S 0200APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING. - RLECPRIGAL.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICALQ
BUILDING PROJECT IDENTIFICATION
PERMIT NO.
0 100
J G
DING ADDRESS:
SANITARY NO.
APPLICATION SUBMITTAL DAT[
BACK FLOW PROTECT. DEVICE
1 herehy affirm under penally of perjury one of the following dcel... Iieus:
OYWNF.AME: PHONE
C NTRACI LIC NO:
NIC
CONTH(ILp
I
1, N
I ARCHITECTAiNGINE '
)RESS.
❑
work for which this peril is issued,
CONTACT: PHONE:
1 have end will maintain Workers Compensation Imunmce, as required by Section
- BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant (Initial)
BLDG E'.p r PLUMB MECH
❑ ❑ ❑
LICENSED coNTRACfoRs DECLARATION
I hereby affirm Ibar I in licensed under provisions of Chapter 9 (commenein6JOB
QTY ELECTRIC PERMIT FEE ;
�
DESCRIPTION
with Section 7") of Division 3 of the Businessand Professions CWa,.nd my license is
in full force and effect.
License Class uc.N
Date Conramnr
PERMIT ISSUANCE
RESIDENTIAL:
❑SFUWI, ❑ KITCHEN REMODEL
El ADDITION El PLUMBING RE PIPE
❑STRUC'FURAI.
MODIPICATION
APPLIANCES -R17STDENTIAL
ARCHI'TECTSDECLARATION
1 understand my plans shall be ural as public recuNs
PANELS❑MUI.TI-UNIT
"
UP TO 2nD AMPS
[]INTERIOR [I CHIMNEY REPAIR
IMPROVEMENT ElSWIMMING POOLS
❑BATH RIiMf�Rli PAIR OLITION
OTIII:R J
Licensed Pmfesei... I .
OWNER BUILDER DECLARATION
1 hereby ti irm m from he 1 aexempt frothe Comracmr's License Law for the
following reason. (Section 7031.5, Hm mess and Professions Code: Any city or county
201-10)(MAMPS
IOBOAMPS
-OVER
SIGNS ELECTRICAL
require. a permit to construct. Tire, improve, dannlish, .,,,Pat, my .hue ore
NEW RESIDENTIAL PLMB. SQ. FT.
Q WPM
ormitsi
pri....ame,alsn compiles theappli...Ifoesueh perino file. signedsmme
teat
SPECIAL CIRCUIT/MISC.
That he is licensed pursuant o the provisions ofthe Contractors Licence Law (Chapter9
TEMP METER OR POLE INST
COMMERCIAL
(commencing with Section 9BW) of Division 3 ofthe Bueinessand Professions CodOor
that he is exempt therefrom vad the two, for the .Ilegcd exemption. Any violation of
❑ NEW BLDG/ADDITION ❑ DEMOL1'TION
POWER DEVICES
Section 7031.5 byany applicant forapermit subjects the Tpplicant to a civil pennh,cid
not more than five hundred dollars ($500).
1-) 1, as owner of the Property, or my employees with wages is theirsole compensation,
L1 TENANT ❑ FOOD SERVICE
IMPROVEMENT
_
SWIMMING POOL FLECTRIC
will do the work, and the structure is nor intended or offered for sale (See. 7044, lousiness
❑ OTHER
unit Professions Cede: The Common's License law does not apply to an owner of
OUTLETS - SWT TCHES-FIXTURIS
Property whe builds or impmven thereon, and who does such work himself or Through
his own employees, provided that such improvements arc not intended or offered for
NEW RESIDENTIAL F.LECTR SQ FT.
sale. If.however, the buildingor improvement is sold within one year ofcompietion,the.'LOOK
AREA
$/SQ. IT.
caner -builder, will have the burden of proving that he did not build or improve for parr -
Point ofsalT.y
C]L as owner of the property, am exclusively contracting with licensed contmetors to
c/�'. N4 �l'CD
TOTAL:
u
co®int The project (Sec. ]044, Business unit Professions Coda) lie Contractor's Li-
use law does not apply to an owner of property who builds or improves material. and
who contracts for such pmjecrs with a contractors) licensed pursuant In the Comramtsrs
U,
L•I/fJt%�i��(ly
QTY' PLUMBING PERMIT FEE
PERMIT ISSGANCE
Licenae Law.
l am exempt under Sec. ,B& 1' C fiddiisrevmn
_
AITPR - DRAIN & VENT- WATER (FA)
-- - -- ----
U O l hereby affimuhat them is a construction lending agency for the pcifomunce of
LLT H the work for which this pcmtit is issued (Sec. 3099, Civ. CJ
Q U larder's Name
[t7 Ixoder's Address
I certify that 1 have read this application and sure that the above information is
&n corer. l agree to comply with all city and county ordinances and state laws relating to QTY.
U admovengamumdirorram hereby umhonprolomeonutives of @la cltymcnurugm the
above-memioned property for inspection puHems. Eli
(We) agree ur save, indemnify and keep tearless rbc City M C,0;nina against
liabilities,judgment, costs and expenses which may in any way accrve against said City A
cnnsequeneeoflhegrami (this permit
APPLICANT UNDERS'FA �S AND WILL COMPLY WITH ALL NON411INT)
HAZARDOUS MATERIALS DISCLOSURE /
Will the applicant or future building occupant store or handle haaallous material
as defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
Code, Seainn 25532(x)?
E3 yes ❑No
Will the applicant or future building occupant use equipment or devices which
emit becommus air contaminants as dedned by the Bay Area Air Quality Management
Disuim?
