S0001 B03004
PPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING -ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING -MECHANICAL
' BUILDING PROJECT IDENTIFICATION
11 PERMITNO O OO
SOOOI
BUILDING ADDRESS -
loco Cb D�vL
SANITARY NO.
APPLICATION SUI{MITTAL DATE
% 23--x'
OWNE'SNAME: PHONE:
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le_ '•1
CONTRACTOR'S AN MP LIC NO:
WC
❑
CONTROLp
ARCHI I'ECTIENGIN1iER: LIC NO:
ADDRESS: -
CON�kTAC., PHONE:
- BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
❑ � ❑ ❑
Os�hyyOr, , �y`Zzy7O
LN^ L 1 �1 -T
El Consultant F". Paid by Applicant(Initial)
LICENSED CONTRACTOR'S DECLARATION
mrat I em licensed under provisions of Chapter 9 (coencing
1 hereby am Nmm
QTY ELECTRIC PERMIT FEE
JOB DESCRIPTION
PERMIT ISSUANCE /
a
with Section 7")of Division Sof the Btimmisvird Professions Code, and an, license is
in full forcennd effect'
RESIDENTIAL:
❑SFDWI. ❑KITCHEN REMODEL
APPLIANCES -RESIDENTIAL
License Class Lick
I DareGalmctor
❑ADDITION El PLUMBING RE -PIPE
[I MULTI -UNIT MODIFICATION
El INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT SWIMMING POOLS
❑ BATH REMODEVREPAIR C1 DEMOLITION
❑OTHER J '�
/� , h�
0 IIT fff///+++///
j ARCHITECTS DECLARATION
I undcatemd my plans shall be used as public records
PANELS
UPT02001AMPS
Licensed professional
OWNER -BUILDER DECLARATION
C 1 hereby affirm that 1 um exempt from the Contractor's License Law lin the
following reason. (Section 703 1.5, Business and Professions Code: Any city or county
j which requires a permit to construct, alter, improve, demolish, or repair any structure
poor o its issuance, also requires the Vlacantfor such permit to file u signed stmement
201-I000AMPS
OVER["AMPS
SIGNS ELECTRICAL:
SPECIAL CIRCUITIMISC
t KAVIMC.AAS I
. that he is licensed pursuant to the provisions of the Contractors License Law (Chapter Y
-
COMMERCIAL,
(commencing with Section]000) of Division 3 of the Business and Professions Code) or
d that he is exempt therefrom nature basis for the alleged exemption. Any violation of
Seetial7031.5 hyuny applicant for is pennitsubjects the upplivirmtoa civil penu0y of
TEMP. METER OR POLE INST.
❑ NEW BLDG/ADDITION ❑ DEMOLITION
[]TENANT ❑ FOOD SERVICE
POWER DEVICES
not more than five hundred dollars ($500).
CI 1, as owner of the propeny, or my employees with wages as their sole compensation.
� will do the work, and the swcwm is not intended or offered for mile (Sec. ]044, Business
and Professions Cede: The Contractors License Law does not apply to an Owner o
IMPROVEMENT
❑OTHER
-
SWIMMING POOL ELECTRIC
OVILETS-SWITCHES - Fl o
NEW RESIDENTIAL ELECTR SQ Ff.
property who builds or improves thereen, unit who does such work M1imself O thmngM1
his own employees, provided Not such improvenents ore nal 'mtentled nr offered ler
sale. l4 hnwevae the building orimpmvemem is sold withinnneyevofcomprban.the
SQ. FT. FLOOR AREA
SISQ. FT.
owner -builder will have the burden of paving Lha he did not hat or improve for par-
TOTAL:
se of sale.).
1, as owner of propeny, a exclusively contracting with licensed commmors m
QTY. PLUMBING PERMIT FEE
',comma Lha project (Sec. 9144, Business and Profession, CrdeU The Cmnlmebn's Li-
censeLaw diva not apply loanowner ofpropcnywho buildsnrImproves thereon,and
who cantons for such pmjeas with a commdoKs) IicenuJ pmmunt Ito Ne Contracmrs
License Law.
❑ I am exempt under Sec. , B & P C for this reason
PERMIT ISSUANCE
VALUATION
ALTER - DRAIN A, VENT- WATER (FA)
D
WORKER'S COMPENSATION DECLARATION I
BACK FLOW PROfGC1'. DEVICE
I hereby affirm under penalty of perjury one of the following dedvmtimns:
❑Ihave will by eCeni3700 of the Labor Code, for the performance of lar -due
motion, as provided for by Sectionssu J]00 of the Isbor Code, for the performance of Nc
work for which this permit is issued.
