31036 APPLICANT TO FILL IN INFORMATION WITHIN REDLINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL - PF.RMI'FNO. �] O^�
BUILDING DIVISION APPLICATIONXERMIT PLUMBING-MECHANICAL J J
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
OS AME: PIfONE CONTR 'I4 NA E: LIC NO:
IffiC/L` NIC CONTROL g
RCHI TEN N ER: LIC NO: ADDRESS:
W , i
- C ACT. / PHONE: r'.1 BUIL PERMIT INFO
�//�Ja�
Consultant Fees Paid by Applicant(Initial) BLDG EL PLUMB M
g
LICENSED CONTRACTOR''SDECLARATION Q7y ELECTRIC PERMIT FEE Qr—J11C\
1 hereby di Thal 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
�O�ypZ with Section 70W)of Divou.3ofthc Businessand Professions Codc,Andmy license is PERMIT ISSUANCE RF I NTIM
�F-W r Licenefail Cls and efi ❑SFDWL [I KITCHEN REMODEL
UUU License Class Lic.N gPPLIANC[S-R[61DEN'1'IAL
W Date Convector []ADDITION ❑PLUMBING REPIPE
((....py ARCHFf[CTS DECLARATION PA ❑MULTI-UNIT ❑STRUCTURAL
Z O h Z" 1 undimmed my plana shall be used As public n,rords MODIFICATION
OZ—O UPT0200AMP5 RIOR ❑CHIMNEY REPAIR
Licensed Pmfcuional 20140WAMPS 1 ROVEMENT
OWNER-BUILDER DECLARATION
Q.OI hereby affirm shat I Am exempt from the Cantmewev License Low for the OVER 1000 AMPS [01 BATH REMODE(REPAIR [IDEMOLITION
��(( 6U Pollowing n,n.�oa(Section]WLS.Business AM Professions Cadc:Any city or county SIGNS ELF.CfRICAL OOT
ly a A,F which regain,,A Amour'to construct,Alm,improve,demolish,ar repair Any structure
�LLO primn.its isuonce.alurryuues fleA.'Imam fofsuch'arritro fileasignW statement SPECIAL CIRCUIT)MISC.
i3"y that he islicensed pursuant tothe provisions ofthe Comactur's License Law(Chapter9 1 13
S'OQ (commencing with Section]Wa)of Division3 ufthe Business and Professions Code)or TEMP.METER OR PDL T. COMMERCIAL:
L M e aC Nal he is exempt thcsofmm and the basis for Ne alleged exemption.Any vMmian of ❑NEW BI�Qpn,�ITION ❑DEMOLITION
,^sy
Section 7031.5 by any applicant for a permit subjects the applicant to a civil Penalty of POWER DEVICES �TENpN /•s .6, �YIIID SERVICE
F�Qnot mote Nan rose hundred dollars(SSW). TENAQVEMFN,I, C
❑1,nownerofshe propcny.or my employees with wages as their sole compematon, SWIMMING POOL ELECTRIC IMPR�(
will do she work,and the swctuteis not intended or offered forsele(Sec.]B4W,Business ❑OT f �1
W and Profession Code The Contractors License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES NV
property who builds or improves thereon,and who does.such work himself or through
his own employees,proviJed(het such improvements are not intended cr a0cred for NEW RESIDENTIALELECTR pfr -
able.If,however.the building or improvement is sold within one year ofcompleuon,the SQ.PT.FLOOR AREA $ISQ.FT.
