99100135 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY F
3
CITY OF CUPERTINO BDILDING-ELN.CTRICAL PERMITN
eUILDINIJ DIVISION APPLICATION/PERMIT PLUMBING MECHANICAL
BUILDING PROJECT 11)ENTIF'ICATION
BUILDINGADDRE NTI'ARY NO. APPLICATION SURMITTAL DATE
105/l 14e_
W 'R' NAM . ,a� ��y ONE:I C ACfO ' AM _LIC NO
K R �� SIC C(INTROhM
CHITELT/ENGINEER: LIC NO: ADDRESS:
T
CINT, r: PHONE:
BUILDING PERMIT INFO
Gr s ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MUCH
LICENSED CONTRACTOR'SDECLARATION QTY ELECTRIC PERMIT PGE ❑ ❑
erehy aRrm Nm 1 am hecused ander provisions of Chapter 9(cammm ing JOB DESCRIPTION
O�Z
with Section 7000 of Divisio 3af the Basions and Professions Cade.endm littnse is PERMIT ISSUANCE
00 w y RESIDENTIAL•
U,. in hall fume and c0ect.
�UV Uccnsc Cl Lic.M ❑SFDWh [I KITCHEN REMODEL
♦n QL Dam Conlmda APPLIANCES-RESIDENTIAL El ADDITION El PLUMBING RE-PIPE
F.ws ARC TECPSDECL ATION PANELS
❑MULTIUNIT ❑STRUCTURAL
z O vn^ ]understand my plans shall be used.,public records MODIFICATION
Oztp UPT02(NIAMPg CINTERIOR ❑CHIMNEY REPAIR
F YJI:W Licensed Promotional 201-1000AMPS PROVEMEN'I'
�YE; OWNER-BUILDER DECLARATION ❑SWIMM DEMOLINGPOOLS
y OVER ILtlD AMPS BATH REM1fODU BEPAI DEMOLITION
�6 1 hereby effimr that 1 am exempt from the Contractor's License Law for the
7a�d'O y V following reason.(Section 7031.5.Bpainns pad Professions Code:Any city m county SIGNS ELECTRICAL C OTHER
W a W h which requires a permit m enmi uct, he,improve,demolish,or repair any structure
FAV,}
Poonoi.isua
snce,also requires the applicant for such Permit o rile a signed statement SPECIAL CIRCUIT/MISC. /
that he is licensed pursuant to the provisions of the Cannata,,License Law(Chapters,
W OC (commencing with Section 700)of Division 3 ofthe Business and Pmfessi.rm Code)or TEMP.METER OR POLE INSL COMMERCIAL:
d y e e' that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BILDG/ADDITION El DEMOLITION
uiCl o, Section]031.S by any applicant for a penth.mbjects the applicant n a ci vil penally of POWER DEVICES ❑TENANT ❑FOOD SERVICE
1-_zy not more than five hundred dollars($500). IMPROVEMENT
aQ Cl,wowner of the property.or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC
will du the work,and the stmcwre is not intmocd oroffered for.sole(Sec.7dW,Business ❑OTHF.k
,�m and Professions Code:The Contractors License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES10
property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements me oat intended or offered far NEW RESIDENTIAL ELECTR SQ FI'.
sale.If,however,the building or improvement is sold within one year ofcompletion,the SQ,FT.FLOOR AREA 5/SQ,FT.
caner-builder will have the burden of proving that he did not build or improve for pur-
pose of sale.).
