99070024APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY / D
CITY OF CUPRRTINO BUILDING - ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING -MECHANICAL
yI BUILDING PROJF= IDENTIFICATION
fECf/F.NGINEER: LICNG:
ADDRIiSS: 11
T�"1
❑
CONTACT : PHONE:
BUILDING PERMIT INFO
APN
❑ Consultant Fees Paid by Applicant (Initial)
BLDG ELECT PLUMB MGECCHH
BUILDING DIVISION FEES
❑ ❑ ❑ J
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm mat 1 um licensed under trowiclons of Chapter 9 (commencing
QTY, ELECTRIC PERMIT FEE
JOB DESCRIPTION
PERMIT ISSUANCE
with Scdinn](N0)of Division3 nfthe Buainezx and Professions Code, and my license is
in full force and eff rtl
RESIDENTIAL
❑ SFDWI. ❑ KITCHEN REMODEL.
APPLIANCES— RESIDENTIAL
Lice Cl Lic'M ex
Dec Contractor
ARCHITECTS DECIfAiATION0MULTFUNIT
1 understand my plans %hall he used as public records -
11 ADDITION ❑PLUMBING RE -PIPE
El STRUCTURAL
MODIFICATION
❑INTERIOR El CHIMNEY REPAIR
IMPROVEMENT 0SWIMMING POOLS
UPT02MAMPS
Licensed Pm4ssionti
201-100I)AMPS
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from The Contractors License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or county
BATH REMOUEIIRI?PAIR [I DEMOLITION
OTHER
OVER 1(NIBAh1P5
SIGNS ELECTRICAL
which requires a permit to aon.strveL ager. improve, demolish, at repair any structure
SPECIAL CIRCUIT/MISC.
prior to its locative. also requires the applicant far such permit to rile a signed statement
that he is licensed pursuant to the provisions offs Contractor's License Law (Chapter')
BUILDING FEE
(commencing with Section 70(g) of Division 3 oldie Business and Profcolons Code) or
that he is eaema loundrnm and The Iasis for the alleged exemption. Any violation of
TEMP. METER OR POLE INST.
COMMERCIAL:
❑ NEW BLDG/ADDITION ❑ DEMOLITION
)e
Section 7031.5 by any applicant fm a permit subjects the applicant to a civil petminor
POWER DEVICES
❑TENANT ❑ FOOD SERVICE
t more than live hundred doll... ($500).
L as owner clue property, or my employees with wages as Their sole compensation.
will do the work, and the swduac is not intended oroffered h rxele (See. 70LI, Business
IMPROVEMENT
❑ OTHER
SWIMMING PDOLELECTRIC
MECHANICAL FEE
and Pmfexsions Code: The Comrador's License Law this, not apply m an owner of
OUTLETS _SWITCHES—FIXTD S
CONSTRUCTION TAX
NEW RFSIDGNTIAI. ELECfR SQ IT.
ptopeny who holds or improves thereon, and who does such work himself or through
his own employees, provided that such improvements am not intended or iffcml for
rofempple,the
sale. ILhowever, the haddingor improvement is sold within one yeatimt
SQ. n'. FLOOR AREA
$/SQ. FT.
owner -builder will have the burden of proving that he did not build to improve for pus -
PAID
Date Receipt#
TOTAL:
pose of sole.).
F11, as owner of The progeny, am exclusively' contracting with licensed contractors to
OTAL:
e
o..0ud the pmjed (Sec. 7(44, Business and Professions Ctde:) The Comvadora Li-
cense Low does not apply toanOwner Ofproperty who build' or mpmves ueenn,and
QTY. PLUMBING PERMIT FEE
ISSUANCE DATE
who contracts for such projects with o cam itrlouz) licensed pursuant to The Cnntmcmrs
PERMIT ISSUANCE
License Law.
I oro exempt under See ,B&PC Por this reason
ALTER— DRAIN & VENT— WATER (EA)
VALUATION
Owner Date
ki WORKER'S COMPENSATION D[CI,ARA1'eION
re
1 hereby nRrm under penalty of perjury, one of me fOlhnving declarations
I have it will maintain a Ce tificme MCom em no self aware far Weaker'. Compen-
sation, as provided for by Section 37M of the Labor Codc, for the pe&mmance of the
work for which cis permit is issued.