owner.builder will have Ne burden ofp.ving that he did not build or improve for pun �O
pounfsale). J
I,as owner of the property,Ara exclusively contracting with licensed contriteness to
onsimet the project(Sec.7044,Business and Professions Come,The Contractors Li-
cense Law does not apply ton owncrofproperty who builds or improvesthemon,And QTY. PLUMBING PERMIT WL FEE
who contracts for such projects wish a contracmgs)licensed pursuant to the Convector's
License Lew. PERMIT ISSUANCE
❑tom exn (under Sec. .B&PCT this reaun
ALTER-DRAIN&VENT-WATER(EA)
OwnerVALUATION
Dare — '7S 000. DO
WORKER'S C 1PENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm mailer penalty of perjury one of the following Worke ,Co
❑(have and will far bynetion37 e.1 am Laborat to selda.fart far Worker'sia of the DRAINS-FLOOR.ROOF.AREA.CONU, STORIES TYPECONSTRUCFION
workfes provided far by Section 3]W of the Labor CMe,fur the perfomwnce of the
work for which this penNi is issued. FIX',VRES-PER TRAP
❑1 have and will maintain Workers Compensation Insurance,as required by Section
J]W of the LeborCWe.fonhe performance of lh6 work for which this permit is issued. GAS-EA.SYSTEM-ZINC. EI'S OCC.GROUP ANN
My Worker's Compensation Insurance carrier and Policy mother am:
Carrico Policy No.: GAS-EA.SYSTEM-OVER 4(EA -
CERTIFICATE OFEXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASMNDUSTRL WASI E_VTERC
(This section ttecd nm be compinedifshe pemm isforunehumbibldallars(SIW) l3VqlN#bIVlSION PEES
or less.) GREASE TRAP PLANCHECK
I cenily Nat in the performance of the work for which this permit is issued,I shall SEWER-SANITARY-STORM EA.
A.employ n in any manner m as m ha E mbjauo the Warkers'Compcn- ENERGY
O Z cation f 'rami..Date WXMR REATER WNENTMLECTH
APPIic a q..4_&:M _ • GRAD( .FE
z rA NOTICETO PPLICANT.If,after m 'ng this Cenificme of Exemption,you shoul; WATER SYSTEAUTREATING
a ' become subject to the Worker's Compensation provisions of the L mor Code,you must SOILS
r. fmthwish comply with such provisions or this permit shall be decmed revoked. WATER SERVICE
Q
U 'z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
LJQ (for hi
chithi that Hereisacd(Six.ionlcnding agency(or the performantt of Dote Raeiplg
{A f~
the work far which this pemtit is issued(Sec.JWJ,Ci,C.)
O Lenders Name TOTAL:
WLembb's Address AL:
gL 1 certify that 1 have mad this application and state that she above information is BUIL NG FEE �+
W) correcLlagrce to comply with all city end county ordinances end static laws relating to QTY. MECHANICAL PERMIT FEE
(J bung con trvnion.and Mrcby authorise n,pn,untativn of scity mentor upon Ne SETS IC FEE
above-mentioned property for inspection puryoses. PERMIT ISS DANCE
(We) Am to save,indemnify and kap harmless the City of Cupertino against IiLE q'NIC FEE
liabilities,judgments,costs and expenses which may in Any way Accrue against said City ALTER OR ADD TO MECH.
in consequence of the granting of this pemsit. - PLU GING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT TO 10.0W CFM)
MECHANI E
SOU �IILATIONS.
;? hz AIR HANDLING UNIT(OVER 10.000 CPM) CONSTRUCTION TA
Signatureof ApplicanUCommc; .I' r a, EXHAUST HOOD(WOUCq HOUSING MITIGATION
HAZARD( MTN
SMATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazvdous material HEATING UNIT(TO 100,000 BTU) .
as defined by the Cupertino Municipal Cale,Chep cr 9.12,and the Health and Safety
Code,Section 25532(o)'I HEATING UNIT(OVER Iblooll RTU)
❑Ycs ❑No
VENTILATION FAN(SINGLE RESID) PAID
Will she applicant or furore building by the Bt use ea Air u or devices which Uma Receipt M
��emhrict?vdoua yr contaminants as defhhcd by the Boy Area Air Quality Management BOILER-COME(JHP OR 1W.lI0U BTU)
DisviclR TOTAL:
❑Yes []No BOILER-COMP(OVER IMAM BTU)
I have mad the hanmlous materials requirements code,Chapter 6.95of the Edi- AIR CONDITIONER ISSUANCE DATE
fore a Health&Safety Code,Sections 22505,25533 And 255]4.1 understand that if she NEW RESIDENTIAL MECH. SQ.IT. '
building docs not currently have a Imanh that it is my msponsibility to notify the occupant
of the requimments which must Is,met prior m issuance of a Certificate of Occupancy.
Ownerafauthodmdagenl Date - 4.4 ISSUED BY:
it OFFICE