28845aOZ
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W
asrrk-IGAW-I w HLL IN INFOHMATION WITHIN RED LINES -
CITY OF CUPERTINO
BUILDING DIVISION APPLICATIONTERMIT r
BUILDING ADDRVSS'.
fCa1.DRM�
POINT PEN ONLY
MECHANICAL
Consultant Fees Paid by Applicant (Initial)
IhereM1 firm that I am licensed under ( Cha ter 9 (commencing QI Y. ELECTRIC PERMIT
y a prervixions u Fl b
with Section 7000) ofDivision 3 ofthe Business and Professions Code, and my license is PERMITISSUANCE
I. full force end effect. r -
LicenseClave Dion -Carer APPLIANCES - RBSIDENEIAL
ARCHITECTS DECLARATION PANELS
1 understand my plans shall be used as public records
UPT02MAMPS
yiOWNER
,g
-BUILDER DECLARATION
❑ KITCHEN REMODEL
aC
ad U
= O
ythat
1 hereby affirm that 1 am exempt from the Contractor's License Law for the
following reason. (Section 7031.5, Business uad Professions Code: Any city oI county
which requires a permit to construct. alter, improve, demolish, or repair any structure
prior to its issuance, also requires the applicant for such perms to file a signed statement
he is licensed pueuam to the provisions of the Connector's License law (Chapter 9
❑ MULTI -UNIT
❑ STRUCTURAL
T
nn
so
Zno,
(commencing with Section 7000) of Division 3 of the Business end pmfessinna Coae)m
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Sectio 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
mare than five hundred dollars 1$500).
❑CHIMNEY REPAIR
IMPROVEMENT
Ca
O
3
E] L as owner of the property, or my employees with wages its their xmc campe anon,
will do the work. and the structure is not intended or offered for sale (Sec. 7014. Business
and Professions Code: The Covaaamrs License Law docs not apply to an owner of
property who builds or improves IIIand who docs such work hinealf or through
❑ OTHER
ALTER OR ADDIO MECH:
his own employees, provided that such improvements are not intended or offered for
AIR HANDLING UNIT (TO IQOW CFM)
axle. IL however, the building ter improvement is sold within one yearnf completion, the
AIR HANDLING UNIT (OVER to." CFM)
owner -builder will have the burden of proving that he did not build or improve for par -
EXHAUST HOOD (WIDUCI)
posse, of
HEATING UNIT (TO 100,0011 BTU)
(] I, as owner of the property, am exclusively contracting with licensed committers to
HEATING UNIT (OVER 100,00) BTU)
construct the project (Sm. 7044, Business unit Professions Comm The Connectors Li.
VENTILATION FAN (SINGLE RESID)
cense Law does not apply to an owner of pmpeny who builds or improves thereon, and
QTY,
BOILER -COMP (3HP OR 1 W,WO BTU)
who eontects for such projects with u comecon(s) licensed pursuanua the Contemnrs
TOTAL:
BOILER -COMP (OVER 100,00) BTU)
License Law.
AIR CONDITIONER
❑ 1 um exempt under Sec. . B & P C for this reason
DATE
NEW RESIDENTIAL MECH. SQ. Cr
Owner Data
WORKER'S COMPENSATION DECLARAq'ION
1 hereby affirm under penalty telperjury one of the following declamations
1 have and will maintain a Certificate of Consent to self -mart for Workers Compen-
sation, as Provided for by Section 3700 of the Lehr Code, for dee performance of the
work for which this Permit is issued.
❑ I have and will maintain Workers Compensation Insurance, as required by Section
37M of the Labor Cede, for the performance of the work for which this pemeil ix issued
My Worker's Compensation Insurance carrier and Policy number we
Cartier. Policy Nn.:
CERTIIgCATI:OF hXEMPTION FROM W(sRKF.RS'
COMPENSATION INSURANCE '
(This section need not becompleted if the permit is for one hundreddollae ISI
ter less)
Icertify that in the per(ormmen of the work for whichthis permit is'- ,I shall
net employ any person in any rammer, so ayr euje nrkets'Compen-
z cation Laws of CnI of Dae _I
Applicant
7
G ,n
a7
LkI
Q
UQ
fEe f+
0 U
NOTICE TO APPL CA : IL If g s Certificate of Exemption, you should
become subject to the Worker's Compe alis provisions of the labor Code. you must
forthwith comply with such previsiam r this Permit shall Ise, deemed Invoked.
