29948AP,PLICANTTO FILL IN INFORMATION WITHIN RED LINES -'USE BALL POINT PEN ONLY. -
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CITYOFCUPERTINO ! BUILDING -ELECTRICAL.
- BUILDING DIVISION APPLICATION/PERMIT. PLUMBING - MECHANICAL -
BUILDING PROJECT IDENTIFICATION
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BUILDING ADDRESS:
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SANITARY NO.
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APPLICATIONSUBMITTAL UATI
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A /J-AY110
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CONTRACT0125 NAME: r _ LIC NO:
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•CONTROL #
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ARCHITECT/ENGINEER: LIC NO:
ADDRESS:
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CONTACT:. - PHONE:s
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❑ Consultant Fees Paid by Applicant (Initial)"' t
BUILDING PERMIT INFO
BLDG .ELECT PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION'
I hereby affirm that 1 am licensed under provisions of Cha ler 9 (commencingQTY.
with Section 9000) ofpivision3 oDhn Business and Precisions Code. and my license
in and effect.
full a Class
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License Class - Conti
Dam Con
ELECTRIC PERMIT FEE
� JOB DBSCRI ION
RESIDENTIAL,
❑SFUWf. ❑KITCHEN REMODEL
❑ADDITION El PLUMBING L PIPE
❑MULTI -UNIT• Ll STRUCTURAL
MODIFICATION
•• ❑CHIMNEY REPAIR 4
•IMPROVEMENT-
E BATH REMODEUREPAIR ❑ DEMOLITION,
❑ OTHERcity _
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PERMITISSUANCE
APPLIANCES -RESIDENTIAL.
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DECL
ARCH —hall he ase DECLARATION -
I J t dray pl hallh ed p61 venues
Lieemaod PrOfiessicandElINTERIOR
OWNER BUILDER DECLARATION
1 hereby affirm that I arrexempt firm the Contractors 1 use Law for the
following -(Sect'90315 Business and Professions Code: A y or countySIGNS
req'r . v permit to emositact.he,, improe democarnepmormay induction'
prior t1issuance, l q the applicant for such permit to file a.ignJ statement
th th I .alp a it it p of the ContracmrsLicense L (Ch pmr9
(tram ngw th Secti 9(100) fD n3ofthe Busioese anJP f .0 de)nr
that he is exempt therefrom and, the bass for Ne alleged exemption. Any violation of
Section 9031..S by any applicant for a permit subjects the applicant to a civil penalty Of
not more than five hundred dollars ($500).
L]I, as oam".fth,property, or my employees with wages as their solo compensation,
will on the work and thesaucwre is nit macrdedomfl'ered forsale($ea 9044, Business
and Professions Code The Contractors License Law does not apply to an, owner of
property who molds or impmrves thereon, and who sees Inch work himself .c through
his own employees, provided shot such immre
proveends anom N
t intended ired
efm
W& If.however, the buildiOR.... ipmvement is sold is hin one year of cnmple'ionthe
owner-huilJer will have the burden of proving that he did nor build nr improve for Pur-.tl
p s sale.)
s of the ge p U n "choicelycontracting
no- t g with licensedr contractors to
c� th) pro)ecl (Se ]W4 Bt and Pr fe"' Cid ) Th C t t Li-
ease Law does not apply t o an w f property h b ld. p thereon, d
hocontractsforsuchpr lea thaaonvat OI eusedpur: rt 0 C vector's
' License Law --
❑I am exempt under Sec. '; (I& P C for this reason
PANELS
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UPT021N1AMPS
201-IMOAMPS '"
OVER IOM AMPS
ELECTRICALhich
SPECIAL CIRCUIT/MISC. p.
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TEMP. METER OR POLE INSTOMM
RIA -
El NEW BLDG/ADDITION ❑DEMOLITION
❑TENANT ❑ FOOD SERVICE .
IMPROVEMENT
❑OTHER
POWER DEVICES
SWIMMING POOLTLE IC
OUTLETS- SWITCHES -FIXTU E9
NEW RESIDENTIAL ELECTR FT. '
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SQ, F f. FLOOR AREA
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4
lz77Op
Pilo�
fVVr't'r
$/SQ, FT.
- TOTAL:
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QTY, PLUMBING PERMIT FEE
PERMIT,ISSUANCE
ALTER - DRAIN '& VENT- WATER (EA)
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`%.