K1 have and will maintain Workeev Compensation Insurance, as required by Section
J lof the Labors Code, for the perfameame of the work for which this permlt is issued.
My Wmk"Noo` lnsuryp(9.yyrler and Pohe
Carrier. F nN �.lD 11 Pulicy No o^5ncs:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPI2NSATION INSURANCE
IThis section recd not beeompleted If the permit is for One hundreddollurs(5 100)
less.)
1 certify that in the performance of the work forwhich this pemot is issued, l shall
not employ any Persian In any manner so as 10 become subject to the Workers' Compen-
sation Laws Of Calimum.. Dae
Applicant
NOTICE TO APPLICANT. If, after making this Cenificvm of Exemption, you should
become subject to the Workers Compensation provisions of the labor Code. you mus
fnnhwith comply with such provisions nr this permit shall he IeemeJ evoked.
BACK FLOW PROTECT. DEVICE
DRAINS —FLOOR. ROOF, AREA. COND.
FIXTURES—PER TRAP
CAS — EA. SYSTEM -I INC. 4 OUTLETS
GAS — FLA. SYSTEM OVER 4 (EA)
GRRASUINDUSTRL WAS fit IMIRC17NOR
GREASETRAP
SEWER — SANITARY — STORM EA. 200 FT.
WATER BEATER WNENTIELECl'R
WATER SYS 'I EMaREN'ING
WATER SERVICE
CONSIR,CTION LENDING AGENCY J I NEW RESIDENTIAL PLMIL SQ, FT.
I hereby affm, that hem is a construction lending agency fortbe perfomtance of
the work for which this )crit Is issued (Sec. 9097, Cit, C.)
Ursice.Address
1 certify that I have read this application and nate that the above information Is
correct, I agree to comply with all city and county ordinances and state laws relating to QTY,
building communion, and herebyaumurile repremonaves Of this city m enter upon the
aba ti memioncd progeny for impediun f urrymses.
(We) agree m save, indemnify !and keep hamilesx the City of Cupertino against
liabilities, judgments, costs and expenses which may in any way accrue against said City
in on unpacnce of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL1, NON -POINT'
SV@ ULATI�I
I HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupmu stare or handle hana dim, material
as defined by the Cupmano Municipal Code, Chapter 9.12, and the Health and Safety
Crile, Section 25592(.)?
❑Yes ON.
Will the applicant or future building tscupant use equipment or devices which
mit harnNous air omonatioums us defined by the Bay Area Air Quality Management
District'
❑Yes F1 No
I have mad the hemmer. nsaed.I.s requirements tinder Chapter 6.95 of the Cali.
f nein Hwlm & Safety Cole. Sections 25505, 25533 and 25534.1 undentaad that if the
building docs not currently have a tenant, that it is my responsibility m notify rhe oxeupam
of the acquirements which met be met prier to i,avance of a Cenificam of Occupancy.
MECHANICAL PERMIT
PERMIT ISSUANCE
ALTER OR ADD TO MECIL
AIR HANDLING UNIT (TO IDOIg) CFM)
AIR HANDLING UNIT (OVER 10.00() CFM)
EXHAUST HOOD 1W/DUCT)
If EATING UNIT (TO 1110,000 BTU)
HEATING UNIT (OVER I00." BTU)
VENTILATION FAN (SINGLE RESID)
BOILER — COMP CHP OR I00.(MXl BTU7
BOILER —COMP (OVER 100,010 BTU)
AIR CONDITIONER
NEW RESIDENTIAL MECH. SQ. FT.
STORIES
L re 11rom I is usuv
OCC GROUP
APN
BUILDING DIVISION FEES
PIANCHECK FEE
ENERGY FEE
GRADING PER
SOILS FEE
PAID
Dae Receipt x
TOTAL
BUILDING FEE
FEE
SEISMIC FEE
)e
ELECTRIC FEE
PLUMBING HE
MECHANICAL FEE
CONSTRUCTION TAX
HOUSING MITIGATION FEE
PAID
Date Receipt#
OTAL:
e
ISSUANCE DATE