S 0080 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING PROJECT IDENTIFICATION -
BUILDING ADDRESS: - SANITARYM. APPLICATION SUBMI'EFAL DATE
nr
OW AME: PHONE: CO CTOR'S NAME: LIC NO:
�Qbga �jlf�j ^ 7 —/7S NIC-7 CON9ROLN
RCHITECT/F.NGI R: LIC NO. ADDRE ❑
S.
CONTACT: PHONE: I BUILDING PERMIT INFO '
' ^W 1 ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT , PLUMB MECH
❑ ❑ ❑
LICENSED that I a CONTRpCnORSder p nF.Cons AI of CON QTY ELECTRIC PERMIT FEE
I hereby affirm that I am IiecnseJ under provisions of Chapter rr(commencing JOB DESCRIPTION
D01Z i full
o)cet. sionJnfthe Busincsa end Rofessions Code,and mylicenxis
�DO w PERMIT ISSUANCE � RESIDENTIAL:
n full force and"Rea.
IUU License Clum Lic.p ❑SFOWI. ❑KITCHEN REMODEL
I-GL Date Contractor APPLIANCES-RESIDENTIAL- ❑ADDITION �LUMBING RE-PIPE
ARCHITECT'S DECLARATION PANELS ❑MULTI.UNIT El STRUCTURAL
zoPw7 .I understand my plans shall he used as public rec his - MODIFICATION
OZ�q UP TO 200 AMPS El INTERIOR - ❑CHIMNEY REPAIR
F�F'aa Licensed Professional 201-1000 AMPS IMPROVEMENT
J ❑SWIMMING POOLS
( Y OWNER-BUILDERDECLARATIONCLARATION OVER❑00AMPS ❑BATH REMODEL/REPAIR [I DEMOLITION
��jj pG I herehy affirm onnt 1 1, exempt from the Cssions Carlo:
License city
o for the
y�s 3 O.F following aimon.(Section]onstr Business and improve,
de Professions Code:Any city osturcucounty SIGNS ELECTRICAL ❑OTHER
0 y which rtquires a pcnnit to construct ager.improve,demolish,or repair any swctam
y�ag prior to its issuance,also requiresihe applicum for such permino film signed statement SPECIAL CIRCUITIMISC.
,a� that he is liamed pursuant 0 the pmvidarsof the Contractees License Law Chapter
al 0 (commencing with Second Division the Rosiness and Professions Code) TEMP.METER OR POLE INST. COMMERCIAL'
ILE m K that he is exempt therefrom and the basis for the alleged exemption.Any violation or ❑NEW BLDG/ADDITION ❑DEMOLITION
X tNt
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES
Y7 n..,union five hundred dollars(8500). ENANT ❑FOODSERVICE.
=Q ❑ 1,as owner of the pro norm employees with wages m their sole compensation, SWIMMING POOL ELECTRIC IMPROVE ENT
ptr y yemp y g panto
y' will doth"work,and Coal:: smremreis not intended Law ciffiand
act apply
apply t an Business E
3 aedr.fwhob Gsor The Contractors License Law Jaecnotapplyt.lf owner of OUTLETS-SWITCIIliS-FIXTURES
his meproperty who builds or improves thereon,and who improvements
such work himself«through
his own employees.the provided mm such mentis old within thin not iornded or altered fur NEW RESIDENTIAL ELECTR SQ FT.
owner hmamc ill hbuil heburg or en of prment ithat hedon build r of or improve completion,theS FT.FLOOR AREA S/SQ.IT.
m Immediate).
will have the boNen.1'pmving that he did not buil)or improve(or par- -� A 0
pox of aaln.
