00030127APPLICANTTO FILL IN INFORMATION WITHIN RED LINES • USE BALL POINT PEN ONLY -
CITY OF CUPERTINO BUILDING. ELF.CTRICAI, PERMIT NO
BUILDING DIVISION APPLICATION/PERMIT PLUMBING. MECHANICAL
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APPLICANT
SOURCE
Slgnamre
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Code,
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District
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building
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Owner
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❑Consultant Fees Paid by Applicant (initial)
PERMIT INPQ '
BLDG ELECT PLUMB MECII
El El El
LICENSED CONTRACTORS UIiCLARArION
I hereby affirm that 1 um licensed under pmvieiom of Chapter 9 (commencing
with Sretion T(Ml0)of Division3oOhe BUSines and Professions Cade andm� :license i..
n full force and eB _
Limns 'I ss Lie, p
Dam�Conuocmr
; PERM PF
. - 1
PERMI "I' ISSUANCE
FEE' t
70B DESCRIPTION
RESIDENTIAL
❑ SFDWL ❑ KITCHEN REMODEL
El ADDITION 11 PLUMBING RE -PIPE
❑MULTI -UNIT ❑STRUCTURAL
MODIFICATION
❑ INTERIOR ❑ CHIMNEY REPAIR
IMPROVEMENT 0$WIMMING POOLS
❑ BATH REMODEUREPAIR C DEMOLITION
11 OTHER
i� JR
APPLIANCES - RESIDENTIAL
ARCHITECTS DECLARATION
I undersanJ my pins Cold be usoA as pblic recods
IsensW I'mfesmnnal
OWNER-HU1I.DER DECLARATION
I hereby affirm that I ant exempt from the Contractor's Licenso Law for the
following leasov. (Section 1031.5. Bu ou
Business and Professions Code: Any city or county
which requires a permit to emswct, alter, improve, demolish, or repair any structure
prorm it' issoance,:dsorequve, theapp l island for aucb permit et file asignedstatement
Ihat he is llcemedpursuaatill l he proviainnc of the Comrucmr's Limtse Law(Chopmr 9
(commencing with Section 7000)o'Division 3 ofthe Business and Professions Code) or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant Fort pemtit subjects theappticion to n civil Penalty of
nor urethan five hundred dollars F600).
❑I, as owner of the property, or my emplayeeswith wages ex theirsol (compensation.
wJl do the work, and the structure is and intended orn(fered for sale (Sec. 161, Business
and Profcsiuns Csde: The Commctor's License Lew does an to an owner of
property who builds Or improves thereon, and who does such work himself or through
his awn employees, pmvided that such improvements are not intended or offered for
m1e. If, however , the buildingm impmvoment is sold within one year ofmmplelion ,the
owner.budder will have the burden of proving that he did not build or improve for pur-
putt or cols.).
❑ 1, as owner of the property, am exclusively con'recting with licensed contmemrs to
construct the pmjal (Sec. 90,14, Ilmsiocxs and Prafc..inrt Codc:) no Con occtm'e LI-
censeLawdoe s not apply to an owner of property who builds or improves thereon. and
who commas for such projects with a comtations) licensed pursuant to the Contractor's
lice se Law.
❑IamcxcmptinitrSce. ,B &PCI'ur this rcnson
PANELS
UP T02 U0 AMPS
201-1000 AMPS
OVER IOW AMPS
SIGNS ELECTRICAL
SPECIAL Cl CIRCUIT' /MISC.
-
NT
'TEMP. METER OR POLE INST
COMMERCIAL
❑NEW g1.DG /ADDITION ❑UIiMO1.ITION
❑117NANT ❑IrOOD SI ?RVICIi
IMPROVRMEIT
❑ OTHER
POW17R DEVICES
SWIMMING POOL ELECTRIC
OUT'.El S. -SWI'1 CITES - FIXTURES
NEW RESIDENTIAL ELECfR SQ EL
SQ. Ff. FLOOR AREA $ /SQ. EL
-
0 VALUATION
TOTAL:
- -
QTY: PLUMBING PERMIT
P
FERMI "I'ISSUANCE
Owner Date
ALTER - DRAIN Cs VENT - WATER(EA)
BACK PLOW PIiM ECT. DEVICE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarnions:
❑Ihave end will maimaina Cenificmeof Consent molt - insure furWmkerk Cnmpen-
sation, as provided for by Section 37Wofthe Labor Code, for the p hrfmmnnce of fhc
work for which this permit is issued.