CONSTRUMI NLENDING AGES
mens
l for whihthi theuhereinane (See, C.)
the work for which this pemeil is issue (Sea. 3119]. Civ. C.) �'
Lenders Name
Lenders Address
`
Ted
U �
1 certify that 1 have read thin n ad coon e thaw union
building 1 agile i comply with all city ted county x Dance d st m laws ralai
eotioned am and hereby amho ize repress u ivcs of ry to dnmr u one
QTY
above-mentioned for inspeaio puns,mrsaves.
above-
(We) .'ream save, indemnify x keep mlas the City of no
mCu
rr Id Ciiy
liahilities,judgmems, costs and expenses hich may in any woy.varu grid City
inconsequence
APPLICANT I
las derned by the Cupertino Municipl(iale, Chapter 9.12, and the Health and Safety
Code, Section M53260?
E3 Yea E] No
Will the applicant or future building occupant use equipment or devices which
emit huzmdons air mntaminoms as defined by the Buy Arca Air Quality Management
District?
❑Yes ❑No
I have read the hozardous mmedals requirements ua&r Chapter 6.95 of the CO.
humin Health & Soley Code, Sections 25505, 25533 and 25534. I understand that if the
building does nm currently have a tenant, thea it is my responsibility to maify the soinqunt
of the acquirements which must be met priorm issuance of a Certificate of Rasions,
Owner or authmiud agent Data
SIGNS ELFCTRICAL
SPECIAL CIRCUITIMISC.
TEMP. METER OR MILE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS -SWITCHES -FUTURES '
NEW RFS AL ELECTR SQ IT.
FETE
?1,E1M131Z,4G PE MIT FEE
PERMIT ISSUANCE
ALTER-DRAIN&VENT- T (EA)
BACK FLOW PROTECT. DEVICE
DRAINS- FLOOR. ROOT, AREA, COKE
FIXTURES - PER TRAP nA
GAS - EA. SYSTEMd INC.4 OUTLETS
GAS - EA. SYSTEM -OVER 4(EA)
7I SMNDUSTRL WASTE INTERCEPTOR
SANITARY -STORM EA. 200 FT.
EATER W/VENT/ELECfR
FE -1
28845
IN SUBMITTAL DATE
OAC
TROLN
INFO
MECH
JOB DESCRIPTION
RESIDENTIAL:
❑SFDWL
❑ KITCHEN REMODEL
❑ADDITION
❑PLUMBING RE -PIPE
❑ MULTI -UNIT
❑ STRUCTURAL
T
MODIFICATION
❑INTERIOR
❑CHIMNEY REPAIR
IMPROVEMENT
❑ BATH REMODEURF.PAIR 0DEMOLITION
❑ OTHER
ALTER OR ADDIO MECH:
COMMERCIAL:
El NEW BLDG/ADDI'NON ❑DEMOLITION
9J41IANT ❑ FOOD SERVICE
IMPROVEMENT
OTHER
SQ. FT MOOR AREA $/SQ. FT
SSP 2 91995
1(y Ut LLdrFu rLso,,
DIVISION FEES
WATER SERVICE
AI
me
Receipt
N 0.ESIDENDALPLM B. SQ. ET.
TOTAL:
T
BUILDING F1 IE
MECHANICAL PERMIT FEE
SEISMIC FE
PERMIT ISSUANCE
ELECTRIC
ALTER OR ADDIO MECH:
PLUMBING FIE
AIR HANDLING UNIT (TO IQOW CFM)
MECHANICA FIEF.
AIR HANDLING UNIT (OVER to." CFM)
CONSTRUCII
EXHAUST HOOD (WIDUCI)
HOUSING MITIGATION
HEATING UNIT (TO 100,0011 BTU)
HEATING UNIT (OVER 100,00) BTU)
PAID
VENTILATION FAN (SINGLE RESID)
Data
Receipt#
BOILER -COMP (3HP OR 1 W,WO BTU)
TOTAL:
BOILER -COMP (OVER 100,00) BTU)
AIR CONDITIONER
ISSUANCE
DATE
NEW RESIDENTIAL MECH. SQ. Cr
OFFICE