S 1200 AFYUUAN I TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. P' MITNO. 1200
BUILDING DIVISION APPLICATION/PERMIT 1'LUYIIIINC MECHANLCF
BUILDING PROJL?CI'IDENTIFICATION
BUILDING ADDRESS: _ SANITARY NO. APPLICATION SUBMITTAL DATE
l Vlrl� 2 tA,4
OW ER'S NAME: PHONE: CONT ACTOR'S NAME:
CONI'ROLN
AR HT rC /ENGINEER: LIC NO: ADDRESS:
' CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) y❑, LI� PLUMB F
EJ
LICENSECONTRACTOR'S DECLARATION QTY. ELECTRIC PERMITFEE IfG`y
I hereby ufftnn that I am h1cloed ander provisions of Chapter 9(commencing JOB DESCRIPTION
0'L'Z with Section7")of Division3 ofthe Business and Professions Cole,and my license is RESIDENTIAL'
00 fall force end effect PERMIT ISSUANCE
'" ❑SFDWI- ❑KITCHEN REMODEL.
TUU License Cl p APPLIANCES—REMDENI'IAI, ❑ADDITION El PLUMBING RE-PIPE
ZdL Dae contractor ARCHITECTS DECLARATION ❑MULTI-UNIT ❑STRUCNRAL
F D y PANELS
Z0.4 1 understand my plum shall M used un public mcnrds MODIFICATION
REPAIR OZ4O uP'fO 2W AMPS ❑INTERIOR El CHIMNEY REPAIR
rLFtH Licensed Professional 20L1"AMPS IMPROVEMENT 0SWIMMING POOLS
J OWNER-BUILDER DECLARATION OVER IIMNI AMPS ❑BATH RHMODFIJREPAIR El DEMOLfI'[ON
d'W I hereby affirm that 1 am exempt from the CommCbm's License Law for the
7000S,,,O yU following reason,(Section 793 L5,Business and Professions Code:Any city or county SIGNS EL[CI'RICAI- ❑OTHER
FO F' which requires a permit to rename,alter,improve,demolish,or repair any structure
pain,to its issuance„also requires NenEdicant lin such permit file.,igned,mucltent SPECIAL CIRCUIT/MISC.
�y the he is lice adpursuamtoNeprovisionofNCCnmmctoraLiteraeLaw(Chapter9
R"mncingwith Section](X10)of Division 3nfthe Basin., ad Professions Code)oat TIiMP.METER OR POLE INST COMMERCIAL:
L e eG
that he is exempt therefrom and he basisfor the alleged exemption.Any violin n of ❑NEW BLDG/ADDITIONElDEMOLITION
Y• Section^ 701 LS by any applicunt fore permit subjects the applicam to a civil penalty of POWER DEV ICES y ❑TENANT ❑FOOD SERVICE
~Z6 m more than rise hundred dollars 15500). IMPROVE
Ol,as owner of the prnpeny,nr my employers with wugea us their sole ennpensatinn, SWIMMINGPOOLULECTRIC
' O will do the work.and the structure,is not intended or offered for sale(See704,1,Business ❑OTHER
W and Professions Code:The Cormorant,License Law does not apply to an owner of OUTLETS—SWITCHES—FIXTURES
property,who build.,or improves Hereon,and who dors such work him self orthnmgh
his own employees,provided that such impnwcomets arc not intended or offered for NEW RESIDENTIAL.HLEC'I'R
sale.If.however,the building or improvement issold within one yevofrompletion,the SQ.FC FLOOR AREA 5/SQ.IT.
owner-huilder will have the burden of proving that he did not build or improve for put-
Poor 01'sale.).
