99100093FILL IN INFORMATION WITHIN RED LINES - USE BALL
PEN ONLY
CITY OF CUPERTINO
APPLICATION/PERMIT 500
PLUMPING MECHANICAL O Ik
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION 01
to AV G
NAM1i:
7E
OFFICE
❑ Consultant Fees Paid by Applicant (Initial)
BLDG ELECT PLUMBMF:CH
1:1 2r 0 ❑
LICENSED COMRACfOR'S DECLARATION
I hereby an. that 1 am licensed under provisions of Chapter 9 (commencing
with Section 7000 of Division 3 ofthe Business and Professions Code, and my license is
Licene fall f Class detTmt.
License Class Uc.a
Date Contractor
QTY ELECTRIC PERMIT FEE
JOB DESCRIPTION
RESIDENTIAL:
OSFDWL CI KITCHEN REMODEL
❑ADDITION El PLUMBING RE -PIPE
0MULTI.UNIT []STRUCTURAL
MODIFICATION
[I INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT C] SWIMMING POOLS
0 BATH REMODEUREPAIR 0 DEMOLITION
I WO O ON
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Z O rant Z
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PERMIT ISSUANCE
APPLIANCES -RESIDENTIAL
ARCHITECTS DECLARATION
I umlerswnd my plans shall be used as public records
PANES
UPT0200AMPS
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby nlfte rthat I am exempt from the Contractor's r's License Lew for the
following rcasan.(Smtion 70JLS, Business and Professions Cele Any city or cnumY
which requires a permit m construct, alar. improve, demolish, or repair any swctim
priurm its issuance, also requires the applicant for such permit n file a signed statement
he is licensed pursuant o the provisions of the Comrmmrs License law (Chepter9
201.1000AMPS
OVER 1000 AMPS
SIGNS ELECTRICAL
SPECIALCIRCUITMISC.
wtaythat
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(commencing with Section 7000) of Division 3 ofthe Business and Professions Codc)or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant a permit subjmts the applicant to a civil penalty of
not more then five hundred do[[.,
pl, as owner.( the pmryny, or my employees with wages as their sale compensation.
will do the work, and the structure is not intended (it offered for sale (See, 7044, Business
and Professions Code: The Contractor's License Law does not apply to an owner of
property who builds or improve% thereon, and who does such work himself or through
his own employees, provided that such improvements ate not intended or offered for
sale. If,however. the building or improvement is mid within one your of completion, flue
TEMP. METER OR POLE INST.
COMMERCIAL:
0 NEW BLDG/ADDITION 0 DEMOLITION
OTENANT 0FOOD SERVICE
IMPROVEMENT
THER
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS -SWITCHES -FIXTURES
NEW RESIDENTIAL ELECfR SQ FI.
SQ. FT. FLOORARIiA
SISQ.I"f.
ner-builder will have the burden of proving that he did not build or improve for pur-
pose of sole^).
0 1, as owner of the property, am exclu.sivdy contracting with licensed contractors to
TOTAL:
construct the project (Sec, 7044, Business and Professions Cede:) no Comae e, U.
se law does not apply to an owner of properly who holds or improves thereon, and
QTY. PLUMBING PERMIT FEE
who cataracts for such pmjeen wish u comm l...v) licensed pursnnnu. the Commotio s
PERMIT ISSUANCE
00
Liemo, Low.
Cl lame rept under Sec. ��.It&P C lin Oix or.
e n« E „- y 1 111q—
AL'1'Hli-DRAIN & VENT -WATER (EA)
VALUADON
BACK FLOW PROTECT. DEVICE
WO
WORKER'S COMPENSATION UECe folio ION
rom..d
1 hereby from under Penalty oeperjury ono of th. following dcvinrvtiow:
O�
❑(have and will mainminn CenifcvteofConsent n xdhinsuml'nr Workers Cmnpcm
cation, m provided for by Section 3700 of the Labor Code, for the performance of the
DRAINS - FLOOR. ROOF. AREA, COND.
