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CITY OF CUPERTINO sun.BING - ELECTRICAL
APPLICATION/PERMIT PLUMBIOJECT I MECHANICAL
BUILDING DIVISION RUILBING PROJECT IBENTIBICAI'ION
-
vegAd]r Ivo. .1878
1 8 7 8
SANITARY NU. APPLICATION SUBMITTAL DATE
BUILDING ADDRESS:-
PH—`: CONTRACTOR'S NAME: LIC NU:
40r1
i
77 /^/
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NIC
CONTROL#
EloVY
TOWN
I,, A HITECTJ1SddLLEER: LIC NO
ADDRESS
coNTAcr: PHON3!1aE:
//
❑ Consultant Fees Paid by Applicant (Initial)
BUILDING PL^^RMIT�/IJN 0
BLDG ELECT PLUMB MECH
_ �
( _ by
LICENSE]) CONTRACTOR'S DECLARATION
1 hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing
with Section 901YJ) of Division3 of the Business and Professions Cade. and my limn, is
. ' full force 7000a it )of /I
I.License Clao Lia#
QTY ELECTRIC PERMIT EEE
JOB DESCRIPTION
RESIDENTIAL:
❑ SFDWL ❑ KITCHEN REMODEL
❑ADDITION El PLUMBING RE -PIPE
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL
1 Da,e Contractor
i RCHITECTS UF.CLAR 'ION
PANELS
❑MUL'CI-UNIT ❑STRUCTURAL
MODIFICATION
1 understand my plfns shall be used as public orcmds
�� -
UP TO 200 AMPS
❑INTERIOR L] CHIMNEY REPAIR
IMPROVEMENT ❑SWIMMING POOLS
F] BATH REMODEUREPAIR L] DEMOLITION
❑ OCHER
Licensed Professinal
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractors License Low for the
following reason. (Section 703 L5, Business and Professions Code: Any city or county
j which requires a permil to construct, alter, Improve, demolish, or repair any structure
t prior to ilsissuance, aloacquims the applicant for Inch permit to lite a signed aiotemcnt
that he is licereadparsrant to the provisionsoflhe Contractor's License Law (Cl9
(commencing with Section 7000) of Division 3 of the Business and Professions Code) in
her he is exempt therefrom and the basis for the alleged exemption Any vielition of
Section 7031.5 by any applicant for Permit subjects the applicant o v civil penally of
not more than loft hundred partw dollars y employees
❑ morownernflhepropcdolrmy500). ccs wilN wages ns thdr sole mmpenaatian,
will do the work, and the snrcture is not intended or offered f rsale(SecAIMq. Haar",
a and Professions Code: The Contractors License Law does not apply to an owner of
v
prepaid, who bands or Improves mercoa, and who does such work himself nr through
his own employees, provided that such improvements air are not intended or offered for
sale. If: however, the building or improvement is said within no year or complelinn, the
woer-builder will have the burden of proving that he did not build or improve for put -
201-1000AMPS
OVER IINN)AMYS
SIGNS ELECTRICAL
SPECIAL CIRCUITIMISC.
TEMP. METER OR POLE INST.
CdMMERCIAL
El NEW BLDG/ADDITION El DEMOLITION
❑TENANT ❑ FOOD SERVICE
IMPROVEMENT ,q �.
❑OTHER // J
OWER DEVICES
SWIMMING POOL ELECTRIC
LETS -SWITCHES -FIXTURES
NE DEN "IAL ELECTR SQ C -L
u
SQ. EC. PLO R ARBA
$/SQ. Ff.
-
TOTAL'
pose of sale.).
❑ I, as owner of the Property, am exclusively contracting with licensed contractors to
construct the project (Sec IlN4, Business and Profusions Code:) the Contractor', LI-
couseLawdoesnotapplytoanownerofpropertywhobuildsorimprovesthereon,and
who contracts for such projects with a commends) licensed pursuant to the Contractor's
,
QTYPLUMBING PERMIT FEE
License Law.
I am exempt radio Sec. , B A, P C for this reason
PERMIT ISSUANCE
ALTER -DkAIN &VENT- WATER (EA)
BACK FLOW PROTECT. DEVICE
VALUATION
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under Penalty of perjury one of the following declarations:
I
❑)have and will maintainaCenifcme of Consent to self -insure for Worker's Comper-
action, as provided for by Section 39W of the Labor Code, for the performance of the
weak Iia which mix permit is issued.
have and will maintain Worker's Compensation Insurance, as required by Scotian
9Wof the Labor Cade, l or the performance of the work for which this permit is issued.
