S 0772 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PE n'No.
BUILDING DIVISION APPLICATIONIPERMIT PLUMB ING-MECIIANICAL kJ 0772
HUtEmG PRojECT IDE:NI IFICATION
SANTT TARY No AI'i'LICATION SUBMITTAL DATE
i
!IJULDING ADDRESS:
NC 'S NAM„CI: P IONI?: CO_N'fRA f`'S NAME. LIC NO: \
f1U�A��Y�A J NIC CONTROLN
•'ARCHITEL ENGINEER: LIC NO'. ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMITINFO
Consultant Faces Pa
�� I ❑ id by Applicant(Initial) BLDG
Y Z ECT PLUMB MECH
11 YJ[(ftXi1' ❑ ❑ ❑
LICENSED CONTRACTO ' ECIA A ON QTY ELECTRIC PERMIT FEE JOB DESCRIPTION
1 M1maby affirm that 1 um IiamseJ under pmvisi.ns of Chupmr 9(rnmmencing
OWZ with section]007 of llivision lnfthe Business and Rofessi...Cadgandmy license is RFCIDENTIAI:
P400 PPRMI'T ISSUANCH
,�pppy. in full torrential after'. ❑STOW'. [I KITCHEN REMODF.I.
QDa¢ Contrenor Licanse Class APPLIANCES-RESIDENTIAL []ADDITION ❑PLUMBINGRE-PIPE
H
ARCHITECT'S DECLARATION PANELS ❑MULT'1ANIT ❑STRUCTURAL.
�,y 2 I understand my plans shall he most as public records MODIFICATIONp Z:J� UPP0200AMPS [I INTERIOR ❑CHIMNEY REPAIR
{-y�tq Licensed Professional 201-HROAMPS IMPROVEMENT SWIMMING POOLS
•1OWNER-BUILDER DECLARATION OVER l(IOIIAMPS ❑BATH kEMODEllR1iPA1R [I DEMOLITION
yy%M 6 1 hereby alarm that 1 in exempt from the Contractor's License I.aw for the
SdOaV followig nmason.(Stan..7031.5.Businmanl Professions Code:Any airy.,county SIGNS ELECfRICAI. ❑OTHER
u 3 KFa which requires a Fent to construct.a11cr,improve,demolish c,repair any mou,u re
�LLhJ prim to its issuance,also requires 0c applicant(orsuch permit to file.signed statement SPECIALCIRCUIT/MISC.
p. Dat he is IicemeJ pwsoannothe provisionsol'the Coatroom'.,License Iaw(Chapter 9
X00 (commencing with Section 7")of Division 3ofthe Business and Professions Gsde)or THMP.METER OR POLE.INST. COMMERCIAL,
0.q e C that he is exempt Nerefmm and the basis for the alleged exemption.Any violation of NEW BLDG/ADDITION [I DEMOLITION
W^rn Section 7031.5 by any applicant for a permit subjects the applicant to a civil Penuhy of POWER DEVICES TCN T ❑FOOD SERVICE
C�Qnm more than five hundred dollars($500). VEMBNT
❑I....wmer.] he property,or any employees with wugesas thei,solc compensation, SWIMMING POOL ELECTRIC
will dothewud,and lhestmcmreisnot intended or offered fersule(Sec.7044,Business ❑OTHER
!art �_ and Profess...Code:The Cuernavaca Lwane Law does ma apply to an owner of OUTLETS-SWITCHES-FIXTURES
el'3 property who bulls or improves thereon,and who does such work himself or through
his own employees,provided that such improvements arc not intended or offered for NEW RESIDENTIAL ELEC R SO FT.
sale.IL however,the buildings impmvenacnt iss.ld within one year of completion,the SQ FII FL(.OR ARCA 5/SQ.IT.
owner-builder will have the burden of proving that he did not build or improve for Pur-
p.se of sale.)' TOTAL:
I,as owner of the property,out cxclusively contracting with liccowd contractors I.
commuct the project(Sec.7044.Business and Professions Code:)The Contractors U. Q 2 1U�41L!
cerise Law does not apply to an owner ofproperty whoholds.,oupmvesthercer,and QTY. PLUMBING PERMIT 17EE DEC, (�
who mummers for such projects with a c.ntmctor(s)licensed pursuant as the Common's n1
License Law. `"
PERMIT ISSUANCE .y ur �Vi'CI1�11,
FI & ea
1 am exempt under See ,B P C far thin rson 1
ALTER-DRAIN&VENT-WATER IEA) ,�- VALUATION
Date
• wrier WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE w/yS�•
1 hereby affirm under Family of perjury one of the following declamtioes: CJ«/
Ihaveandwill mammin aCcniOcale n(Consennnaelpinsure for Wnrkern Cnmpen- DRAINS-FLOOR,ROOF AREA,COND' STORIES TYPE CONS'BUCfION
tin.,us Provided for by Section 37M of the Labor Cole,for the performance of the
Irk far which this permit is issued. FIXTUR17S-PER TRAP
1 have and will maintain WomA Compensation Insurance.as required by Stan..
37M of the labor Code.for the Performance ofthe work for which this permit is issued. GAS-HLA.SYS]EM- INC.4 OUT OCCGROUP APN
My Workers Compensation Insurance carrier and Policy comfort art:
Currier: Policy No.: GAS-EA.SYSTEM OVER 4(Ea)
CERTII7CATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASIIINDUSTRL WASTE INTERCEPTOR BUILDING DIVISION PEES
(Thissectionneedmn M1ecompleml ifthepernitis fomnmhoudreddollor,4100) GREASETRAP
or less.) PLANCHECK PEE
I certify that in the performance of@e work to which this Permit is issued,l shall SEWER-SANITARY-STORM FA.HO FT.
nom
t employ any person in any manrso as to hecnmsubject e subjeco the Workets'Camper. ENERGY ITE
0 satin lows of C.11fnmio Data WATER P ATER WNF.NT/ELECTR GRADING FET.
z Applicant
NOTICE TO APPLICANT'.If,after making this Cenificam of Exemption,you should WATER SYSTEMOREATING
I" become subject m the Workers Compensation f the Labor Coda,you must SOILS PEE
n prnaii ionsn
La17 forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
CONSTRUCTION LENDING AGENCY NEW RESIDENT'I Al.PLMB. SQ FT. PAID Dam Be Ir
C.) Ihemby affirm that hem is a connotation lending agency for the performance of
R. the work for which this permit in Issued(See.3097,Civ.C) 'TOTAL
0 Lerml(x Name
r Larolms Address TOTAL:
E-' 1 cenify that 1 have read thin application and sure that the nonce information is BUILDING PEI:
osIa
rre 1.l agree to comply with all city and county ordinances and state laws relating m QTY. MECHANICAL PERMIT FEE
V h.ildingconstmction,and herebymuM1nrim re,mmooltives.fthin city t.comer, Ithe SEISMIC FEE
above-mentioned put for inspection purposes. PERMIT ISSUANCE
(We)agree ua save,indemnify and keep harmless the City of Cupeninn.,ain't ELECTRIC FEE
l9
iabilities.judgmems,costo anal expenses uhicM1 may in any woo accrue against mid City ANTER OR ADO TO MECH. PLUMBING ITiH
in conayuence.1 nor gmntIng.f this permit.
PI'I CANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT'(T(l 10,00 CPM) MECHANICAL FEE
IU CE RE LATIONS.
AIR HANDLING UNIT(OVER 10.IXIO CFM) CONSTRUCUON TAX
Signaler .f pIr tar r4 Data EXIIAUST GOOD(WIDUC , HOUSING MITIGATION IEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant.,future building carousal store or handle hazardous material HEATING UNIT(TO 100,001 BTU)
as defined by the Cupeninn Municipal Cosle,Chapter 9.12,and the Health and Safety
Code,Section 25532(x)? HEATING UNIT(OVER 1(B.00 BTU)
ED Yes [-1 No VENTILATION FAN(SINGLE RESI)) PAID Date RCceipl#
Will the applicant or future building occupant use equipment or devices which 00900 BTU)
•emit h...a ons air contaminants as JcBOILER-COMP(31111 OR 1
fined Fy the Bay Are.Air Quality Munigentenl TOTAL:
District? BOILER-COMP(OVER 100.0X)BTU)
E3 Yea 7N
I have ricin the hromatquirement
mus melots,es no&,Chapter 6.95 of the Cali- AIN CONDITIONIiR ISSUANCE DATE
four,,Gratia&Safety Code,Sections 25505,25533 uad 25534.1 undemmnd that if the NEW RESIDENTIAL MECH. SQ.ET.
building does not currently hove a team,that it is my nesponsibibly m notify Bae ucupant
of the{r.bemenb which must timet no,to issuance Ila Certificate of'Occupancy.
Ostommauthmiadagem Data TOTAL: ISSUEDBY:
OFFICE