_ 0
net Date T
'VALUATION
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WORKER'S COMPENSATION DECLARATION•'
I hereby affirm under penalty of perjury one of the inllawing dedvrations:
❑ I have and will maintain a Certificate nfConsem m self -inane for Worker's Compem.
solum. va provided for by Section 3900 of the Labor Crate, forthe perfomuance m the
,work for which this permit is issued. i
❑ I have and will maintain Worker's Compensation Insurance, as required by Section
3000 of the Labor Code. frrthe Performance ofthe work for which this permit is issued.
M Worker's Com
Y Compensation Insurance cartiuondy No, number ora'
Cartier: Polley Na:
N FROM WORKERS' t
CERTIFICCOMPEN COMPENSATION
om be co NSATIONINSURANCE
l'phie section need not be completed if the permit is for nne hundred differ ($100)
or least
Ioe any that in the ourany ancanro the work as
int employ any person In any manner so as to became suM1jea to the Workers' Camper.
subject
bjech tto perthe it Wisiss'Corapr.
A I Laws of Glifomia. Dam
Applicam � - �
BACK PLOW PROTECT. DEVICE
DRAINS- FLOOR, ROOF, AkGA,CONp.-
STORIESTYPE
OCC. GROUP
CONSTRUC3'ION
APN '
FIXTURES-PER'rRAP
GAS- EA. SYSTEM- I INC. 4 OUTLETS
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GAS - EA. SYSTEM -OVER 4(EA)
GRF.ASE/INDUSTkL WASTE IM'ERCEPTOR
GREASETRAP,
�$o gIU11,DINGDIVIS NIsE&S
PLANCHCCK FEE,
SEWER - SANITARY - STORM EA. 2N) FT.
ENERGY FEE
WATER HEATER WNF.NT/ELECTR
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GRADING FEE
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NOTICE TO APPLICANT If, otter andmal'his Certificate of Exemption, you should
Serum, subject 0r he Worker's Compemealm provisions of the labor Code, yam must
forthwith comply with such provisions or tCeemerevo
his anmit shall be dd ked
.. CONSTRUCTION LENDING AGENCY
"']hereby aIDrm thanherciearnnswmion lending agency dame performance of
the work for which this p t is issued(Sec 3099. Civ. C)
Least Name
Lente Address
r certify that I haved this application and state that the M f mum on is
correct I g t c reply with all city and )runty ordinances and tam laws relating to
braiding constiucvon, and hereby authorizereprerenmtnes of this city to war upon the
LM1nve-memiones popery for inspection purposes.
. (We) agree to m
save, indemnify and keep harless the City of Cupertino retired
Ilabllities,judgmeds. costs and expenses which may in any way accrue against said City
onsoquence of the granting of this permit. -
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS.
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WATER SYSTEMOREATING
SOILS PEE -
WpTEk SERVICN
PAID '
.Do's Receipt# -
NEW RESIDENTIAL PLNHL SQ. FF. -
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- TOTAL'
BUILDING F v
. QTY, MECHANICAL PERMIT FEE
SEISMICFE
ISSUANCEst
ELECTRIC •EE � ..
ALTER OR ADD TO MECH.
PLUMB] .FEE
AIR HANDLING UNIT TO 10,0W CFM)
MECHA ]CAL FEE
AIR HANDLING UNIT (OVER 10,0(1(1 CPM)
CONS ION TAX -
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Signora ofAppheanUConrt ,.' „r Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle uncommon, material
as defined by the Caperton Municipal Code, Chapter 9.12, and the Health and Salety
Code, Section 25532FIC . ' t sr
FT Yes []No,HEATINGATiNO
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Will theapplicam mfumre bonding occupant use equipmrntcor devices which
emit hazardous air amtamimante as defined by the Boy Area Air Quality Management
District'
❑Yes 7NO 1 "'
I have read the hzzardrus .aidmquirementS under Chapter 6.95 of the Cali-
isHealth & Safety Colo, Sections 25505, 255 3] and 25534. 1 understand shot If the
builtlmgdoes not cunen'ly hoveatemm�, that it is my responsihillty to notify theoceupem
of the requirements which must he me' prior m issuance of a CotiOcute of (kcupnncy.
EXHAUST HOOD(W/DUCT)
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HOUSINGM IGATIONFEE
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HEATING UNIT TO 100,000 BTU)
UNIT (OVER 100,00OBTU)
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PAID
Date Receipt#
VENTILATION FAN (SINGLE RES[ D)
BOILER -COMP (JHP OR IOQOW BTU) -
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Toy,:
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BOILER- COMP (OVER 100,000 BTU)
AIR CONDITIONER
ISS NCE DATE
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ISSUED BY: �
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NEW RESIDENTIAL MECH: SQ, FI'.
Owner or a domowd agent Dom ,
TOTAL:
OFFICE" ',