ED Yes 7 N
1 have read the haanNous materials resp iremnns under Chapter 6.95 of The Cut-
formalHtulth & Safety Code, Sections 25505, 25533 and 25534. 1 conclusion! that if rhe
building does not currently have a moral, Ill., it is my respomihila, to notify the occupant
ofthe mquimmenrs which must be mel prior In issuance of a CediOcme of Oecupvncy.
RMIT ISSUANCE
AU OR ADD TO MUCH.
R HANDLING UNIT O-0 10,000 CFM)
R HANDLING UNIT (OVER 10,000 CFM)
:HAUST HOOD (WNUCU
!ATING UNIT (TO 10T),O BTU)
:ATING UNIT (OVER I W.000 BTU)
lNTILATION PAN (SINGLE RESI))
TILER -COMP (3HP OR I ff.000 BTU)
TILER- COMP (OVER ion" B'Out
R CONDITIONER
IW RESIDENTIAL MECH. SQ. IT
OFFICE
PLANCI ECK FEE
ENERGY FEE
GRADING 17EE
SOILS PEE
PAID
Dare Receipt IT
BUILDING PEE
FEE
SEISMIC FEE
ELECTRIC FEE
PLUMBING FEF.
MECHANICAL PER
CONSTRUCTION TAX
HOUSING MITIGATION FEE
PAID
Date Receipt T
TOTAL:
ISSUANCE DATE
ISSUED BY:
Owner Data
WORKER'S COMPENSATION DECLARATION
BACK FLOW PROTECT. DEVICE
1 herehy affirm under penally of perjury one of the following dcel... Iieus:
DRAINS- FLOOR, ROOK AREA. COND.
❑IM1ave and will mainmin aCenifcam of Cnnxnl ro sciGinxure for Workers ComFen-
cation, as Provided for by Section 37M of the Labor Code. for the performance of the
FIXTURES - PER TRAP
work for which this peril is issued,
1 have end will maintain Workers Compensation Imunmce, as required by Section
37M ofthe Lxur Cuda. for the perfonnence ofthe work for which this permit is issued.
My Workers Cnmpemmtiom lmsumnce Turner and Policy m�
GAS - EA. SYSTEM -1 INC. 40UTLEfS
W5A
Carib: Policyls.:0V
EA. SYSTEM -OVER 4(EA)
CERTIFICATE OP EXEMPTION FROM WORK •RS'
.y_
COMPENSATION INSURANCE
GREASMNDUS'TRL WASTE INTERCEPTOR
(Thisxctionneednor W completed ifrhe perms is forone hundreddollars($100)
or last.)
GREASETRAP
SEWER -SANITARY- STORM EA. 300 FT.
oz
Q
I codify that in the performance ofrhe work for which this Permit is issued,Ishan
not employ, any Petrillo in any manner so as m become subject o the Worken' Compen-
smion Laws of California. Data
Applicant
WNGIR HEAT ER W/VENLELECTR
z
y
a;
[Ta
01 Q
7z
NOTICE TO APPLICANT: IL after making this Certificate of Exemption, you should
become subject to the Workers Compensation previsions ofthe Labor Code, you must
forthwith comply with such provisions or this Peril shall he deemed revoked,
CONSTRUCTION LENDING AGENCY
WATER SYSTHM/IREATING
WAl'ER SERVICE
NEW RESIDENTIAL PLMB. SQ. FT.
U O l hereby affimuhat them is a construction lending agency for the pcifomunce of
LLT H the work for which this pcmtit is issued (Sec. 3099, Civ. CJ
Q U larder's Name
[t7 Ixoder's Address
I certify that 1 have read this application and sure that the above information is
&n corer. l agree to comply with all city and county ordinances and state laws relating to QTY.
U admovengamumdirorram hereby umhonprolomeonutives of @la cltymcnurugm the
above-memioned property for inspection puHems. Eli
(We) agree ur save, indemnify and keep tearless rbc City M C,0;nina against
liabilities,judgment, costs and expenses which may in any way accrve against said City A
cnnsequeneeoflhegrami (this permit
APPLICANT UNDERS'FA �S AND WILL COMPLY WITH ALL NON411INT)
HAZARDOUS MATERIALS DISCLOSURE /
Will the applicant or future building occupant store or handle haaallous material
as defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
Code, Seainn 25532(x)?
E3 yes ❑No
Will the applicant or future building occupant use equipment or devices which
emit becommus air contaminants as dedned by the Bay Area Air Quality Management
Disuim?
ED Yes 7 N
1 have read the haanNous materials resp iremnns under Chapter 6.95 of The Cut-
formalHtulth & Safety Code, Sections 25505, 25533 and 25534. 1 conclusion! that if rhe
building does not currently have a moral, Ill., it is my respomihila, to notify the occupant
ofthe mquimmenrs which must be mel prior In issuance of a CediOcme of Oecupvncy.
RMIT ISSUANCE
AU OR ADD TO MUCH.
R HANDLING UNIT O-0 10,000 CFM)
R HANDLING UNIT (OVER 10,000 CFM)
:HAUST HOOD (WNUCU
!ATING UNIT (TO 10T),O BTU)
:ATING UNIT (OVER I W.000 BTU)
lNTILATION PAN (SINGLE RESI))
TILER -COMP (3HP OR I ff.000 BTU)
TILER- COMP (OVER ion" B'Out
R CONDITIONER
IW RESIDENTIAL MECH. SQ. IT
OFFICE
PLANCI ECK FEE
ENERGY FEE
GRADING 17EE
SOILS PEE
PAID
Dare Receipt IT
BUILDING PEE
FEE
SEISMIC FEE
ELECTRIC FEE
PLUMBING FEF.
MECHANICAL PER
CONSTRUCTION TAX
HOUSING MITIGATION FEE
PAID
Date Receipt T
TOTAL:
ISSUANCE DATE
ISSUED BY: