S 0484 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT 'PLUMBING-MECHANICAL S '0484
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: - -SANITARY NO. APPLICATION SUBMITTAL DATI
20
OWNE 'S NAME: E CONTRACPOR'S NAME: LIC NO:
N/C CONTROL#
.ARCHITECT/ENGINEER: LIC NO: ADDRESS: ❑
CONTACT PHONE: nE
DING PERMIT INFO
❑Consultant Fees Paid by Applicant(Initial) LECT PLUMB MECH_
❑ ❑ erKlyl
LICENSED CONTRACTOR'S DECLARATION QTY, ELECTRIC PERMIT FEE DESCRIPTION
I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing
G0 with Section 7"Eir Division 3ofthe Business and PfofesslonsCode.and my license is n PERMIT ISSUANC
E
W U� in en a Class
e t C�/may �' .G O ❑SFDW L [I KITCHEN REMODEL
aUzU License Class Lic.# ALJ APPLIANCES-RESIDeN9'IAL ❑ADDITION L1 PLUMBING RB-PIPE
in6G Das Contractor El MULTI-UNIT ❑STRUCTURAL
ARCHITECTS DECLARATION PANELS MODIFICATION
G 1 understand my plans shall he used as public records
Dy-O, UP TO 2W AMPS [_1 INTERIOR El CHIMNEY REPAIR
Licensed Professional 201-B]WAMPS IMPROVEMENT E]SWIMMING POOLS
5 � OWNER-BUILDER DECLARATION OVER 10(N)AMPS El BATH REMODEL/REPAIR El DEMOLITION
RR PPPGGG I hereby affirm that 1 am exempt from the Contractor's License Law for the OTHER ip5,O y U following reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL _
u+ WO y which requires a permit to constmct,alter.improve,demolish or repair any structure
prior 0 its issuance,also requires the applicantfor such permit to file a signed statement SPECIAL CIRCUIT/MISC.
'bat he is licensed pussour ome provisions ufthe Contractor's License Law(Chapter9
CSO (commencing with Section 7")of Division 3 afthe Business and Profeasinns Code)or TEMP.METER OR POLE INST. COMMERCIAL
a y
,vi
e' that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION [I DEMOLITION
WX W Section 1011S by any applicant fm a permit subjects the applicant no a civil penalty of POWER DEVICES El TENANT ❑FOOD SERVICE
' are than five hundred cut...($5W). IMPROVEMENT
E]1,as ownerof'beproperty,or'my employees with wages talluarsvle campenwtion, SWIMMING POOL ELECTRIC
[I OTHER
will do the work,and the structure oroff
is not intended ered for sale(Sec.]044,Business
and Professions Cele:The Continuities License Law does not apply to an owner of OUTLETS—SWITCHES—FIXTURES
4i property who builds or improves thereon,and who does such work himself or through
his own employees,provided Rod such impmvemen's are not intended or offered for NEW RESIDENTIAL AR SQ FT.
sale.IL however,the building or improvement is sold within one year efcompletion,the SQ.FT.FLOOR AREA $ISQ.FT.
caner-builder will have the burden of proving that he did not build or improve for pur- pp
IDposenfsaleJ. ' - yi
TOTAL:
1,as owner of the property,am exclusively contracting with licensed Imorears to
construct the project(Sec.7044,Business and Rofesslons Cade:)The Comracar'a Li- ;BACK�OW
.,'�y �Ay.rn
cense Law does not apply to an owner of property who builds or improves thereon,and QTY. LUM If RM FIEE _ �(„pID
who ematnrms fimsuch Projocn with a contract (a)licensed pursmanun the Contractors AR ANS
License Law. ANCE
❑1 am exempt under Sec. .B&P C for'his reason I
ALTER—DRAINir L A
rROV
Owner Date
WORKER'S COMPENSATION DECLARATION PROTECT.UEVIC_F.
I hereby affirm under Penalty of perjury one of the following declarations.
17 l have and will maintain a Certificate of Consent to self-insure l'orWoraces Compen- DRAINS—FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCTION.
sotion,as provided for by Section 3700 of the Labor Cade,for the performance of the
yk for which this permit is issued. FIXTURES—PER TRAP
1 have and will maintain Workers Compensation Insuamce,as required by Section
Rhm ofine Labor Code,for the performance of the work for which this permit is issued. GAS—EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My Worsgs Co pe ationl and Policy num re G S—EA.SYSTEM-OVER4(EA)
Cartier: Ve ., Policy No.:
CE IFI ATE O• EMPTION FROM WORKERS' GREASEJINDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(Tots section Deed nm be aomPleted if the permit lsfor me hundred dollars($IW) GREASETRAP
or less) � PLANCIIECK FEE
I certifythat in the pertmmance ofthe work forwhich thispemul is issued,I shell SEWER—SANITARY—STORM EA.2W FE
not employ any person in any manner so as to become subject to the Workers Compen- ENERGY FEE
Z sotion Laws of Califomia.Date WATER HEATER WNENT/ELECTR
Applicant t GRADING FEE
F7 NOTICE TO APPLICANT:If,after making this Cenificme of Exemption.you should WATER SYSTEMITREATING
become subject to the Worker's Compensation powistons of the Labor Code,you mus' SOILS FEE
fonhwith comply with such provisions or this Permit shell be deemed revoked. WATER SERVICE
Q PAID
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FI'. Date Receipt#
Ihereby motor that there iso comuuctiom lending agency for the Performnc
ae of
U z
W F the work for which this permit is issued(Sec.3097,Civ.CJ WFEE
L:
O U Lender's Name
Lenders Address TOTAL'.
a I certify that 1 have read this application and state that the above information is F,E
sF.t N correct.I agree to comply with all city and county ordinances and sate laws relating to QTY. MECHANICAL PERMIT FEE Ebuilding conswction,and hereby authorize representatives ofthis cityto enter upon the.above-mentioned property for inspection purposes. PERMIT ISSUANCE E(We)agree ustave,indemnify antl keep harmless the City of Cupenlno against
liabililies,judgmems.costs and expenses which mayin any wayaceme against said City ALTER OR ADO TO MECH. FEEin consequence of the granting of this Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IB(100 CFM) A ESOUR EGUL TIONS. 1
AIR HANDLING UNIT(OVER I0.00ECFM) TI TAXSiloam, of pplicaMCon r ".Dm EXHAUST FOOD(W/DUCT) ITIGAT NFEE
HAZA D US MATERIALS DISCLOSURE
Will the applicant of building occupant store or handle hazardous material HEATING UNIT(TO Md"BTU)
as toed by the Copeninm Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,(M BTU)
Code,Section 25532m)?
[D yes ❑No VENTILATION FAN(SINGLE RESID) PAID
Date Receipt it
Will the applicant or future building use equipment ofdevices which BOILER—COMP(3HP OR 1 W000 BTU)
emhazardous
it air rnmininntaants as defined by by the the Bay Arca Air Quality Management TOP AL:
Delc. -Yes N
BOILER—COME(OVER 100,000 BTU)❑ ❑ o .. —
I have mad the hazardous materials requirements under Chapter 6.95 ofihe Cali- AIR CONDITIONER ISSUANCE�DATE
forma Health&Safety Cade,Sections 25505,25533 and 25534.I understand that if the NEW RESIDENTIAL MECH.. SQ.Ff4
building does not currently have atenant,that it is my responsibility to notify the occupant.
of the m{amnne is which must be met prior to issuance of a Certificate of Occupancy.
i
Owner or authorized agent Date, TOTAL; ISSUED BY:
OFFICE