29385 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN,ONLY
CITY OF CUPERTINO BUILDING•ELECTRICAL PERMITNO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL OC
BUILDING PROJECT IDENTIPICA'11ON o J
BUI D GADDRESS: .� SANITARY NO, APPLICATION SUBMITTAL DATE
ONA I'HGNE: C RA WS NAME: LIC NO,
ft N/C CONfROLO
AR IDECf/ENGINEER: LIC NO: DD Ii. e e ❑
J
CONTACT: - PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ D ❑
LICENSED CONTRACTORS DECLARATION QTY, ELECTRIC PERMIT FEE
1 hereby aflirin that 1 um licensed under provisions of Chapter 9(com acrcing JOB DESCRIPTION
QWZ with Section 7000)of Divisio0oflw Business and Professions Cwle,and my license is RESIDENTIAL
Op in full force end eRec PERMIT ISSUANCE
lU� License us LICk 0SFDWL D KITCHEN REMODEL
zkU,� APPLIANCES-RESIDENTIAL
�Qy Uma Co or []ADDITION DPLUMBWG RE-PIPE
HI SD RATION PANELS ❑MULTIUNIT ' DSTRUCfURAL
OZzi2 Iu n y aspu ABUT MODIFICATION
QPTO200AMP5
��] Li sW es' - DINTERIOR El CHIMNEY REPAIR
6d S-�3 OWNER-BUILDER DECLARATION 201-1000 AMPS IMPROVEMENT
yy CC z a I here, nm that I oro exempt fent.the Cnnuanames License Law for the OVER 1000 AMPS D BATH REMODEUREPAIR D DEMOLI'T'ION
pe O a H following re n.(Sari..7031.5,Business and Professions Code:Any city of county SIGNS ELHCIRICAL D OTHER
ii:4`LLO y which requires a permit t.emend d,alter,improve,demolish,or repair any structure
yy,Q miorm us Issuance,xlanrequires the ap,licam Is pimantta fileusigned dntement SPECIAL CIRCUIT/MISC.
K� that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter9
^OQ (commencing with Section 711110)of Division 3 of the Business and Professions Code)or TEMP.MITER OR POLE INST COMM R IA
6pi5�c¢' that he is exempt therefrom and the hueis for the alleged exemption.Any viohni.n of ❑NEW BLDG/ADDITION D DEMOLITION
Way Section 71131,5 by any applicant for apermRnifficts the applicant t.a civil penalty of POWER DEVICES GTENANT [I FOOD SERVICE.
F Z Y not more than five hundred dollars($50o). IMPROVEMENT
OC] Lazowner of the property.or my employees with wages es their sole compensation, SWIMMING POOL ELECTRIC'
will do the work,and rhe stmenhe is not intended.rnl'feted fnrcele(Sec.7044,Business D OTHER
mand Professions Code:The Cnntnctor's License law docs not apply to an owner of OUTLETS-SWITCHES-FIXTURES
6 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 PF,
aide.If.however,the building or improvement is and within one year efcomplelion,the SQ.FTtl O It ARBA SISQ.IT.
er-builder will have the burden of proving that he did not build or improve far par-
pose of sole.). pp
[_] 1,as owner of the property,am exclusively contracting with licensed contractors to TOTAL: MHf� 7 1996
consultant the project(Sm.7044,Business and Professions Code,The ConW-
tractor's
crnselaw does not apply to an owner diuretically who builds or improves rhneon.and QT'Y. PLUMBING PERMIT FEE
who commis for such projen withewnnradmisl licenscJ pursuant mdse Contractor's CII Y Ur GIJY'ctil MOLicense Low.
