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APPLICANTTO-FILL IN INFORMATION WITHIN RED LINES -USE BALL POINY PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING -MECHANICAL
BUILDING PROJECT IDENTIFICATION "
PES l I NO.
J 1213
BUILDINOADDRESS:
SANITARY NO.
APPLICATION SUBMITTAL DATE
O ER' E'. PHONE: I fG
TrAl:
uz
CONTRACTOR'S NAME. LIC NOj25
0I8541� VAN 734
N/C
❑
CONTROL#
'
ARCH ]'ECT/ENOL 'ER: LIC NO: -
p[ ES$:
/AMwI-
CON9'ACT�:( PHONE: -
To/� Jv -S v tiu
❑Consultant Fees Paid by Applicant (Initial)
BUILDING PERMIT INFO
VWD^ ELECT PLUMB SUCH
laq7
LICENSED CONTRACTOR'S15ECLARATION
1 hereby affirm that 1 am licensed under previsions of chapter 9 (commencing
QTY ELECTRIC PERMIT FEE
LOB DESCRIPTION
PERMIT ISSUANCE
-
in 9whh lSectionapld affect. Division3 of 0e Business and Profaxslans Code, and myllconse is
License Clamd _I Lic.# Ll3 &
Date Contractor
RESIDENTIAL'
❑SFDWL Ll KITCHEN REMODEL
El ADDITION ❑PLUMBING L PIPE
El MULTI -UNIT ❑STRUCTURA
MODIFICATION
APPLIANCES -RESIDENTIAL
ABOUT EC I'S DECLARATION
I understand my plans shall he m ed ue public records
PANELS
UPTO200AMPS --
El INTERIOR Ll CHIMNEY REPAIR
IMPROVEMENT E]SWIMMING POOLS
[I BATH REMODEWREPpr�AIR ❑ TI N
❑ OTHER
bS
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Law for the
following rwson. (Section ]031.5, Bminm9 and Pmfossions Cade: Any city or coumY
201-1010AMPS
OVER IINx1AMP5
SIGNS ELECTRICAL
which requires a permit to consumer, alter, improve, demolish, or repair any strucwre
SPECIAL CIRCUITIMISC.that
prier to its issuance, also requires the applicant for such permit to file a signed statement
he is Iamused pursuant to the provisions of the Contractor's License Law (Chapter 9
(commends, with Section 900Eof Division Sof the Business and Prnfessinns Corl
TEMP. METER OR POLE INST.
COMMERCIAL:
that he is exemptdomfrom and the basis for the alleged exemption. Any violation of
❑ NEW BLDGIADDITION ❑ DEMOLITION
-
POWER DEVICES
Section 90315 by anynpplicam forapermit subjects lheapplicamm a civil penalty of
not more than five hundred dolism(S500).
D I, as owner of the property, or my employees with wages as their sole compensation,
will do the work, and the structure is not intended or offered for sale (Sec. 9044, Business
❑TENANT ❑FOODSERVICE
IMPROVEMENT
❑ OTHER
SWIMMING POOL EL
and Professions Cade: The Contractors Licame Law docs not apply m m owner of
OUTLETS -SWITCH IXTURES
,.pony who builds or improves,hereom and who does such work homelier through
his own employees, provided that such improvements are not intended or offered for
sale. If,however, the building or improvement is sold within one year of completion, the
'NEW R8 ENTIAL F,LE - SQ FT.
SQ. FT. FLOOR AREAS/SQ.
PT.
fir -builder will have the burden of proving that he did not build or improve for par -
pose of sale.).
L] 1. as owner of the property. am exclusively contracting licensed contrac�orsm
AL:
rumors, the puffer, (Sec. ]1144, Bminess and Net ..ism C,vep The Contramnrs Li-
me Law does no, apply to an owner of property who builds or lmpmves Iherenn, and
QTY. G P MIT FEE
who ennwctx far such pmjeets with a cnnurucmr(s) licensed purvuunt m the Cnntmdors
PERMIT ISSUANCE
License Law.
1 am exempt under Ser. , B& P C for this reason
A
Owner Date
ALTER- DRAIN& ENT- ATER(8A)
VALUATION
\®/ �y -I/ •� /� -
WORKER'S COMPENSATION DECLARATION
RACK FLAW P ECT. VICE
Ihereby aflirmunder Penalty ofperjuryone of the following declarations:
❑ I have and will maintain a Crc enifiruof Consent .self-Insum for Workers Compcn-
sound, as provided for by Section 3700 of the Labor Code, for the performance of the
k for which this permit is issued,
DRAINS-FLO ,ARA, v
S
!^ �tl(Yj/
L`
TYPECONSTRUCr10N
FIXTURES-PERTIlh
ynar��t have and will moinain Worker's Cnrritom lion lmmmmce, as required by Section
�"
9100 ofthe Labor Code, forthe pertmmance ofthe work for which this permit is issued.