C I,n owner of the property,am exclusively convecting with licensed contractors to TOTAL:
construct the project(Sec.7044,Business and Professions Code)The Comracmr's Us
sense Law does 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 pursuant 1.the Contractor's
License taw. PERMIT ISSUANCE
C l am exempt under Sec. ,B&P C for this,damn
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Date } q
rte WORKER'S COMPENSATION DECLARATION BACK ROW PROTECT.DEVICE
w Ihereby affirm under Penalty of perjury one of the following declarations:
I have and will maintain a Certificate ofCansent to self-insure for Workers Compen- DRAINS-BOOR,ROOF,AREA,GOND. STORIES TYPE CONS'1'RUCI'[ON
mlion,ns provided for by Section 37M of the Labor Code,for the N fo a of the
ark for which this permit is issued. FIXTURES—PER I RAP
I have and will commit Workers Compensation In��''yr rt by Sation
3710.1'the Labor Code.for the forbearance of the wodWO It th dpcmutis ixwed. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC GROUP �j" /
My Wo r stionI he,n a eJ {Q
AY f0
Carried ¢y Nn: GAS-EA.SYSTEM-OVER 4(EA)
C sFl A A 1EXEh PITON FROM WORKERS'
v ENSATION INSURANCE GREASE/INDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
(This section need not he complete)ifthe permit is(Drone hundreddollars 0)(510
GREASETRAP
a Ii,".) PLANCHIiCK FEE
(certify[but,.the permy nomm r o w t become suork far bject
thus she W rkersuComm alln- SEW Ek-SANITARY-S'IUkM liA.200 FT.
not employ any person in any mvnner so ns m become.subject m the Workers'Compcn- ENERGY FEE
Q ,Z smiun Laws of California.Data WATER HEATER WNENT(ELECfR
yyy O Applicant GRADING FEE
tiNOTICE TO APPLICANT:IL after making this Cenifiane of Exemption,you should WATER SYSTEM,9 BEATING
a ' become.subject m the Warker's Compensation Provisions of the Labor Cole,you must SOILS FEE
4T1 ti forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
O
CONSTRUCTION LENDING AGENCY NEW RI?SIDENTIAL PLMB. SQ.FT PAID
I hereby affirm Net them iso Oamanlum leadingagency forth.performance of Date Receipts
1`6P ate work for which this permit is irsued(sec.300.Civ,C.)
O U Lender's Name 'I(ITAL:
W Lender's Address TOTAL:
1 certify that I have read this application and state that the above information is BUILDING PQE
't151 em,ml.l agree m comply with all city and county oudinwees and state laws relating to QTY. MECHANICAL PERMIT F
U z building construction.and hereby nuthariu represemiI of Nis city m enter upon the e5L'IS1s11C0FEE `I
ids"e-mentioned property for inspection purposes. PERMIT ISSUANCE 'JO/I /
(We)agree to save,indemnify and keep hamtless the City of Cupenina against ELECTRIC PEE/J Y
liddlities,judgmen¢,coos and expenses which may in a way acapea most said City ALTER OR ADD'IO MECH. B PLUMBING FEE /
in canscquence of Ne®arcing of this permit.
APP 'ANTUNDERSTANDS AND WIL C . PLY WITH LL N-POINT AIR HANDLING UNIT(TO 11.00 CFM) 'ICAL FEE
It
S REGULATIONS,
1 AIR HANDLING UNIT(OVER 10,00 ) CONSTRUCfI
S tore ApplicanVContremm Da EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOU MATURIAIS DISCLOSURE.
Will lheaPPliwnl or paper building occupunrotorem It V ad.usmacrial HEATING UNIT f 0110,IK0 B'1'U)
m def ted by the CUPenina Municipal Cale.Chapter 9.12.ai I the callh and Safety
Code.Section 25532nd? HEATING UNIT(OVER 100.00 BTU)
C Yes CN.
VENTILATION PAN(SINGLE kCSID) PAID Will the applicant or future building occupant use equipment or devices which Date Receipt M
pp gce parrBOILER-COMPQHP OR 100.00BTU)
mit hvallosox air c.nlaniwnts az defined by the Bay Area Air Quality Menpgement
lie
District? TO A
Cl Yes f2 No BOILER-COMP(OVER 101,000 BTU)
I have read the hasardons materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
f is H.alth&Safety Calc,Sections 25505.25 and 8534 a rsmnd that if the NEW RPSIDENTIAI.MECH. SQ.FT.
but not currentlyhIailwun6t I' my resP.nsi 'ny lr otify the occupant /� ^ 2�/ �1
.it in m is which must be met t.lssupncc aria enh' me of en y. 6 p
er or authurized agcm sae TOTAL: ISSUED BY:
OFFICE