S 1437 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PE ITNO 1 /� /�
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL, y 4 3 7
tlU G PROJECT IDE IFICATION 1
BUILDING ADDRESSf �7 r SANITARY NO. APPLICATION SUBM1'1-1'AI.DATE
R'S NAME: PHONE,: CONTRACTOR'S NAME: LIC NO: N/C CON TROLN
CHI'fECI'/LNCINEEFir LIC NO: ADDRESS: ❑
CONTACT: PHONE BUILDING PERMIT INFO
❑ Consultant Pees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ rse ❑
LICENSED CONTRACTORS DECLARATION rN
QTY ELECTRIC PERMIT FEE
I hereby arum that Thal 1 am licensed under provisions ofChop r,9(commencing JOB DESCRIPTIO
wo, with Section 70(10)ofDiAsion 3ofthe Business and Professions Cortical!my below is RESIDENTIAL'
F'al UU License Class Li,,in full force and creel. PERMIT ISSUANCE ❑SPDWL El KITCHEN REMODEL
�
y Q W Date Contramnr APPLIANCES-RESIDENTIAL DADDITION []PLUMBING RE-PIPE
ARCHITECTS DECLARATION PANELS
DMULTI-UNIT []STRUCTURAL
Zololz I oderstandmy planssholl he used as puhli,wonnls MODIFICATION
O�Z� UP'10 200 AMPS
F.�ticJ Leenscd Pnsfes,nmal []INTERIOR DCHIMNEYREPAIR
j OWNER-BUILDER DECLARNI'ION 201-1000AMPS IMPROVEMENT []SWIMMING POOLS
W Q 1 hereby affimt that I am exempt from the Cnmmeel's License Law for the OVER INNIAMPS []BATA REMODRAEPAIR []DEMOLITION
aO y U following reason.(Su:tion 7031.5,Businessland Prafe oma,Calc:Any dly or coney SIGNS ELECTRICAL []OTHER
W N which requires a permit sat constrai alley,improve,demolish,ur rcpuir any slmeaum ` /
MOQ prior tell,ismaner,elm requires Weapplicaut for such permit a file a rignul statement
N.� SPECIAL.CIRCUIT/MISC.
WD' wommiscing wait pursuant 70AR or Division 3 these usinessLicense Law(Chape)
UI G1d� dau Ina ,exemith Sermon and of UlvisionrdRhdeged exempton.An and vi Gale)or TEMP.MP,'feR OR PoLE INST. COMMERCIAL
Thal he i7 exempt therefrom and the hosts Iia the allege)excmpnoa a civil
violation of [-]NEW BLDG/ADDITION D DEMOLITION
Seclinnfla.Sve handleday dc1lid,S50R.nllsuM1jedsthe applicant macivil penalty of POWER DEVICES Or
sat more than five hundred Aollors($5100). []TENANT []FOOD SERVICE
Q I,as dwnerofahe IMPROVEMENT
❑ pro pengannyemplendes withered fos lold(Se. W,I,Bsidon, SWIMMING POOL []OTHER
cacwill do the work,and the ale Co a is not intended orow do for gale(Sec.]1144,Buam of
C'm and Pry who
Cwle:The Contractor,License Law does nm apply m an own^r ILC OUTLCfs-SW I'TCIIES-FIXTURES
6 property who bails,,or improves thereon,and who Joey cash work intended
o Cor Ihmagh
his own employeese provided that arch Improvements are not intended oC plebewhered,Cur NEW RESIDENTIAL ELEC!'R SQ
seller Ehnwever r will have tile
grrimprovement issoldhwithin on build or Improve for Fam-the , SQ.FT FLOOR AREA $ISQ,FT.
owner will hove the harden of proving that he did not build or Improve for puz-
puce of oda owner
E] ],,as owner of the pmptny,am exclusively contracting wish licensed contractors to TOTAL:
ennwun the prglem(Sec 7044.Businevv and Prnfcssions CodeU The Computer's Li- O
cease Law does not apply to an owner of property who builds or improves thereon,and QTY PLUMBING PERMIT FEE g A�Sa
who contracts for such projects with a contrueors)licensed pursuown,the Convectors �1� sax,
License Law.
