30879 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMITNO. O
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
w BUILDING PROJ ECL'IDEN IF'I CATION
879
If1041'R' S. MD v i 0 SANITARY NO. APPLICATION SUBMITTAL DATI
1 .
NERSN PiD[4E CONTRACTOR'S NAME: LIC NO:
Ak �- N/C CONTROL N
sRCHITECTAINGINEER:A IACNO: ADDRESS: ❑
CONTACT: PHONE:
- BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE ❑ ❑
1 hereby affirm that I um licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
with Seetirn7k00).f DDi.i.m3.f NC BusinessanJ Pmf,sinna Code,,maim Ittnse is
FowO in and effect. RESIDENTIAL:
VZ Liccns. yr PERMIT ISSUANCE ❑SFDWL OKITCHEN REMODEL
Class
F. U full Claw Liv.k
NQS Dam Contmarr APPLIANCES-RIiSIDF:NTIAL ❑ADDITION ❑PLUMBING RE-PIPE
Z O7 vdi ARCHITECTS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
i Z I undersand my plans shall heused as Public records PANELS MODIFICATION
O Z UP TO 2fg1 AMPS
Fs H a2 Licensed Professional - 0INTERIOR 0 CHIMNEY REPAIR
CY -4OWNER-BUILDER DECLARATION 201401))AMPS IMPROVEMENT
Q I hereby affirm that 1 em exempt from the C.m.emr's License law far the OVER 1000 AMPS 0 BATH REMOD AIR 0 DEMOLITION
V fallowing reason.(Section 7031.3,Business and Professions Code:Any city or countySIGNS ELECTRICAL OOTHER
w F which requires u permit to cunstmet, he,improve,demolish,or repair any svucmre
�EFD Y, prior to its issuance,also requires the applicant for such permiuo file a signed statement SPECIAL CIRCUIT/MISC.
�a•{•t That he is licensed puruam 1.the provisions ofine Contractor's License Law(Chapter 9
qty O (commencing with Section 7000)of Di vision 3 of the Business and RrfOoker Code)Or TEMP.MIT ER OR POLE INST. COMMERCIAL:
li L q5 K 'hut he is exempt therefrom and the basis for the alleged exemption,Any violation Of ❑NEW BLOG/ADDITION 0 DEMOLITION
i� Vee. Sec'inn 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES GTENANT GFOOD SERVICE
F Z> t mare than five hundred dollar(5500).
01,As owner of the properly,Or my employees with wages as their sale compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
a l..$ will dothe work.and thehe Comslars Liens nrroaredfor not Apply
an,Business - OTHER
5b
and Professions Code:The Conuaaor's License Law does not npply'n an owner of OUTLETS-SWITCHES-FI%TURES
pmpeny who builds or improves thereon,and who does such work himself or through
his own employe,,provided that such improvements Are not intended or offered for NEW RESIDENTIAL ELECTR
sale.If,hrwever[he building or improvement issnld withinome ycm.fcompEd.n,the Q. LOQRtREA VSQ.IT.
saner-builder will have the burden of proving that he did not build or improve for put- /�A D
you of role.).
