S 1028 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PE51T NO. 10
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL I l`�
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: - SANITARY NO. APPLICATION SUBMITTAL DATE
Z 131XL3Y DR,@
OWNERIS NAME: P ONEINTRACTOR'S NAME'. LIC NO'. O ` +
v/ - 01
,.�^� �f v O N/C CONTROL#
.11
ARCHITECT/ENGINEER: LIC NO: ADDRESS: t> ❑
CONTACT: PHONE:
ED Consultant
PERMIT INFO
Consultant Fees Paid by Applicant(Initial) LD ELECT PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR'SDECam.1'Choose,
QTY. ELECTRIC PERMIT FEE I hereby omi' mat I..licensed under provisions of Chapter 9 my licendns JOB DESCRIPTION
qw with Section an effect.
Division Sof the Business vena Professions Code,and my license is RESIDENTIAL:
�VU Lifullcere forearm-effect. PERMIT ISSUANCE
V License Class Lia# ❑SFDWL El KITCHEN REMODEL
H<L Date Contractor APPLIANCES-RESIDEN'i'[A]. [I ADDITION ❑PLUMBING RE-PIPE
p7 ARCHITECTS DECLARATION El MULTFUNIT ❑STRUCTURAL
.
y a m a I understand my plan,shall stated as public records PANELS MODIFICATION
O Z Z YY]] UP'f0 200 AMPS
O El INTERIOR ❑CHIMNF,V REPAIR
Licensed Professional 201-11(a)AMPS IMPROVEMENT
,j
OWNER-BUILDER DECLARATION ❑DEMOLINGPOOLS
g 6 1 batch,affirm that 1 am exempt from the Contractor's License Law for the OVER WOAMPS ❑BATH REMO DEMOLITION
'3O y U following reason.(Section 70315.Business and Professions Code:Any city or county SIGNS ELECTRICAL f]OTHER
O IIy, which requires a permit no constmed alter,improve,demolish,or repair any someone, —I/f'.x_
�m j prior tonal....and.also requirestheapplicato nt for suchinedut file.signedsmtement SPECIAL CIRCUIT/MISC.
d tNI
hat he is licensed pursuant to the provisions of the Contractors License Law(Chapter 9 W
Qp (commencing with Section]WP.MTE
(EidDivision 3 ofthe Business add Professions Colbor TEMP. OR POLE INST. COMMERCIAL:
6 y m y that he is exempt therefrom and the basis fur the alleged exemption.Any sideline of ❑NEW BLDG/ADDITION El DEMOLITION
Ed Section'/031.5 by any applicant for v permit subjects the applicant to a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
1111........,,,, not more than five hundred dollars($500).
has owner ofthe ro norm loses with woes as their sole con+ nmtion, SWIMMING POOL ELECTRIC IMPROVEMENT
aXsO ❑ the
pe Y Yet in Y g Pc
F_ dll dothewon,anile:The CureianotinLnded oralwdoes sale out
tapply 1144,Business ❑OTHER
4am and Professions Coale:The Contractor's,and al Law doesnotapplyslf owner if OUTLETS-SWITCHES-PIXtURES
his o
property who builds or improves thenen,and who does such work himself or through
his own employees,e provided that such improvementsissoldwithin un not Intended nr offered for NBW RESIDENTIAL ELECCR SQ PT.
sale.IL bower will hive t ing or e bu d n of pro int ithat heid one build
or improve
the SQ.FT.FLOOR AREA 3/SQ.FT.