DRAINS - FLDOR, ROOF, AREA. COND.
- STORIES
FIXTURES -Pf:R TRAP
GAS -EA. SYS TEM- I INC. 4OUTLETS
❑ 1 have and will ode, f.n Worker's Compensation workfor hi h resound by Section
J]Dpl of the Labor Code, for the prof ornanee of the work for which this permit is issued
UCC. GROUP
[�7PECONSTRU�10r
GAS -EA. SYSTEM -OVER 4 (FA)
My Worker's Compensation Insurance carrier and Policy canner mire:
Carrier: Policy No.:
CERTIFICATE OF EXEMPDON FROM WORKERS'
COMPENSATION INSURANCE
(9his seotien need me he completed if the permit is for one hundred dollars ($100)
or le".)
I versify that in the verframnmif the work for which this permit is allied.I shall
nm employ any pecan in any manner an as to become subject m the Wmkere Compen-
GREASFIINDUSTRI. WASTF.INTF.R R
BUILDING DIVISION FELS
Gy
GREASETRAP k/ J
PLANCHECK RAE
SEWER -SANITARY -STORM P.A.2 FT.
ENERGY FEF.
WATER HEATER WNENTXLE
WATER SYSTEM/TREATING `I
GRADING FEE
= via. Laws D,t�
Applicant fE h 1YA
NOTICE TO APPLICANT: If, after making this Cestifteme of Exemption, you should
became sahjcet to the Worker's Compensation Provisions of the labor Code, you must
forshwith comply with such provisions or this permit shall be deemed revoked
SOILS FEE
V ,
WATER SERVICE
CONSTRUCTION LENDING AGENCY
I hemby affirm that there is a construction lending agency for the perfurmuneeof
the work far which this permit is issued(Sec. 3007, Civ. C.)
PAID
Date Receipt
NEW RESIDENTIAL PI -MB. SQ. FT
•
TOTAL:
Lender's Name
Lender's Address
ycenify that I have read this application and state that the above infomsaion is
A cemrt. l agree m comply with all city and county ordinances and Stam laws mlaing to
Z building construction, and hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection Purposes.
(We) agree Ito save, indemnify mind keep harmless the City of Capetian vguinst
Iiabilines,judgmems, costs and expenses which may in any wayvicemeagammodd City
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
TOTAL:
BUILDING FEE
QTY. MECHANICAL. PERMIT FEE
SEISMIC FEL?
PERMIT ISSUANCE
ALTER ORADDTO MECH.
ELECTRIC FEE
PLUMBING FEE
AIR HANDLING UNIT (TO 10.WO CFM)
MECHANICAL FEE
SOURCE REGULATIONS.
DLING UNIT (OVER I(I,(Ng]CFM)
CONSTRUCTION TA%
Signuture of ApplicarmContrecmr Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building cecupant store or handle hazardous material
as deputed by the Cupenino Municipal Code, Chapter 9. 12. and the Health and SafetyG
Section 2553Na)t
T HOOD(W/DUCT)
HOUSING MITIGATION IEE
UNIT f1'o 100,000 HIM)
UNIT (OVER 1 W,IKO BTU)Coln,
ATION FAIS(SINGLE RESID)
❑Yes ❑No
PAID pvm Rcceiptk
-COMP QHP OR 100,000 BTU)mail
on
Will the applicant or future building cecupant use equipment or devices which
harardous air contaminnts as defined by Ne Bay Area Air Quality ManagementDistrict?
-COMP (OVER 100,000 BTU)❑Yes
❑No
ISSUANCE DATE
/ 2�building
I have read the hmrdnus materials requirements under Chapter fi.95 Of the CalmDI"I'[ONER
fomia Health & Safety Code, Sections 25505,25533 and 25574.1 makoumnd tha if NeSIDENTIAL
MECH. SQ. FI'.
Nes riot cumntly have, moan, that it is my responsibility tat naify the tc 11
of the rrymarramu which mast be met prior to is,-- of a Ceaificate of OccuparoyOwner
ISSUED BY'. v_ "A 1
or authorized agent DateTOTAL:
UFFIGt