S 2539F
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES • USE BALL POINT PEWONLY
CITY OF CUPF.RTINO BUILD ING-HLF,LTRICAL I PERMITNO.
BUIIAINO VISION APPLICATION/PFRMIT PLUMBING-!11FCHANICA6 ;>539
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CONTACT, PHONE
BUILDING PERMIT INFO
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❑ Consultant Fees Paid by Applicant (Initial)
IILDGELECT PLUMB MFCH
a ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm than I am licensed under provisions of Chapter 9 (commencing
with Section 9010)of Division) ofthe Business and Professions Code, and my license is
to full force and effect.
]-accuse Class hic.M
Date Contmetm
QTY ELECTRIC PERMIT FEE
JOB DESCRIPTION
RESIDENTIAL:
❑SF'DWL El KITCHEN REMODEL
[]ADDITION❑PLUMBING RF. -PIPIT
❑MULTI -UNIT ❑STRUCTURAL.
MODIFICATION
[I INTERIOR C1 CHIMNEY REPAIR
2ltiZ
405
$cdF
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7,itz
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PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL
ARCHECTS DECLARATION
IT
I understand my plans shall be used., ImithemooW,
PANELS
UPTO200AMPS
�tw
O a U
W C H
IMPROVEMENT E]SWIMMING POOLS
[3 BATH REMODF.UREPAIR El DEMOLITION
[]OTHER
Licensed Professional
OWNER-HUILDER DECLARATION
1 reach, affirm that 1 um ct from the Contractor's License Law far the
xemp
following reason. (Section ]031 5, Bu,incs, and I'ndcainno Code: Any city, m county
which acquire, a peri, to canowct, alley, improve, demolish, of repair.ny structure
primmas boammi sentims the applicant for such pennitm file.Jgnedd.wrocnt
Into he is licensed punuanl to the pro,iwoes rf the Comraamr', Licen,e Lw(Chupher9
101-1( MAMPS
OVER Iq%LAMPS
SIGNS ELECTRICAL
SPECIAL CIRCUITIMISC.
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%m V,
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aF�
Its
(commencing with Scennn700()of Division 3oFlbe Businessand l'ndcsoion.s Cutle)nr
that he is cxempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not mom than live hundred dollars(1500),
❑ [,as owner of the property, or my employees with wages as their sole cnmpenmtion,
will do the work, and the structure is not intended credit for subc(Sec.](W4, Business
and Professions Code: The Contractors License law docs not apply In an owner of
property who builds or improves thereon, and who does such work himself or through
his own employees, provided that such improvements arenot intended or offered for
sale. IL howeve,, the building m improvement is sold within one year of complmlm, the
THMP. MF!1'ER OR POLE INST.
'
Xe NEW NLDO ADDITION ❑ DEMOLITION
❑ FOOD SERVICE
IMPROVEMENT
❑O'THIiR
POWER DEVICES❑TIiNANT
SWIMMING POOL IiLF:CTRIC
OUTLLTti-SWI'fCfiES-PI%lVRES
NEW RF_SID1iNI IAL ELECIR SQ 14.
SQ. FT. FLOOR AREA
ESQ. FT.
owner -builder will have the burden of proving that he did not au lld or improve for pury
KIof sole.),
I ns owner of the property, am exclusively contracting with licensed contractors to
'f01'AL:
tmct the project (Sec. FNy Business and Profession., Gde:)'Ihe Contractor, Li-
seLaw does not apply manowner oTpropertywho bulIds or Improve.a lament, and
QTY PLUMBING PERMIT FEE
who cnntmets for such projects with it ovntraemrls) licensed pursuant to the Contrdetnrs
PERMIT ISSUANCE
License Law.
❑ I am exempl under Sec. ..B & P C for this reason
WE
O�yrALTER
Dan,WORKER'S
- DRAIN & VENT - WATI'.R (ITA)
VALUATION
O 0
COMPENSATION DECLARATION
1 hereby alum under pertly of perjuryone of the followinsum or declannWorker's
HACK FLOW PR(YI'F.C'I'. DEVICE
DRAINS-FLIX)R, RIH)F,AREA, GOND.
in-liAuEs
T�CONST UCTION
Co:
andwill muimuin uCeniticam of Conscntmsclf-Insure for Worker's Campcm
sutiou, a, provided far by Section 37Mof the labor Code, for the performance of the
work for which this permit in issue.