1,tou owner of the See70property,an exclusively contracting with:) no Continuous contractors TOTAL:
construct the project(Sec.o an r Business and Professions code:)The o, JUN: �
Li-
cense Law J«snot
uchapply
ro roan with
a cafpropeny whosedprsds oruant tutee thereon,and QTY. PLUMBING PERMIT FEE (�,e
whocontractsLaw.for such projects with n cono-cmr(s)licensed pursuant m the Conuadoex
0
License int Law. PERMIT ISSUANCE 117 Ur
❑lam exempt under S«. ,B&PCfor mix mason UurtHTINO '
Own<r Dam ALTER-DRAIN&VENT-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 herehy affirm under penalty of perjury one of the following doca cations:
I have and will maintain a Cenificate of C.nxnt to self-insure for Worker's Camper- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCTIONsatin.,as provided for by Section 37M of the LaW,Cale,for the performance of the
work for which this permit is issued. FIXTURES-PER TRAP
I have and will maintain Workers Compensation Insurance,as required by Section
37M of the Wbo,Cmde,for the performance of the work for which this pernit is issued GAS-EA.SYSTEM-I INC.4 OUTLETS DEC.GROUP APN
My Wo Ca pens.io - eme eerier and Policy.yu^mbc g�q
Cartier: Policy No:%2RT&d 1 a n GAS-EA.SYSTEM-OVER4(EAI
C RTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFIINDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FEES _
(This secdmassed not W completed ifthe permit is for.hundred dollmx(SIW) GREASETRAP
in less.) PLANCHECK FEE
Icenilythatinthe any manner
be as
work for subjetto the ail Wisiss'Compall SEWER-SANITARY-STORM EA.200 PT.
not employ any person in any manner x m ro become subject t.the Workeri Compen- ENERGY FEE
ZAaiun Laws of California Date
Q � WATER HEATER WNEM'/ELI:LTR ,
Q Applicant - CRAVING PEE
� NOTICE TO APPLICANT:If,of e,makingthis Cenificate of Exemption,you should
r WATER SYSTLM/IREATING
abecome abject y the Workeor Compensation provisions M the Labor Code,you must SOILS FEE
W fdnhwith comply with such provisions or this permit shall he deemed revoked. WATER SERVICE
Q
CONSTRUCTION[.ENDING AGENCY NEW RESIDENTIAL PCMSQ.FL PAID
U0 Iherehy alBnn that them iseconswnion lending agency Forth"perfohmance of Date R ,1_ 'd is
GL r the work for which this permit is issued(Sea 3097,Civ.C.)
O U Lender's Nume TOTAL:
Wj Leaders Address TOTAL.:
0. 1 certify not 1 have read this application and state that she above information is UIL NO FF.
W correct.I ague to comply with all city and county ordinances and state laws relating to QTY, MECHANICAL PERMIT � .FEF.
U Z building construction,and hereby authorize representatives of this city to enter upon the SE IS MIC FE
ebnve-memioned property for inspection l'Wx'xs. PERMIT ISSUANCE ELE .1
(We)agree to save,indemnify and keep harotless the City of Cupertino against
liahilitieajndgments,enmsand expenses whi in any way accrue againstxaid City ALTER OR ADD TO MECH. PLU ING FEE
in nxqucnce of the PgrantithispeAPPLICANT UNDP. AN IL 'O IPLY WITH ALL NON-POINT gIRHANDLING UNIT GO 10.0011 CFM) MECHANICALFEE
S CER �!
G / AIR HANDLING UNIT(OVER I(I,BW CFM) CONSTRUCTION TAX
Signature of and oma"norgr Date EXHAUST HOOD(W/DUC i
HArARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Will theupplicuntnf futare building«cnpam soust handle httallous material HEATING UNI'r(To 1011.0)0 BTU)
v defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cede.Section 25532(.)? HEATING UNIT(OVER I0y010 BTU)
-1 Yes 7 N
VENTILATION FAN(SINGLE RESID) PAID
Will thea licant or future Wilding ecu t use Date Receipt t
pp g pen Area
Air Quality
Management
BOILER-COMPf3HP OR 100,0y)BTU)
"roti hazardous air contaminants m defined by the Bay Areo Air Qualify Mwagement
Disuitt? TOTAL:
❑Yes ❑No BOILER-COMP(OVBR 100,000BTU)
1 have mad the hazardous materials requirements under Chapter fi 95 of the Cali- AIR CONDITIONER ISSUANCE DATE
forma Health&Safety Cale,Sections 25505,25533 and 255]4.I understand that if the
buildin does not currently have a tenant mm it is NEW RESIDENTIAL MECH. SQ.FT.
g y toy t
of the regmimmcnts which mum be mm prim m issuenre of a Cenificate of Qcupnncy.
Owner«authorimdagent Date TOTAL ISSUED BY:
OFFICE