1:1 pun I exemPERMIT ISSUANCE
pl under See. ,B&P C for this reason ck III\V
Owner G— Dnte ALTER-DRAIN&VENT-WATT?k(W) Q1I1 Ur v gLUAT10N
• ORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby affirm under Penalty of perjury one or the following declarations:
❑IM1ave and willntainamnnCenificaudfCunsenlmxelf-Insure fm Workers Concern- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCTIONstain.ax provided for by Section 3700of the Labor Code,for We performance of the
work for which this permit is issued, FIXTURES-PER TRAP
❑ 1 have and will maintain Worker's Compvnsainn Insurance,as NgLaa d by Section
3700 ofahe Labor Gale,for the pertmarancerf the work for which this permit,issued, GAS-EA.SYSTEM-I INC.4 OUTLETS OCC GROUP AIN
My Worker's Compensation Uxurance carrier and Policy number are:
Caries Policy No.: GAS-EA.SYSTEMOVER4 H]A)
CERI'BgCATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASIIINDUSTRL WAS'T'E INTERCEPTOR BUILDING DIVISION FP,13S
(Thoserionneednnt becont letaJ iflheperrad lsfomnrhundredmilurs($100) _BUILD
F GREASETRAP
or ler,.) PLANCHECK FEE
Loy any lM1mintin anynarrowolthe to ber Cor sujM1tto the at WrkesuCompml SEWER-SANITARY-STORM P.A.200 IT.not employ any parson in any manner s^as m became subject to the Workers'Compel- ENERGY PEE
,Z sudor Laws dfCxlifarniu.Dole
O O Applicant WATER HEATER W/VGNf/GLECTR GRADING FEE
NOT ICE TO APLICAN I.If,alter making this Cenificar of Exemption,V] g pion,you should WATER SYS'1'BM?BEATING
abecame sobject,.the Workers Cnmpenr iprovisions df the Lobar Code,you man SOILS FEE
{Ta
Forthwith comply with suchprovisiothis
ns or Thi.,permit shall he deemed rcvakeJ. WATER SERVICE
G Q
CONSTRUCTION LENDINGAGENCY NEW RESIDENTIAL PLMR. SQ.FT PAID
V Iherebyuffirmthnuhvro isaamn ton 30 lending agency for the perlhnnance of Dote R
fL H the work fur which this permit is issued(Sec.309),Civ.C)
Q Lenders Name TOTAL
V Lenders Address TOTAL
y I reality that 1 have read this indication and state that The above infornahon is BUILDING PEE
VI correct.I agree to comply with all city and county ordinances orad save Ivwsrelming m QTY, MECHANICAL PERMIT FEE
U z building construction,and hereby authorize representatives ofthls city to enter upon the SEISMIC FEE
w. above-mentioned pmpeny for inspection purposes.
(We)agrce to save,indemnify and keep hormlesa the City of Condi imo against PERMIT ISSUANCE ELECTRIC PEE
Iiabililios,judgments,costs and expenses which may in any way accme against said City gLTER OR ADD ID MECH.
a.consequence of the granting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO I(I,INIO CFM)
SOUR UGULATIONS. /// MECHANICALFi
V" � b AIR HANDLING UNIT(OVER 10,(1010 CPM) CONSTRUCIONT
/ Sn nmure of Apple � / Dale O EXHAUST HOOD(W/DUC) -
/ HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Will the applicant or future building occupant sere or handle hazardous material HEATING UNIT(TO 100,000 BTU)
os defined by the Copeland Municipal Code,Chapter 9.12,and the Health and Safety
Grade,Seclinn 25532m)? HEATING UNIT(OVER IIN),000 BTU)
[]Yes []No PAID VENTILATION FAN(SINGLE RES[D) Due Receiptp
. Will the iremapplicant or future deft led by the nt Bay Appyuipmeun or lily Maragences u nb BOILER-COMP(3HPOR 100,0000 TIE -
emit hazardous air mnmminpnls as defnetl by the Bay Arca Air Quality Manegcmern TOTAL:
Uislrict?
❑Yea No BOILER-COMP(OVER III(I,INHI RTU)
I have mild the hazardous materials requirements under Chapter 695 of the Cali- AIR CONDT'f[ONE R
4 ISSUANCE DATE
forma Health&Safely Code,Section,25505.25533 and 25534.1 malciscrod that if the NEW RESIDF.N'1'Igl.MGCH. SQ.FT
building dors not currently have a tenure,that it is my responsibilitythe to notify crpnm
of up requirements which
must be ost pr
aior a ivsnerector a CenihemOccupancy e of cupancy.
Owner or aulhori zed age^a Dec TOTAL: ISSUED BY:
OFFICE