99090162 (3) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY q 09 O 1 2
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT N
'BUILDING DIVISION APPLICATION/PERMrr PLUMBING-MECHANICAL
BUILDING PROJECT'IDENTIFICATION
HUILDING ADDRESS SANITARY NO. APPLICATION SUBMITTAL DATE
WCH
' ER'SNAME: PHON�� OI,S CONTRACTORS NAME: LIC NO:
TT NIC CONTROL#
ITECT/ENGINEER: LIC NO. ADDRESS: ❑
CONTACT: PHONE: - BUILDING PERMIT INTO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
®� ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that l am licensed under provisions of Chapter 9([ommencing TOB DESCRIPTION
wo, with Section]OW)of Division 3 ofthe Business and Professions Code,and my license is RESIDENTIAL:
Fqw= ass in full force and effect. PERMIT ISSUANCE �❑�S [I KI
�FDWL KITCHEN REMODEL
REMODEL
6VzU LicenseClTit. APPLIANCES-RESIDENTIAL. LYAIII)ITION ❑PLUMBING RE-PIPE
top DaLL Contractor
,=t.
ARCH]'TECT'S DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAI.
I understand my pl...hall b,used as Public records MODIFICATION
OZND UPT020hAMPS ❑INTERIOR ❑CHIMNEY REPAIR
W Licensed Professional 201-IgM)Ah1Pg IMPROVEMENT
OWNER-BUILDER DECLARATION ❑SWIMMING POOLS
I%a 1 Inc by aftimt that I am exempt form the Contrucmr's License Law for the OVER 1010 AMPS ❑BATH REMOODDEeliPAIR DEMOLITION
K L U following rnunn.(Section]031.5,Businessand Profession+CnJe:Any city or county SIGNS ELECI'ItICAI. (]OUT I'R �LKi--
ul�+4 F which requires a from,to construct,alter,improve,demol'nh ar mpair any structure I ,r
C prior hfixisxa.nce,al+n regairextheapplicatnfdrsach permit m file signed statement SPECIAL CIRCUCHMISC.
IY
cg=} That he is licensed pursthe omrmr
uant to e provisions dl the Cac 's License Law(Chapmr9
� �O (commencing with Section 7")of Division 3 of the Business and Professions Clde)ar TEMP.METER OR POLE INST. COMMERCIAL
d d cy that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
WMN Section 7031,5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
am more than five hundred dollars($500).
Qn ❑I,as ownernfthe property,onnyempinyceswithwages us lheirsolecompensutinn, SWIMMING POOL ELECTRIC IMPROVEMENT
will do the work,and the structure is not intended oroffered for sale(Sm.]094,Business ❑OTHER
and Professions CnJe:The Contractor's License Law does not apply to an owner of OUTLITS-. TCHES-FIX1URES
property who builds ar impmves thereon,and who does such work himself or through
his own employees,provided that such improvements are not iniendc l or offered for NEW
,da,
ELECfR S FT.
,da,IL however.the building or improvement is sold within one year of completion.the SQ.FT.FLOOR AREA $/SQ.FT.
owner-builder will have the burden of proving that he did not build or improve for put-
It.).
I,as owner of the Pmpany,am exclusively cdntraming with 11ce:vW Conwemm In TOTAL:
construct the project(Sec.7044,Budiess and Pronssimis Cmp:)The Contractors Li-
License law. MfJ r-/
Cease Lawdias not apply to an ownerofpfopeny,who builds or improves thereon,and QTY, PLUMBI .RMIT iLSp IILJ., �[ u
who contracts for such projects with a contmapursuant ons)licensed pursuano the Contncum's
1 C 4
11737W
❑lam exempt under ,13&PCfor This reason PERMIT ISSUANCE
et Date •� ALTER-DRAIN&VENT-WATE.R(EA) � VA A O
WORK ION DECLARATION BACK FLOW PROTECT.DEVICE /
I herehy aff irtn under penalty Of perjury one of die following declarations:
have and will maintain.Cenificme of Consent toself-insure hu Worker's Compem DRAINS-FLOOR,ROOF,AREA,COND.