0 1,as owner of the property,am exclusively contracting with licensed contractor to TOTAL: APR
P a��
construct the project(Sec.7044,Business and Professions Code:)The Cont=toes U. /A — 9 ZCV
cense Law does not apply to an owner of properly who builds or improves thereon,and QTY, PLUMBING PERMIT FEE
who convects for such pmjens with a comracmr(s)licensed purauan'to the Contractors /+'�y
License Law. PERMIT ISSUANCE V I
0 lam axe ,See. ,B&P C for this mann ser wdrCtiI live
Owner pate ALTER-DRAIN&VENT-WATER(EA) VALUATION
WORKER'S CO SATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby afirtn under penahyr ,perjury one of the following declarations:
I have and will maintain a CeniOcAte ofConsenuo self-insum for WeAces Compen- DRAINS-FLOOR.ROOF,AREA,CONI, STORIES TYPE CONSTRUCTION
whom,As provided far by Section 37M of the Labor Code,for thfamt
e perance of the
work for which this permit is issued. FIXTURES-PER TRAP
0 1 have and will mainmin Worker's Compensation Insumme,as required by Sermon
3700.fthe Labor Code,for Nnfonmuneeof the work far whichthis Noun is issued. GAS-EA.SYSTEM-1 INC.4 OUTLETS OCC.GROUP APN
My Workers Compensation Insurance carrier and Policy number am:
Curie'. Policy No.: GAS-EA.SYSTEMAVER 4(G)
CERTIFICATE OF EXCMPTION I7ROM WOR KERS'
COMPENSATION INSURANCE. GREASMNDUSTRL WASTE INTERCEPTOR ) L NO DIVISION FRGS
(This action need nm becompl,eJ ifthe permit is(Drone hundred dollar(5100)
or less.) GREASE TRAP
PLANCHE P
Loy Any
nin sayAbrvnceof the wuronte subject
ubjeto the Workers
SEWER-SANITARY-STORM EA.2W FT.
not employ of Canon in any manner so us m beatme subjecnr the Workm'Co.,..Compe- ENER
Z motion Laws of California,Dam
O Applicant WATER HEATER WNENT/ELCCfR GRA NG -
tiNOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should
bccomesuhjen inthe WrrkersCompenwtirnpraskions ofth,LaborCode,you must WATER SYSTEMOREATING SOI(Stew
I� forthwith comply with such provisions or this pemtit shill b,deemed revoked. WATER SERVICE
.7Q CONST'RUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
U
the tryaffrm that here is.o.ma ximn icraingagency(.,the performance of ale ReceipiN
0.
Ltier's Name for which this permit is issued(S<c.3097,Civ.CJ TOTAL:
O U
Ila Lendermbur's Address TOTAL:
fY 'A 1 certify that 1 have reed this application and state than the rbove information is BUILDIN FEB �
tn c&—.1 Agree m comply with ill city and county ordinances and sour lawn 71.6a'to QTY. MECHANICAL PERMIT FEE
V rZ--t building construction,And herebynmhorise representatives of'hiscityto en'eru'm the SEISMIC E
slot)vo-mcontract]property far move...un,turpoi
(We)agree to save.indemnify and keep harmless the City of Cupertino against PERMIT ISSUANCE - ELECTRIC
Iiabilities,judgmems,cavus And expenses which may in any way acemeagvina said City ALTER OR ADD TO MF.CH.
in consequence,of the grunting of this permit. PLUMBING FE'
APPLICA JNDERSTANDS 'sly VLJ COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,600 CFM) MECHANICAL vE
SO 1RC,r •C NATIONS. ��
AIR HANDLING UNIT(OVER 10,1100 CFM) CONSTRUCTION A%
Sig e' fApplican/ on own" [)an EXHAUST HOOD(WMUCT) HOUSING MITIGA ON FEE
FIXEDOU ATERIALS DISCLOSURE
Will the epplicent or furore itJing oecmpanumre or haMle luvrdous maonel HEATING UNIT(TO 1(X1,0110 BTU7
As defined by Ne Cupertino Municipal Code,Chapter 9.12,And the Health and Safety
Cod.,Section 25532(0)'1 HEATING UNIT(OVER 100,1100 PTU)
❑Yes ON. VENTILATION FAN(SINGLE RESID) PAID
Will the applicant m future building occupant use equipment or devices Dae Rce
which eipt
in Insurances Air contaminants as defined BOILER-COMP(3HP OR IOO,WO BTU by the Buy Arca Air Quality Management )
,nnc'^
❑Yes ONo BOILER-COMP(OVER 100,000 BTU)
I have read the hazardous matenals«yuiremems notice Chapter 6.9.1 of the CAI(- AIR CONDITIONER ISSUANCE DATE
Armin Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL.MECH. SQ.FT.
buildingdces mt currently have n movtt,that it is my responsibility to Imtify the cexAgent
of the requirements which must Is:met Error to issuance of a CeniOcate of Occupancy.
Owner ars authmiud Agent Dare TOTAL: ISSUED BY:
OFFICE
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