S 1159 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
,CITY OF COPFRTINO - BUILDING-ELECTRICAL - PERMITNO.
BUILDING DI VISION APPLICATION/PF.RMIT PLUMBING-MECxnNICAL S '1 O
BUILDING PROJECT IDENTIEICATION v 1 N
BUILDING ADDR S. ,SANITARY N0. APPLICATION SUBMITTAL DATT.
506.1 I OWNE AVGPHONE ( ACO 'S?;�, LIC NO:
--2�5
O
C CONI'ROL»
ARCHITECT/ENGINEER: - LIC NO: _ ASN
CONTACT PHON& - BUILDING PERMIT INFO
❑ ChnSiltant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby iffirm.hot I am licensed antler provisions of Chapter 9(commencing JOB DESCRIPTION
��ZO wim Section]000)of in full force and effect.Division3of the Business and Pmfeseions Cede,vnd mylicenu is PERMIT ISSUANCE RESIDENTIAL:
tYU WF License Clash LIC.N '❑SFDWL [I KITCHEN REMODEL
a UU
y4y Dam Commcmr APPLIANCES-RESIDENTIAL. ,(]ADDITION ❑PLUMHING REPIPE
Z OD on ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT [-]STRUCTURAL
y 1 undershsnr my plans shall be used is public records MODIFICATION
OZ0, UPT02MAMPS INTERIOR - ❑CHIMNEY REPAIR
lUP�Bl Licensed Prnfessi...I C OWNER-BUILDER DECLARATION 201-1006 MP$ IMPROVEMENT SWIMMING POOLS
I hereby affirm that 1 am exempt from the Contractor's License Law for the OVER 1000AMP5 ATH REMODEL/REPAIRD DEMOLITION
ip5. 4 U following ream..(Section 7031.5,Business and Pmfetmai a Code:Any eqn,county SIGNS ELECTRICAL ElHER
W 3 WW which requires a permit.o emalruct,alter,improve,demolish,or repair any aramm
.F.�y.Q]
prior o its issuance,also requires the applicant for such permit n File a signed smtement SPECIAL CIRCUIT/MISC.
tvvtyyss p+ that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 t
CLQ (commencing wiN Section].X10)of Division Sof the Business and Profession,Cody Or TEMP.METER OR POLE INST. 'COMMERCIAL'
4 pi M eG Nat he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW RIAG/ADDITION ❑DEMOLITION
"' net
on 703 mthan five
any hundrelicantfor a rs($50tmit.mhjecls the applicant acivil Penalty of POWER DEVICES '[]TENANT ❑FOODSERVICE
p- t more than five h grope dollars eny,or y employees
IMPROVEMENT
M ❑Lo the work,the pelaractme is emntended camberth gesas their compensation, SWIMMING POOL IC []OTHER
will do the work,and the sh Con is not,Livens cambered du for sale(Sea 7044,Business
and Professions Cade:The oyes Tome License Law does not apply s if owner of OUTLETS-SWITCHES- URF.S
n' his o
property who builds or improves.Muco^,and who ones such mi work himself or through
his own employee.,provided that such impmvemems are not intended or offered for NEW RESIDENTIAL GLECTR QFC
sale.If.hnweveathe building or improvement is sold within one year of completion the SQ.CLPO.4 AR Pb $/SQ.FI'.
wernar-builder will have the burden of proving that he did net build or improve for par- i" i1 1
Poaa of axle). - ^
❑L as owner oftheprogeny,,B exclusively contracting with licensed ntracteton i- TOTAL: I�%/V O X'N,J ry
01.as the project(Sec.]044,Businessand contracting Galeli The Contmaors to
cause Law docs not apply to an owner of property who builds or improves thereon,and QTY, PLUMBING PERMIT FEE
who contracts for such projects with a contractor(s)licensed punuanl to the Contractor's C�T'�z 11 Ur'
License law.
Io ` PERMIT ISSUANCE U01-CMI INU
❑, am exempt under Sac. ,B&PCfor Nis mason
Owner Date ALTER-DRAIN&VP,NT-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICEaa
1 hereby wfhm under penalty of perjury one of the following dccltiens: ♦�'
❑"meml will maintains Cetifiwtrof Consent to self-insure for Worker's Cmapsm- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE.CONS'TRUCT'ION
cation,as provided for by Section 3]1X1 of the Lalwr Cale,for.he performance of the
work rot which this permit is issued. FIXTURES-PF,RTRAP
❑I have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance of the work for which[his permit is issued. GAS-EA.SYSTEM-1 INC.4 OUTLETS OCC.GROUP APN
My Worker's Compensation Insurance carrier and Policy number are:
/ Carrier: Policy Nn: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GRF.ASFIINUUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE.
(This section need not be completed if the permit is pence hundred dollars($100) BUILDING DIVISION FEES
nr less) GREASETRAP
PLANCHECK FEE
Ice ny that inthe mmammceofNewmkforwhich this permit in issued,)shell SF.WP.R-SANITARY-STORM EA.200 FT.
not emLit any pe t any manner so as.o become subjecym W.k ENERGY FF.F.
O ,� Armon law f ti .Dale _ WATER HEATER WNENT/ELECTR
APP1iea^� GRADING PEE
NOTICE T ':If,after making this Certificate of Exemption,you should WATER SYSTEMOTEATING
ai become jest to the War ' Compensation provisions of the Labor Cade,you muss SOILS FEE
forth N comply with such provisions or this permit shall be deemed meeker. WATER SERVICE
� z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLM. SQ.FT PAID
IJ Ihereby affirm End the.is a construction leadingagency forme peutomunceof Date in
the work for which this permit is issued(Sec.3097,Co.CJ
0 Lender's Name TOTAL;
Ltmalm,Address TOTAL:
04 1 certify than have read this application and sum that the those information is - BUILDING E
tr V2 correct.l agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
U z buildin ...trucdon.and hereby authorize representatives of this city nomination.the SEISMIC FEE
w+ above-mentioned property for inspection purposes.
(we)agree to save,indemnify and keep harmless the City of Cupertino against PERMIT ISSUANCE ELECTRIC FE
liabilities,judgments,costs and expenses which may many way accrue against said City ALTER ORADD TO MECH.
in c.nsequ grunting of this permit, PLUMBING
APPI.1 NT UND'RSTANDS AND WILL COMPLY WITH ALL NON-POINTAIR HANDLING UNIT(TO 111,(11X)CFM) MECHANICAL hE
SOUR E GUL IONS. \
11, 20 AIR HANDLING UNIT(OVER 10.01))CI I CONSTRUCTION TA
�BlgpmIaWtT,4,ljcamuCmdtaglm Date EXHAUST HOOD(W/DUC) HOUSINGMITIGATIO FEE
ZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous treaterial HEATING UNIT(TO It1g"BTU)
as defined by the Cameroon Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? HEATING UNIT(OVER 100,000 BTI)
❑Yes El No VENTILATION FANOJNGLE REMU, PAID -
Date R mp.N
Willes it cintatorfuture building occupancy Area
AirQuordeviceswhich BOILER-COMP(3HP OR 1(X),0011 BTU)
emit District'
us air contaminants as defined by the Buy Arca Air Quality Managcmcnt TOTAL:
Dist ct?
❑Yes ❑No - BOILER-COMP(OVER HM"BTU)
I have read me hazardous materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
founts Health&Safety Cale,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.Fr'.
building does not currently have a tenant,that it is my responsibility to notify the occupant
of me requirements which musts met prior to issuance of a Certificate of Occupancy. -
Owner or authorized agent Date TOTAL: ISSUED RY:
OFFICE