❑has owner of the prnpeny,am exclusively convecting with licenud nmtmenn tm TOTAL;
construct the projent(Sce."LPW,Business and Professions Code:)The Convector's mLi-
sense Law dues not apply to an owner of propeny who builds or intpves P thereon. QTY. PLUMBING PERMIT FEE A D
who contracts for such projects with.terwacbouid licensed pursuant o the Contractor's
License Law. PERMIT ISSUANCE
❑I am exempt under Seo. ,B&P C for this reason FjEPa
Owner Dae ALTER—DRAIN&VENT—WATER(EA) 11S11JAHON
,• WORKER'S COMPENSATION DECLARATION BACK MOW PROTECT DEVICE
I hereby affirm under penalryof perjury one of Ne following declumtions: Ur UUrCh
I have and will maintain u Certificate ofCmnem to self-iroure for Workers Compre- DRAINS—FLOOR.ROOF,AREA.COND. STORIES TYPECONSTRUCIION
satirn,as provided for by Section 371X)of the latem Code,for the performance of the
work far which this permit is issued. FIXTURES—PER TRAP
1 have and will maintain Worker's Compensation Insurance,in required by Section
3700units,labor Code,for the performance of Ne work for which this permit is issued GAS—EA.SYSTEM-I INC.4 OUTLETS OCC.GROUT' MIN
My W..set's Cnmpensmin i Insurance carrier and Policy number are:
alaaas Carrier: Policy No.: GAS—EA.SYSTEM-OVEN 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASIVINDUSTRI,WASTI3 INTERCEPTER BUILDING DIVISION FEES
('This section need not he completed ifthe permit is forma humboddollar,D Hot GREASE TRAP
nr less.) PLANCHECK FEE
I cenify that in the performance ofthework for which Ilak,rmitaissued.(shut SEWER—SANITARY—STORM EA.21X1 IT.
not employ any Prop n any manner so as to becomesubject to the Workers'Compen- ENERGY FELE
anion lawn u�Cpli oie.Dat WATER HEATER W/VEM'/ELECTR
Applicnm, GRADING FER
NOTICE.TO APIOCNrNT.IL after making this Certificate of Exemption,you should WATER SYS'1'EMaREATING
become subject to the Workers Compensation provisions of the labor Code,you most SOLI S FEE
Ws,y forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
0. Q
CONSTRUCTION uENDINGAGENCY NEW RESIDENTIAL PCMB. SQ,FT. PAID
V n Ihcreby elTrm den them isa[nnswctinn lending urgency for the perfnnnance of Use RecciptM
W. It-.41 the work lith which this pemil is iawwd(See.JIM)],Civ.CJ
lander',Name TOTAL:
lander',Address TOTAL:
1 certify that I have read this application and scam that the above iammodnli is BUIL :It
f0./] correct.I agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
VZ building consvudion,and hereby antenna mpxsenwtives ofthis city to enter upon the SEIS C
uMrve mentioned pmpeny for inspection pugmses. PERMIT ISSUANCE.
(We)agree to save,indemnify and keep harmless the City of Cupcnimo against ELLCfRIC I iE
habiluies,judgmems.,simsmnd expenses whichmay in any way acemc...to,,said City ALTER OR ADD TO MECH.
in consequence of the granting of this parent. P A IFEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 111,010 CFM)
SOURCE:REGIAMHONS. bTECH4ICAL FEE
ZN e/'� � AIR HANDLING UNIT(OVER 10,IMM)CMD CONS'RUC'I ON TAX
rn
Signature of ppHeam/Contmcmr /G )ate EXHAUST HOOD(W/DUCt7
HAZARDOUS MATERIALS DISCLOSUREHOU LNG MITIGATION HE
lheim,heann or future building mevpam.00mor handle hazardme,material HEAPING UNIP TO I(XI,(XXI BT U)
as defined by the Cupenimo Municipal Calc,Chapter 9.12,and the Health and Safety
Code,Section 255321a)? HEATING UNIT(OVER 100,010 BTU)
❑Ye, 0 N P ID -
VF.N'I'ILATION FAN MINGLE RISIDI Dam Receipt M
Will the air o cam or furore building occupant vee e.Air Qu or devices Management
canDisrhazallous air contaminants as defined by the Bay Area Air Quality Munegentnt BOILER—COMP(3HI'OR 101,11(p BTU)
TOTAL,:
District?❑Yee ON. BOILER—COMP(OVER Iftfl) BTU)
I have real the havrbus materials requirements under Chapter 6.95 mf the Cid- AIR CONDITIONER ISSUANCE DATE
Farm Health&Safety Code.Sections;25505.25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.Fr.
building dcas not currently have a tenant,that it is my respmsibility no notify the occupant
mf the myuirements which must be net pdorc to issuance of a Certificate,I Ocetachey.
Owner or authafized agent Date TOTAL: ISSUED BY:
OFFICE