
ignature of Applic UContractor Date EXHAUST HOOD(W/DUCT) HOUSI G MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(TO 100,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? HEATING UNIT(OVER 100,000 BTU)
E]Yes ro PAID
VENTILATION FAN(SINGLE RESID) 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 100.000 BTU) T AL'
r
District? BOILER-COMP(OVER 100,000 BTU)
E]Yes 'Q,No
I have read the hazardous materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
fomia Health&S fety Code,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.FT.
building does n t rrentl have a tenant,that it is my responsibility to notify the occupant
Of the nt is must be met prior to issuance of a Certificate of Occupancy.
ner or au rize agent Date A ISSUED BY:
OFFICE