—T1lY6CONSLR CfION
n,az provided far by Section 3700 of the labor Cada for the performance of the
far which this permit is issued. FIXTURES-PER TRAP
have and will maintain Warup%Compensation Insurance,as required by Section
of the Latin Cde.far the performonceof the work for whiodidn,permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLLTS OCC.GROUPAPN
Worker's Compensation Insurance currier and Policy number are:ier: Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSA'T'ION INSURANCE GREASFIINDUSTRL WASTE INTERCEPTOR DING DIVISION FEES
(This section random be Completed tithe permit is(drone hunJrNddlo rs($10W
f
less) I GREASE.TRAP PLANCHECK FEE
- erfo
Iretail,that in prnanceofthe work for whicttthispe.it is issued,T shall SLWER-SANITARY-STORM EA. FT.
not employ any Peron in any manner sen as m become subject to the Workers'Compact. ENERGY FEE
xtian Laos soot Califamia.Date
Applicant
Z WATER HEATER WNENT/ELECM
GRAVING FEE
1.NOTICE TO APPLICANT:IL after making this Certificate of Exeroption,you should WATER SYSTIW- OREATING
become subject m the Workers Compensation previsions of the Labor Code,you must - SOILS FEE
[i7 forthwith comply with such previsions or this permit shall be Jremed revoked. WATER SERVICE
a0
Uz CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ,FT. PAID
V 0 kfmwyich his #there issued(metionlending agency for the Performance of Date Rtteiplp
w U thework for which this permit is issued(Ser.3097.Civ.C.)
Q Lnders Name TOTAL:
Ixnders Address TOTAL:
I sanity that 1 have mad this application and state that the above information is BUILDING FEE
TA correct.l agree to comply with all miry and county ordinances and state laws relating to QTY, MECHANICAL PERMIT FEE
U z building Construction,and hereby authorize«prexnmtives Of this city to enter upon the SEISMIC FEE
above-mentioned pmperty for inspection purposes. PERMIT ISSUANCE
(We)agree m save,indemnify and keep harmless the City of Cupertino againot ELECTRIC FEE
Iiabilific,jadgmenl,coxts peaseswaccrue against may in any way accagainst said City ALTER OR ADD TO MECH.
in onsequenee ol'the gra li-a,,cthis
pcnnik PLUMPING PEE
APPLICANT UNDERSkNrAAND WILL COMPLY WITH ALL NON-POINT ALR HANDLING UNIT(TO 10.000CFM) MECHANICAL FEE
SOURCE ULATIONS
AIR HANDLING UNIT(OVER 10,0110CFM) CONSTRUCTION TAX
gnayfcyPAp lis dtC000poapm Date EXHAUST HOOD(W/DUCD HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building ocupam store or handle hazardous mamfin HEA'T'ING UNIT CTO I0d000 B'IU)
as nit by Ibc Cupertino Municipal Code.Coupler 9.12,and the Health and Safaly
Crile.Section 25532(a)1 HEATING UNIT'(OVER 100,001 BTU)
❑Yes ❑Na F_SIPAID
VENTILATION FAN(SINGLE RU) Date ReceiptM
Will us cipair Contaminants
or nts a building occupant tax equipment of devices Management
BOILER-COMP(3HP OR 100,000 BTU)
ch
¢mil hazardous air ammminan[s as defined by the Bay Arca Air Quality Management TOTAL'
Owner'
❑Yes No, BOILER-COM P(OVER IfN1,IX111TUU)
I have mail h odious marc.isisrequirertenB antler Chapter 695 of the Cali. AIR CONDI'r10NER ISSUANCE ATE
forma Health&Safety ,Seniors 8505,25533 and 25534.1 undersand that if the NEW RESIDENUAL MECH. SQ.FT.
buildin nmctumm hrveatenant.dustifism its nsibilaymnodfytheccmpant 7`
of repo and pont m issuance of a Certificate f Oc[upan[y_
m
O rauthort. Orae TOTAL.. ISSUED BY:
OFFICE /