STORIES TYPE CONSTRUCTION
work for which this permit is issued
FIXTURES- PER TRAP
11
❑ 1 have and will maintain Worker's Cmnpensntinn Insurance, as required by SecJo 07
Code, for the pertnwntt.1 the work for which this permit is issued.
arGam
3700.1' the Lbo
GAS -EA.SYSTEM-I INC. 4 OUTLETS
OCC. GROUP � AI'N
My Worker's Compensation lostommearrimund Policy number are:
Cartier: Policy No.:
GAS -EA. SYSTEM -OVER
D C
GREASFIINDUSTRL WASTE INTERCEPTORCOMPENSATION
CERTIFICATE OF EXEMPTION FROM WORKERS'
INSURANCE
BUILDING DIVISION FEES
(This ofeu n need not be completed if be peorit is for one hundred dollars isIDl
cr less.)
GREASETRAP
_
PIANCHECK FEE
I eerily that in the pMomtnnce of the work for which this ponnit is issued, l shall
not employ any Person in any manner so as to become subjecfto the Workers' Compen-
SEWER -SANITARY -STORM EA. 200 FT.
ENERGY FEE
WATER HEATER WNENT/ELECTR
GRADING FEE
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satin. Laws of California. Dae
Applicant I
NOTICE TO APPLICANT. If, after making this Certificate of Exemption, you should
become subject m the Workers Compensation provisions of the Labor Cade, you must
forthwith comply with such provisions or permit shall 1'e dcamed revoked.
CONSTRUCTION LENDING AGENCY
l hereby often that there isoemnsaunion lendingagemcy boob. performance of
lie work for which this permit is issued (Sm. 3097, Cr, C.)
WATER SYSTEMG'REATING
SOILS FEE
WATER SERVICE
PAID`�Date. Rmei t p
_ p
NEW RESIDENTIAL PLMB. SQ. pp.
TOTAL :
Lenders Address
USEISMIGILDING FEE
I certify then 1 have rcaJ this application and store that the above information is
r0./]
U s7,
cored. l groom comply with all city and county ordinances and state laws relatingm
building construni.n, end hemhy authnriurepmscntatives of thiscirymrn¢r upon the
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep hamlet are City of Cupertino against
QTY MECHANICAL PERMIT FEE
uu lIJ (�(}
FF.�
E v IJJ
PERMIT ISSUANCE
ELECTRIC FEE
liabilities,judgments, cosnandexpenses which may in any way aceta, against said City
in o nsequentt of the granting of this permit
ALTERORADDTOMECH.
PLUMBING FTE
AIR HANDLING UNIT (TO 10,000 CFM)
APLICA NT UNDERSTANDS AND WILT. )MPLY WITH ALL NON -POINT
M[CHANICAL F'L'E
S UR E REGULATIONS. —'
AIR HANDLING UNIT (OVER 10,000 CFM)
CONSTRUCTION TAX
4 1
Si ore of A"ReanVCnmrvcmr Dam
HAZARDOUS MATERIALS DISCLOSURE
EXHAUST HOOD (W/DUCO
HOUSING MITIGATION FEE
HEATING UNIT (TO 100.00O BTU)
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code. Chapter 9.12, and are Health and Safety
Cade, Section 25532(.17
HEATING UNIT (OVER 100,000 BTU)
❑Yes ❑No -
PAID
D.tc Remi
VENTILATION FAN (SINGLE RESID)
BOILER -COMP (3HPOR 100,000 BTU)
Will the applicant or future building occupant me equipment or devices which
emit humrd.us sir em aminnms as defined by the Bay Are. Air Quality Management
,L.
Disvlct4
❑ yes ❑ N.
BOILER- COMP (OVER 100,000 BTU)
AIR CONDITIONER
I have rend the hazardous materials requirements under Chapter 695 of the Cali-
forma Health & Safety Code. Smossra 25505, 25533 and 255311 understand than If the
huibin6Jres nrncurteady hnventcttnnl then it+t y(cxrymsihilitym notify the nccu am
of the re6uirements which must bd nice poor to nsua/ce nl' a Cvnllicnm of Ogcnpvn „
/ ISSUANCE DATE
O P 9
NEW RESIDENTIAL MECH. SQ. FT.
OFFICE