S1991 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PEE IT NO. 91
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL eV
BUILDING PROJECT IDENTIFICATION
19
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DA
d o��
W E 'S NAME: PHONE: C RACTOR'S NAME: UC NO:
NIC CONTROL 8
ARCHITECT/ENGINEER:cA, LIC NO: DR °�3 ❑
1400 9 7
CONTACT: PHONE: BUILDING PERMIT INFO
❑ 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
Ca p PERMIT ISSUANCE
5 Z with Section 7000)of Division 3 of the Business and Professions Code,and my license is RESIDENTIAL:
W O
in full force and effect. ❑SFDWL El KITCHEN REMODEL
Q Z U License Class Ltc.ff APPLIANCES—RESIDENTIAL ❑ADDITION J4P6UKBING RE-PIPE
�Q W WDate Contractor
L-::)Ln ARCHITECT'S DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
O rn Z I understand my plans shall be used as public records MODIFICATION
Z Ca UP TO 200 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
I,W Licensed Professional 201-1000 AMPS IMPROVEMENT ❑SWIMMING POOLS
J OWNER-BUILDER DECLARATION OVER 1000 AMPS ❑BATH REMODEL/REPAIR ❑DEMOLITION
PS 9,t I hereby affirm that I am exempt from the Contractor's License Law for the
O 0.U following reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
1 w WO rj which requires a permit to construct,alter,improve,demolish,or repair any structure
V)Q prior to its issuance,also requires the applicant for such permit to file a signed statement SPECIAL CIRCUIT/MISC.
that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9
per$A (commencing with Section 7000)of Division 3 of the Business and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL:
0.o a that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
W Section 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 POOL ELECTRIC
will do the work,and the structure is not intended or offered for sale(Sec.7044,Business ❑OTHER
a�3 00 and Professions Code:The Contractor's License Law does not apply to an owner of OUTLETS—SWITCHES—FIXTURES
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 FT.
sale.If,however,the building or improvement is sold within one year of completion,the SQ._ OOR AREA $/SQ.FC.
owner-builder will have the burden of proving that he did not build or improve for pur-
pose of sale.). /! '
❑1,as owner of the property,am exclusively contracting with licensed contractors to TOTAL: �! /
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 QTY, PLUMBING PERMIT FEE
who contracts for such projects with a contractor(s)licensed pursuant to the Contractors 6
License Law. PERMIT ISSUANCE
❑ I am exempt under Sec. ,B&P C for this reason r
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 CONSTRUCTIOI
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 OUTLETS OCC.GROUP APN
My Wo s Com a sai ns once brier and Policy 7, 17!E'7
ryn�q�.�e_,�j�
Cam - Policy No.: / S S!E GAS—EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXE ION FROM WORKERS'
COMPENSATION INSURANCE GREASE/INDUSTRL WASTE INTERCEPTOR BUILDING DPVISION PEES
(This section need not be completed if the permit is for one hundred dollars($100) GREASE TRAP
or less.) PLANCHECK FEE
I certify that in the performance of the work for which this permit is issued,I shall SEWER—SANITARY—STORM EA.200 FT.
not employ any person in any manner so as to become subject to the Workers'Compen- ENERGY FEE K.„ V
O Z sation Laws of California.Date WATER HEATER WNENT/ELECIR GRADING FEE
Z C) Applicant
.. tj NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEM/PREATING SOILS FEE
become subject to the Worker's Compensation provisions of the Labor Code,you must
w Al IG
H forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
p" A CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
U0 I hereby affirm that there is a construction lending agency for the performance of _GrWeurecerpt
0-4 the work for which this permit is issued(Sec.3097,Civ.C.)
w H Lender's Name _Lt,/TAL:
OU Lender's Address TOT L: r BUILDING FEE
I certify that I have read this application and state that the above information is
�r V) correct.I agree to comply with all city and county ordinances and state laws relating to QTY MECHANICAL PERMIT FEE
V Z building construction,and hereby authorize representatives of this city to enter upon the SEISMIC FEE
~ above-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against PERMIT ISSUANCE ELECTRIC FEE
liabilities,judgments,costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECH. 0
in consequence of the granting f this permit PLUMBING FEE f
APPLICANT UNDERT SAND L CO LY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
S E REG MECHANICAL FEE
Daire AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signature pplic t/Contractor te 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 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? HEATING UNIT(OVER 100.000 BTU)
❑Yes ❑No
VENTILATION FAN(SINGLE RESID) PAID
Date Receipt 4
Will the applicant or future building occupant use equipment or devices which 11 09
emit hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER—COMP(3HP OR 100,000 BTU) TOTA V
District? r
❑Yes ❑No BOILER—COMP(OVER 100,000 BTU)
I have read the hazardous materials requirements CONDITIONERrements under Chapter 6.95 of the Cali- ISSUANCE DATE
n
forma Health&Safety Code,Sections 25505,25533 and 25534.I understand that if the NEW RESIDENTIAL MECH. SQ.FT. Y
building does not currently have a tenant,that it is my responsibility to notify the occupant r r 2-
of the requirements which must be met prior to issuance of a Certificate of Occupancy.
Owner or authorized agent Date TOTAL: ISSUED BY-
OFFICE