My Workki s �o� lion Ins carrier and Policy number
Carver, C F(1•kl Policy No.: %lrQIse- .3
GAS -EA. SYSTEM -I INCA JI&TS
GROUP APN
RAE
CJ
GAS - EA. SYSTEM -OVER
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
,arm,
(This,came mordant be eompletedlfthe ft is future lumdred dollars
or less.)
GREASE/INDUSTR, WASTE INTERCEPTOR
CN
BGf V11 LvS
- -
PLANCHECK
GREASE'1'RAP
Loy any that irthe performance of the workfor ms,which this the Woaissue..pa,shall
nw employ any person in any mono eq�� o become subjeer to the Workers' Compen-
SEWER - SANITARY -STORM EA. 21s)FT.
ENERGY FEE NNJ
snlimn Laws of CaHfomia. Dae //
Applicata
WATER HEATER WNENVELECTR
GRADING FEE
NOTICE TO APPLICANT: If, after refusing this Certificate of Exemption, you should
become subject in the Worker's Compensation of the Labor Code you must
WATER SYSTEM/TREATING
SOILS
(hien orman hal
e
forthwith comply with xuCM1 pmvisinns or this permit shall be demned revoked.
WATER SF.RVICF.
CONS'TRUC'TION LENDING AGENCY
I hereby ofBmUhat there is a construction lending agency for the Pedernales, of
PAID
NEW RESIDENTIAL PLMB. SQ, FT.
D' a Receipt,
-
the work for which this permi�Lesued (Sea. 3097, Civ. C.)
Leader'sName SIT-
TOTAL:
TOTAL:
Lender's Address NU
-
1 certify that I hove read thio oppliwtion roti sera that the above infnrmntirn is
BUILDING fEE
correct. Iagree to comply with all city and county ordinances and state laws relating to
building construction, and hereby authorize nomasenativesofthis city In enterupon the
QTY. MECHANICAL. PERMIT FEE'
-
SEISMIC E
PERMIT ISSUANCE
ELECTRIC PE
abrve-mentioned property for inspection purposes.
(We) aee m save, indemnify and keep harmless the City of Cupcaino against
gr
Ilabilities,judgmena,costs and "Emove.s which may in any way accrue again.c, said City
se
in ngnence of the granting of this permit.
ALTERORADDTOMECH.
FEE
AIR HANDLING UNIT (TO 10,000 CPM)
MECHANICAL ME
APPLICANT UNDERSTANDS JINJP WILL COMPLY WITH ALL NON -POINT
SOURCE EGU TIONS. -
AIR HANDLING UNIT (OVER IQW(I CFM)
CONSTRUCTION TAX
�,�/D-•GO
Signa. of Appluent/Coumpeor Dam
HAZARDOUS MATERIALS DISCLOSURE
EXHAUST HOOD(W/DUCT)
HOUSING MITIGATION FEE -
HEATING UNIT (TO 100,001 BTU)
-
ill the applicant or future building ntcuporl store or handle hazardous material
sa Je toed by the Capetian Municipal Code, Chapter 9.12, and the Health and Safety
HEATING UNIT (OVER 100.000 B'TO)
Code, Section 25532(n)9
❑Yes I ^•No
PAID
VENTILATION FAN (SINGLE RESID)
Data Romm,#
BOILER- COMP UHP OR 100,x10 BTU)
Will the appliwmmfurore bonding by the BayManageces ment
emir hazardous sir contaminants as defined by the Buy Arra Alr Qmli,y Management
tyAea ipment or Air
District
❑Yes PIN.
TOTAL,
BOILER-COMP (OVER 100,0(X) BTU)
,
AIR CONDITIONER
I have haoffidOm matetions ials under Chapter 6.95 thethat Cali-
- - ISSUANCE�E
NEW RESIDENTIAL MECH. SQ. FT.
& S fet M505,11533 a name
Sections 25505, 2553] ad 25534.1 i nnotahmd that if the
Tania g allS &Safety only have
building tlees n , currently M1avr a tenant, that h Is my responsibility m notify the occupant of the uirco ms which nus metTrior to iasmmceofu Cetifame oftXcupnn.
4
ISSUED BY:
TOTAL]
O ser rnuthorizc g t Dam
OFFICE