B0284 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL S00o
BUILDING PROJECT IDENTIFICATION LLV�i
SANITARY"NO. APPLICATION SUBMITTAL DATE
BUILDING ADDRESS' ` ^ „, `n _ 1'Q D� �e e- � ! co � 4
OWNER'S NAME: PHONE: CONTR TOR'S NAME: LIC NO:
jJ N/C CONTROL#
ARCHITECT/ENGINEER: LIC NO. ADDRESS: k'1� Z 4409-6 ❑
O )
CONTACT: PHONE: r�Tc) BUILDING PERMIT INFO
C ?pGJ L ❑ Consultant Fees Paid by Applicant(Initial) __.__ BLDG ELECT PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
n q4 Z with Section 7000)of Division 3 of the Business and Professions Code,and my license is RESIDENTIAL:
W O O PERMIT ISSUANCE
H w in full force and effect. v 8 FDWL ❑KITCHEN REMODEL
Q U U License Class Lie.# i APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
F•Z W Date Contractor
ElMULTI-UNIT []STRUCTURAL
ARCHITECT'S DECLARATION
F"rn Z I understand my plans shall be used as public records PANELS MODIFICATION
Z O , UP TO 200 AMPS
4
O Z••G ❑INTERIOR %4 CHIMNEY REPAIR
F. E w Licensed Professional 201-1000 AMPS IMPROVEMENT ❑SWIMMING POOLS
W a OWNER-BUILDER DECLARATION OVER 1000 AMPS [_1BATH REMOD /REPAIR ❑DEMOLITION
a a Q I hereby affirm that I am exempt from the Contractor's License Law for the
X 00..U following reason.(Section 7031.5,Business and Professions Code:An cit or count ❑OTHER 'f O /r.L
Y Y Y SIGNS ELECTRICAL r r
w 3 w F which requires a permit to construct,alter,improve,demolish,or repair any structure ry a arze&f- J f/�e 1 Q
Q prior to its issuance,also requires the applicant for such permit to file a signed statement SPECIAL CIRCUIT/MISC.
rA
.a
w�.. that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9
WIx A (commencing with Section 7000)of Division 3 of the Business and Professions Code)or TEMP.METER OR POLE IN . COMMERCIAL:
0. w that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Semon 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES
[]TENANT ❑FOOD SERVICE
not more than five hundred dollars($500) IMPROVEMENT
Q ❑I,as owner of the property,or my employees with wages as their sole compensation, SWIMMING POO LECTRIC
E., will do the work,and the structure is not intended or offered for sale(Sec 7044,Business []OTHER
W 3 0000 and Professions Code:The Contractor's License Law does not apply to an owner of OUTLETS-S TCHES-FIXT
UA
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 RE ENTIAL ELECTR S
sale.If,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 pur-
pose of sale).
❑ TOTAL:
I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Contractor's Li-
cense Law does not apply to an owner of property who builds or improves thereon,and PLUMBING PERMIT FEE
who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's
License Law. PERMIT ISSUANCE
❑1 am exempt under Sec. ,B&P C for this reason
i
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Owner Date
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE '
I hereby affirm under penalty of perjury one of the following declarations:
❑ I have and will maintain a Certificate of Consent to self-insure for Worker's Compen- DRAINS-FLOOR,ROOF.AREA,GOND. STORIES TYPE CONSTRUCTION
sation,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued. FIXTURES-PER TRAP
I have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued. GAS-EA SYSTEM-I INC.4 OUTLE OCC.GROUP ANN
My Worke's Co ensation In nce carrier and Policy number are:
Camer: +i_'41, Policy No.:# GAS-EA.SYSTEM-OVER 4(E
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASE/INDUSTRL WASTEAERCIPOR BUILDING DIVISION FEES
or less.)(This section need not be completed if the permit is for one hundred dollars($100) GREASE TRAP
PLANCHECK FEE
I certify that in the performance of the work for which this permit is issued,I shall SEWER-SANITARY/STORM EA.
not employ any person in any manner so as to become subject to the Workers'Compen- NER
O Z sation Laws of California Date WATER HEATE NENTIELECT GRAD E
Z O Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER Sy/Em/TREATING IfIle
2
h ? become subject to the Worker's Compensation provisions of the Labor Code,you must IL F
wi..i forthwith comply with such provisions or this permit shall be deemed revoked. WATE ERVICE
Z CONSTRUCTION LENDING AGENCY NE RESIDENTIAL PLMB. .FT. PA
I hereby affirm that there is a construction lending agency for the performance of Dale,/ R
U Z Receipt#
w the work for which this permit is issued(Sec.3097,Civ.C.)
OV Lender's Name TOTAL
w Lender's Address TOTAL:
a 1 certify that I have read this application and state that the above information is BUILDING FEE
correct.I agree to comply with all city and county ordinances and state laws relatin€to TY. MECHANICAL PERMIT FE
V Z budding construction,and hereby authorize representatives of this city to enter upon the SEISMIC FEE
~ above-mentioned property for inspection purposes.
PERMIT ISSUANCE ELECTRIC FEE
(We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,judgments,costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECH.
PLUMBING FEF.
in consequence of the granting of this permit.
\11111 KAN"I IiNI)FRS LANDS AND\N ILL('O\1PL) NNIIH ALI \ON-I'O1\I AIR HANDLING UNIT(TO 10,000 CFM) MECHANICAL FEE
S(A R('f.ki(It'I \HONS
AIR HANDLING UNIT(OVER 10,000 CF ) CONSTRUCTION TAX
Signature of Applicant/Contractor Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(TO 100,000 )
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? HEATING UNIT(OVER ,000 BTU)
❑Yes No VENTILATION FA INGLE RESID) PAID Date Receipt#
V IU
Will the applicant or future budding occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER-CO (3HP OR 100,000 BTU)
T TA L
District? BOILER- OMP(OVER 100,000BTU)
❑Yes �J No
I have read the hazardous materials requirements under Chapter 6.95 of the Cali- AIR NDITIONER ISSUANCE DATE
forma Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the N RESIDENTIAL MECH. SQ.FT. 9
building does not currently have a tenant,that it is my responsibility to notify the occupant
of the req a ents whichi be et prior to issuance of a Certificate f Occup
Owner or au ori zed gent tare` TOTAL: ISSUED BY:
OFFICE