0 1 have and will maintain Workers Compensation Insumnce, as required by Section
31W ofthe Labor Costa. for perfommnce ofthe work for which this permit is is sued.
My Worker' a Compmottion Insumnce currier and Policy number are:
Cartier: Policy No
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
frhis section seal urn he complemd irdw permit Is fora ne hundrul dollars 1$100)
or IessJ
I stuffy thin in Neperformance nfthe work for which this pemtit is issued, I shall
rim en Lows l personia any manner so as in become subjecuo OC Wnrkcrs 'ComPen-
Applicant Luwn of California. Date
Applicant t
DRAINS - FLOOR, ROOK AREA, COND.
STORIES
TYPE CONSTRUCTION
PIX'NRES - I'ER TRAP
GAS - BA. SYSIEM -I INC, a OUTLETS
GAS - BA. SYS I I;M -OVIiR 4(EA) n
OCC. GROUP 1
dye
/S
GREASE/INDUSTRI. WASTE INTERCEPTOR
GREASH TRAP
HIJILDING DIVISION PEES
-
PLANCHECK THE
SEWER- SANITARY -STORM EA. 200 FT.
ENERGY FEE
WA'T'ER HEATER W /V[N'fIELECTR
GRADING FEE
NOTICE10
Indb APPLICANT: IL Cro mating this Cellonal of Exemption, you should
become subject m the Worker's Compenr 11u, provision] of the Labor Gale, you must
fonhwiN comply with such provisions or this pertni' shall be JeemN revoked.
CONS'1'RUCTION LENDING AGENCY
Ilmrebyaffmnlhmthemlvuum svuctinn lcnJing agency for the perfarmonmof'
work for which 'his permit is issued (See. 3091, Cis, C.)
WATER SYSTRM/fREATING
SOILS FEE
WATER SERVICI3
PAID
NEW RESIDENTIAL PLMD SQ, ET'.
Dm Receipt#
Lender's Name
Lender's AJdms
TOTAL
TOTAL:
1 certify that 1 have read this application end state that the above information is
l agree to comply with all city and county ordinances and slam laws relating to
construction, and hereby aumanc representatives ordis city to enter upon the
mentlnned pntpeny for in.apection puBxtses.
(We) agree it) save, indemnify and keep harmles the City of Cupertino against
judgments, costs and expenses which may in any way some against said City
consequence of the granting of this pemtit.
UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
RF.GIILNPIONS.
BUILDING FEE
_
QTY, MECHANICAL PERMIT
FEE
SEISMIC FEfi
PF.RMI'1' ISSUANCE
ELECTRIC FEE
ALTER OR ADD TO MECtI.
PLUMBING FEE
q1µ DANDLING UNIT (fn Ill,f CPM7
klH
MECHANICAL PEE .
AIR HANDLING UNIT (OVER 10,000 CFM)
CONSTRUCUO( TAX
ofppplicanVConuaclor one
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle havnlous material
define(] by the Cupertino Monalipal Gdc, Chop'cf 9.12, unit the Health and Safety
Section 25532(a)°
❑Yea ON.
Will the applicant or future building wapnm use equipment or devices which
linowsous air contaminants as definal by the Bay Area Air Quality Management
?
❑Yes ❑No
1 hove read the h ado, S s manna 5 tcquire33 an under Chalaer 6.95 of Ne Cali-
Health & Safety Coda Sanians 25505, 25513 and 255:M1. I understand that if the
Nie]not curmnlyhavcurcnmtlhm it is my rcspotsihility to nnWy tlm occupant
the mquimmenu which must he met prior to issuance of a Ceniftcate of 0ext panes.
EXHAUST HOOD(W /DUCT)
HOUSING MITIGATION FEE
HEATING UNIT (TO IOO,(XM BTU)
HEATING UNIT(OVER 1010,00) BTU)
PAID
VENTI LATION pp N(S INGLE RES I DI
BOILER- COMPDHPOR IW,0009TU1
Dato Receipt»
TOTAL
BOILER- COMI'(OVER1100.l00B'I'U)
... ��
AIR CONDITIONER
ISSUANCE DATE
HY: /
NEW RCSIUEN'r1Al. MIiCH,
or aonoo.. agent Dam
TOTAL:
ISSl1ED
OFFICE