D I am exempt under See ,B&P C fmthPERMIT ISSUANCEis reason
Owner Date ALTER-DRAIN A,VCNT-WATER IRA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE t
I hereby affirm under penalty of perjury one of the following declarations
D l have and will maintain o Cenificmc.1 Camara(l.self-insure for Worker's Ca.pen' DRAINS-FLOOR,ROOF AREA,COND.
cation.as provided for by Section 3700 of the Labor Code,for the perfomann n,of the STORIES TYPE CONSTRUCTION
work for which Nis permit is issued. FIXTURES-PER TRAP
D 1 have and will maintain Worker's Compensation Insurance;as required by Section
37M of am Labor Cale,for the performance of the work for which this permit is issued. GAS-EA.SYSTEM.I INC.4 OUTLETS (L O� OCC.GROUP APN
My Worker's Compensation Insurance earner and Policy number arc:
Carrier: P.Iie,No: GAS-EA.SYSTEM OVER 4 BDO
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE I GREASFIINDUSTRL.WASTE INTERCEPTOR
(This sedion need sol be completed if rhe permit is fvrone hundreddoliars($100) BUILDING DIVISION FEESor assail GREASE TRAP PLANCHECK FEE
Icenify that in the performance o0he weak
hisime midpoch nto the W is korC lshml SEWER-SANITARY-STORM EA.200 FT.
not employ any Actor.d any manner as as m become s.bject m the Workers C.mpen- ENERGY FEC
zZ A,pli Lows nl California.Dom
O Applicant - I WA'1'F.R HEATER WNENf/ELF.CfR Z CI GRADING FEE
fA NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you should WATER SYSTEM/TItCATING
become subject to the Worker's Compensation provisions of the Labor Code,you must SOILS FEE
I'onbwidt comply with such pmvisionsor this permitshall be,deemalrevoked WATERSERVICE
UO CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.PT. PAID
I hereby affind that there is a construction lending agency for the performance of Date Raeiptp
U. �--� the work for which this perem is issued(Sa.3097,Civ,C.)
0 f' Terraces Name TOTAL:
{U Lender's Address TOTAL:
Ry I cenify that L have read this application and stare that the above information is BUILDING FEE
N comet.l agree or comply with all city and county migration and state laws relating to QTY, MECHANICAL PERMIT FEE
U building construction,and hereby authorize reprewriatives of thiscily In enter upon the SEISMIC FEE h
above-mentioned property for ne,setinn purposes. PERMIT ISSUANCE
(We)agree to save.indemnify and keep hamless the Cityof Cupmmo against ELECTRIC FEE
liabilities,judgments,cons and expenses wh'1 ,y in any way accrue against said City ALTER OR ADD TO MECH.
of .fou' 1. PLUMBING FEC
in�msequenceo gta pc
APPLICANT UND AN VI COMPLY WITH ALL NON-
SOURCE Rf:G POI ALR HANDLING UNIT(TO 10,000 CFM7 MECHANICAL PEE S3 v
AIR HANDLING UNIT(OVER 10.00)CFM) CONSTRICTION TAX
Signaw ofd mor c P.XHAUSI'HWUfW/DUCT) HOUSING MITIGATION FEE
ARDOUS MATERIALS DISCLOSURE
Will hes I' nl or future building occupant store or handle harurdmentaderial HEATING UNIT(TO 100.000 BTU)
as Jcfined by N upenin.Municipal Cale,Chapter 9.12,and the Hemth and Safety
ClAr.Section 25532(x1? HEATING UNIT(OVER 100,000 BTU)
D Yea . ❑No VENTILATION FAN(SINGLE RFSID) PAID
WI1 the applicant or future building occupant use equipment a devices which Date Receipt x
emit hezoNnue air dmtan ant,as defined by the Bay Arca Air Quality Management BOILER-COMP(JHP OR 100,001)BTU)
TOTAL:
District?
D Yes 0 N BOILER-COMP(OVER KIRIN BTU)
'
I have read the homrioe materials raryircmens under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
farms Health&Safety Code,Sarins 25I15,M533 and 25534.1 aMenand that if the NF.W RESIDEMIAL MECH. SQ.FT.
building does not innerly have a tenant,that it is my respmnsibility or notify the occupant
of the requirements which must oumet prior to issuance of a Certificate or Occupancy.
Owner nr amhnriaed.gent Date TOTAL: ISSUED BY:
OFFICE