DRAINS- FLOOR, ROOF, AREA. COND.
STORIES
'IYPE CONST RUCTION
_
FIX'1'URP,S-PLR TRAP
GAS-F.A. SYS'CEM-1 INC, a O
OCC. GROUP
APN
GAS-EA.SYS'C8Ebl "R4 EA)
M Wor sCr�m tion ln. dP yrs her
�� inr:= - �ti e�; �ar�:8c
CERTIFICATE OF EXEMPT ION FROM WORKERS'
COMPENSATION INSURANCE
GREASE/INDUSTRL WASTE IN R R
BUILDING DIVISION FEES
GREASE'CRAP Ji � S$ttl`,
PLANCUECK FEE
(This sunfair neednot F, area letcd p umiemtit is forone hundred doll ars($100)
or less.)t.�,
I carry, thalrefte performance ofthe work for which this turner, is issued, ],hall
not employ any person in any manner sa as m become subject to the Workus' Cnmpnn-
7 sation Laws of Cali forma. Date
Applicant t
'0 APPLICANT: If, fear aking this Certificate of Exemption, you should
NOTICE *1akm
become subject m the Worker's Compensation provisions of the Lama Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
SEWER - SANITARY - STORM 200E
ENERGY FEE
GRADING FEE
SOILS FEE
WA'I ER HEA'rF.R WNENT/ELECTR
WATER SYSTEM/TREATING
WA9'ER SERVICE,
.i
Z CONSTRUCTION LENDING AGENCY
tiI hereby offrm that there is a couswnion lending agency for the Performance of
the work for which this Pamir s isoewl(Sec. 3099, Civ. C)
PAID
pate carp, p
NEW RESIDENTIAL PLMR, 50. FT
TOTAL
TOTAL:
Lender's Name
Lender's Address
I certify that I have read this application and state that the above importation isIf
Ae reef. I agree to comply with an city and county ordinances and state laws raising to
Z building construction, and hereby authorize representatives of this city to enmrupon the
abov:m,1t uned property far inspection purposes
BUILDING FEF,
QTY. MECHANICAL PERMIT FEE
SEISMIC FEE
PERM19' ISSUANCE O
IA,ECTRIG PEE
(Wid agree to save, indemnify and kwp harmless sur Cir of Cuputinn ugainat
linbilitios,judgments, costs and expenses which may in any way accrueagainst said Ciry
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NUN-POIN"I�
AL9'ER OR ADD TO M[Cf{. 3
AIR HANDLING UNIT (TO 10,000 CFM)
PLUMBING FE -
MECHANICAL E i/O
SOURCE REGULATIONS. ,
'
AIR HANDLING UNIT (OVER 10.000 CFM)
CONSTRUCTION AX
SignatumcfApplirmasCvntredor Dam
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant ar future bulldingoccupantstorcorharale hazardous material
es defined by ,he Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
CWe, Section 25532(a)Y
El Yes C]No
EXHAUST HOOD(W/DUCT)
HOUSING MITIGA ON FEE
HEATING UNIT (TO 100.000 BTU)
HEAPING UNIT (OVER I00.000 BTU)
PAIL)
Date Receipt#
VENTI LATION FAN (SINGLE RESID)
'Will the applicant or future building occupant use equipment or devices which
emit hammers air contaminants as definul by the Buy Arca Air Quality Management
BOILER -COMP (JHP OR 1 W,000 BTU)
TOT D
BOILER-COMPHOVER 100,00)Bq'U)
District?
❑Yce Ed No
AIR CONDITIONER
ISSUANCE DATE
'� /` �, '� q
ISSUED RY:
1 invented the h ode, Se materials 5, 2553 an under Chapter rsta of the Cali -
fbmiahealth & Safety Code, eaten 25545, 25533 and 25536.1 understand that tithe
buildinghredoes ton currentlywbeen mosta tenet prior o is ua responsibility a Cilhy to notify cc pecreant
anty
of me requirements which most be net poor ro issuance n[ a Cenificum of Occupancy.
of
NEW RESIDENTIAL MECH. SQ, ET.
T Al,
Owner or amhnrizod agent Date
OFriCE