S 0674 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL P ITNO
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BUILDING DIVISION APPLICATIONTERMIT PLUMBING-MECHANICAL 0674
BUILDING PROJECT IDENTIFICATION _
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
e� �FTLAve. - 9 3aq
WNER'S NA41 PHONE: CONT LTO 'S NAME: LIC NO:
/ N/C CONTROL#
ARCHITECT/ENG] EER: LIC NO: ADDRE .:
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB M_EC,{f
LICENSEDmthatICONTRd under
SoomersDECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby affirm that I um life B.under provision.of s Code 9(commencing LOB DESCRIPTION
aZ withS Bron ndeffec Divieinn3of the Business and professionsC a,and my 1
MW=0 in full force and effect r yicense PERMIT ISSUANCE RESIDENTIAL:
�WF 16 945k ❑SFDWI. ❑KITCHEN REMODEL.
OU Urease Class Lio.W ¢.
F�u1 Date Commctnr APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMNING kE-PIPE.
S
ARCHITECT'S DECLARATION public ❑MULTI-UNIT [-],STRUCTURAL
Z O'er LZ y pas 1 understand my shall be used blic records MODIFICATION
O Z PANELS UPTO 200 AMPS
.w{.I•'4Q,1 Licensed Professional ❑INTERIOR El CHIMNEY REPAIR
201-1000AMPS IMPROVEMENT SWIMMING POOLS
OWNER-BUILDER m Ce Cort ON OVER Hiro AMPS ❑
6 1 hereby affirm that 1 am exempt from the Contractors License Law far the ❑BATH REMODELBEPAIR F1 DEMOLITION
iq5 O t1 U following reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
FWO 1- which requires a permit to construct.alter,improve,demolish,or repair any structure
prior to its issuance,also requires the applicant for such permiuo rile as signed statement SPECIAL CIRCUIT/MISC.
A Wpr that he is licensed pursuant to the provisions ofthe Contractor's License Law(Chapter 9
444#�OC (commencing with Station of Division 3 ofthe Business and Professions Cale)or TEMP.METER OR POLE INST. COMMERCIAL:
6 y o y that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
W"h Section 7031.5 by any applicant for a permit subjects the applicant to a civil Penalty of POWER DEVICES ❑TENANT ❑FOODSERVICE
t one than five hundred dollars($500.YIMPROVEMENT D ❑ 1,as owner of the property,or my employees with wages as their sole compensation. SWIMMING POOL ELECTRIC
will do the work,and the structure is not intended mounted for sale(Sec 70U,Business ❑OTHER
antl Professions Code:The Cmararmn's License Law does not apply m an owner oI OUTLF"I'S-SWITCHES-FIXTURES
A'3 property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvdmems ate not intended or offered for NEW RESIDENTIAL ELECTR SQ FT Arl
sale.If,how ever,the building or improvement is sold within one year of completion,the SQ. ORAR A $/SQ.IT.