PIXl'URES -TEST RAI'
'
CI have and will maintain Workers Compensation Insurance, as required by Section
OUT fine labor Code, for the pelwatimeorthe work for whivh,his petmil is issued,
GAS-EA.SYSTEM-I INC.4OUTLETS
1/
OCCGROUPAI'
i
My Workers Cnmpcnsmian Insurance carrier and Policy number am
Cance Policy No.:
GAS - EA. SYSTEM -OVER 4 (FA)CERTIFICATE
3
3 /4 9�
CRFASI%INDUSTRL WASTE INTERCEPTORCOMPHNSATION
OI' EXEMPTION IBOM WORKERS'
INSURANCE
BUILDING DIVISION FEES
Thmmti... medrainceomplemd iNimpermit is basoohmodreddoll.s.4100)
or leu)
GREASIi TRAP
PIANCHECK FEE
SEWER -SANITARY -S'T'ORM PA.2W 14.
ENERGY FEE
I certify that in the Performance of the work for which this permit is issued, I shall
not employ any person in any manner se as to become subject,, the Workers' Campers-
WATER HEATER WNF.NTIELECIR
GRADING FEE
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onion Laws of Calimmin. Date
Applicant
NOTICE TO APPLICANT: If, otter making Nis Ccnilicute alEncmplmn, you should
become suhiect In the Worker's Compensation provisions of the Labor Code, you had
forthwith comply with such provision, or this penton shall he deemed revoked.
CONSTRUCTIONLENDING iNCY
(hereby affirm thatthere is nennxwninn lendingng ageney fmthc performance of
'be work for which en, permit i, issued (See, 30G. Co, C.)
Lender, Name
WATER SYSTT;M/IRI!Al'INC
WATER SERVICE
$OILS PEE
PAIU )a RcceiMM
N ' S .FT.
ntv
1
TOTAL:
Lenders Address
BUILD( Auy
I certify that 1 have read this application and state that the above information is�(;
unrest. I agreeto comply with all city and county ordinances and state laws minting to
building construction, and hereby authorize representatives of this city to enter upon the
'�II�� �ryy
QTY f :EIBNJ-ALPJq9@
FEE
SEISM f P C)
PF IWITT ISSUANCE,
El.li :E
ihow.hood one proryrty, for inspection Ym,wt,s.
eno against
(We) agree to save. indemnify and keep harmless the City of Cuprti
PLUMHIN FEE
liahilid.,sjudgments, contend expenses which may, many wuy.ecme.gainsaid City
in consummate of the granting of ibis potion.
At rieRADD TOMECH.
AIR HANDLING UNIT(TO IQIXM CFM)
MF.CHAN ALFEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCBIIF.GULATIONS.
AIR HANDLING UNIT (OVER 0,000CFM)
CONS'CRUC' )"AX
SittimagrgifffA,ficanuiCentontim Dae
EXHAUST HOOD GYMUCf)
HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (10 I00,000 WE UI
Will the applicant or future building occupant stow or handle harallous material
as define by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
Code, Section 25532(a)4
HEATING UNIT (OVER IUO.gM BTU)
VENTILATION FAN (S INGLE RESID)
❑Yes es
PAID Dam ReceiPtN
Will the applicant or future building occupant use equipment or devices which
aoair commitments as JcEncJ by the any Area Air Quality Management'OT
emit harNm
pOILiiR -COMP (311P OR 00.000 BTU)
O
District? —/
EI Vic, Ij'l9"
BOILER - COMP (OVER 1011" BTU)
AIR CON DIT TONER
ISSUANCE DATE
I have read he amarmal mammals requiwarre, ander chapter 6.95 ofthe Cali-
NEN' RESIDENTIAL MECIL SQ. FT./i
tbriu Health & Safety Code, Sections 2.5505, 25533 and 25534. 1 understand Na if the
In reify the oupant
building John not currently have a tenant, that it is my responabilirycc
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