owner-builder will have the burden of proving that he did not build or improve for pur-
po.eofso
E] 1,as owner of the property,am exclusively nd contracting with licensed cnmramors i- TOTAL: A '
construct the pmjeet(Sac.]044,Buainess and Processions Cale:)The G+mms L
racr' i-
censeLawdoesnotapplytoanownerofpropenywhobuildsorimprovesthereon,and QTY, PLUMBING PERMIT PEE OCT I
who commets for such projects with a contrdcnsr(s)licensed pursuant to the Gmmaemrs d eraS�
License Law, PERMIT ISSUANCE
RE
❑I am exempt antler Sec. N&P C for O+is reason
Owner I Date ALTER—DRAIN&VENT-WATER(EA) PN
RKER'S COMPENSATION D' LARATION BACK FLOW PROTECT,DEVICE V
•t Iherebya a under penalty of perjury one o the following declarations:
I have and will maintain aCenificatenf Consenttoself-insun for Workers Compen- DRAINS-FLOOR,ROOF,AREA COND. STORIES TYPF.CONSTRUCTION
cation,as provided for by Section 37W of the Labor Code,for the performance of the
work for which this permit is issnwL FIXTURES-PER TRAP
❑ 1 have and will maintain Workers Compensation Insurance,as required by Section
37M.fthc labor Code,for the perfnrmanccofthe work for which this permit is issued. GAS-EA.SYSTEM-1 INC.4 OUTLETS OCOGROUP APN
My Workers Compensation Insurance carrier and Policy number arc:
Cartier: Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFJINDUSTRL WASTE INTERCEPTOR
(Chis section need Mat be complueed Ifthe permit Is for one hundred d.h.rs($1 W) BUILDING DIVISION FEES
or less.) GREASE TRAP
PLANCIIHCK PEE
Ioyan)fy thatin lie anymnnerof new as
for whichthis the ot Worker,
issued.[,hall SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any manner so as to become subject to the Wnrkerk Compm+- ENERGY FEE
cation� ant of California.Date O
Applicant 1 WATER HEATER WNF,NT/ELF,CTR
PP GRADING FEE
r~Ni NOTICE TO APPLICANT:If,after making this Cerfificateof of Gxea+ptiod you should WATER SYSTEMOREATING
(ti Icu+me subject m the Workers Compensation provisions of the Labor Cale,yon must SOILS FEB
talo ti forthwith comply with such provisions or this permit shell be deemed revoked WATER SERVICE
Q
CONSTRUCTION exam LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT PAID
V,0 Ihereby affirmipniereissued(metionlending agency For the performance of Dm Rcc ' #
W tr+ the .,it for which this pumit is issued(Sec.309],C1v.CJ
0 V Lenders Name TOTAL:
Lit Lender's Address TOTAL:
yt I verify that 1 have read this application and state that the above information is BUILDING FEE
tea Z)y cored 1 agree to comply with all city and county ordinances and state laws mating to QTY, MECHANICAL PERMIT FEE
Ll #7 building construction,and hereby authorize representatives ofthis city menter upon the SEISMIC IF It
nbove-memioned property for inspection purposes. PERMIT ISSUANCE(We)agree to save,indemnify and keep handless the City of Cupertino against ELECTRIC FEE
liabilities,judgments,costsand expenses which maymany way accrue against said City AMERORADDTOMECH.
in consequence of the gmtning of this permit. PLUMBING FEE
'APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
SOURCE EGULATIONS, MECHANICAL FEE
AIR HANDLING UNIT(OVER ITT00CFM)
.V CONSTRUC'f10N'TA%
Signature pplican/Contractor Dme EXHAUST HOOD(W/DUM)
HAZARDOUS MATERIALS DJ ILOSURE HOUSING MITIGATION FEE
Will theapplienm orfumre buildingoceupanimnanr handle hazardous mammal HEATING UNIT(TO IW,009 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safely
Code,Section 25532(a)P HEATING UNIT(OVER 100,000 BTU)
F1 Yes I]No PAID
VP.NTILATION PAN(SINGLE RESID) Date Receipt#
Will the it co.m or futon building y the Ba use equipment nr device.which BOILER-COMP(3HP OR 100,000 BTU)
mit District,
dus air ammminvnts as defined by the Bay Areu Air Quality Management TOTAL
District!
L-]Yes ❑No BOILER-COME(OVER 100,1100 BTU) _
I have read the hazardous materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
f nom.Health&Safety Code,Sections 25505,25533 and 25534.1 understatul that if the NEW RESIDENTIAL MECH. SQ.ET
building does not curnody have v tenant that it Is my responsibility m notify the..,an]
of the requirements which must he met prior m issuance of a Certificate of Occupancy.
Owner or authorized agent Date TOTAL: ISSUED BY:
OFFICE