olarlder will have the burden of r-
forcing that he did not build or improve for pa
pose of ande.),
❑1,as as,of the property,am exclusively contracting with licensed contractors to TOTAL: 10 (�
construct the project(Seo.9044,Business and Professions Code:)The Contractors Li-
coast,
i-c t,Law does not apply to an owner of progeny who builds or improves thereon,and QTY. PLUMBINOPERMIT FEE
who contracts for such projects with a conio cmr(s)licensed pursuant o the Contractors k
License Law. PERMIT ISSUANCE. w
I am exempt under Sec. ,B&PCfsrthicreason
owner ALTER-DRAIN&VENT-WATER(EA) NlCatl pV�O,�•au�
Date IP 'I ID 'IL1J C
WORKER'S COMPENSATION DECLARATION BACK FLOW PROI'ELT.DEVICE
1 hereby affirm under penalty of ofjury one of the following for declarations:
Fl on,as prorated for b in ection Scam of the scalLgh r Cod self-insure for Worker's ce Compen-the DRAINS-FLOOR,ROOIr,AREA,COND, 1 1
cation,as provided for by Section 3]00 of the LaMa Code,for the Performance of the SIJr itour STRUCTION
work for which this Permit is issued. FIXTURES-PER TRAP
❑I have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance of the work far which this perm it is issued. GAS-EA.SYSTEM-1 INC 40lpfLETS FICC.GROUP APN
My Workq'x ComRensa�oance contractor!policy
eo Polley Nr.: GAS-EA.SYSTEM OVER 4(BA)
CERTIFICATE OF EXEMPT ION FROMWORKERS'
COMPENSATION INSURANCE ORUSF/INDUSTRL WASTE INTERCEPTOR
(This seotiov need not be crmplmrd ifthe Permit is furans hundred dollars($100 BUILDING DIVISION FEES
nr less) GREASETRAP
PLANCHECK FEE
I eanify that in the performance of the wad frrwhich this permit is isstetl,I shall
not emfiuy any per m manner so as m become subject to the Workers Com _ SP,WER-SANITARY-STORM F.A.2fq P1:
z satire Laws of 'fomi a at Pon ENERGY FEE
WATER HEATER WNENT/ELECTR
plicam - • GRADING FEB
[W4
E AFl�i ,a ter making this Ccnif<ate of F;xempti.......hould WATER SVS'IEMITREATING
aed he Ylorl r'cCompensation provisions of the Labor Code,you must SOILS FEE
forthwith comply with such Provision or this permit shall be deemed revoked. WATER SERVICE
.U. z CONSTRUCTION LENDINGAGENCY NEW RESIDENTIAL PCMB. SQ.FT. PAID
U I for which this
thouhercisaed(Sec.30lending agency l'nrthe Performance of Date Receipt#
V. � the wad for which this pemtit is issued(Seo.309],Co,Cd
Q U Lenders Name �LAL:
Lenders Address TOTAL:
I certify that 1 have read this application and state that the above information is BUILDING FEE
w+ h correct.i signed to comply with all city and county ordinances and state laws relating to QTY, MECHANICAL PERMIT FEE
U4 building contraction,and hereby authorize representatives of this city to enter upon the SEISMICFEE
abrsomearlionul Property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against PERMIT ISSUANCE ELECTRIC FI
liabilities,judgment,costs and expenses which may in anyway acerae against said City p1:fER OR ADD TO MECH.
in consequence of the granting of this permit PLUMHIN 'EE
APPLICANT UNDERSTANDS ND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
SOURCE REGUL S. MECHANICALFille
FiS7 AIR HANDLING UNIT(OVER 10.001 CFM) CONSTRUCTI TAX
en �7
ZA O MATERIALS DISCLOSURE Delf EXHAUST HOOD(W/DUCT) HOUSING IGATION FEE
Will the applicant or future building ace apants(are or handle hazari comen.l HEATING UNIT(TO 100,001)BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532m)4 HEATING UNIT(OVER 100,000 BTU)
❑Yes C]No VENTI LATION FAN(SINGLE RES]D) PAID
Date Receipt
Will the applicant or future betided eause epment or devices which
mnthacontaminancontaminantszardnus air contaminants as defiby thB qui (3
ned by the Bay Area Air Quality Management BOILER-COMPHPOR 1111,000BTU)
District? TOT L:
❑Yes [-I No BOILER-COMp(OVER 100,fKN BTU)
I have read the hazardous macerials requirements under Chapter 6,95 of the Cut- AIR CONDITIONER ISSUA CE DATE
fom
in Health&Safety Code,Sections 25505,25533 and 25534.I understand that lithe NEW RESIDENTIAL MECH.
building does not currently have a tenant,that it is my responsibility to notify thececupant
of the icquimments which must be met poor to issuance of Certificate of Occupancy.
Owner or authorized agent Date TOTAL: ISSUED BY:
OFFICE