29539APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
❑ Consultant F"s Paid by Applicant Tnitlap'
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CITY OF CUPERTINO
Qom' ELECTRIC PERMIT
BUILDING - ELECTRICAL.
APPLIANCES - RESIDENTIAL
PERMITNO.
ARCHITECTS DECLARATION
1. 1 ter Plans be used a, tecards
BUILDING DIVISION
APPLICATIONIPERMIT
PLUMBING -MECHANICAL .
UPTO 2W AMPS
29539
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OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Law for the
following rtavm. (Section 1031.5, Business and Professions Coda: Any city or county
201-LNMAMPS
OVER Ial0AMP5
BUII,T)ING PROJISCT IDENTIFICATION
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which require., a parenit m conswet, alter, improve, demolish, to repair any sweture
poor its issuance. also requires theapideant for such Permit rile a signed statement
that he is licensed pursuant m the provisions of the Contractors License Law (Chapter 9
SPECIAL CIRCUITIMISC.
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SANITARY NO.
APPLICATION SUtlMITTAL UATk
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rule. IL however, the building or improvement is sold within one yearofcompletion, the
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QTY, PLUMBING PERMIT
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1 hereby flan Thal 1 am licensed under proisi nos of Chapter 9 (commencing
with Section 7") of Division 3 of the Business and ProfessionsCode, and my license is
in full forcemd etTea
License Class' Lick
Date Contractor
Qom' ELECTRIC PERMIT
PERMIT ISSUANCE -
APPLIANCES - RESIDENTIAL
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ARCHITECTS DECLARATION
1. 1 ter Plans be used a, tecards
PANELS
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UPTO 2W AMPS
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OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Law for the
following rtavm. (Section 1031.5, Business and Professions Coda: Any city or county
201-LNMAMPS
OVER Ial0AMP5
SIGNS ELECTRICAL
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which require., a parenit m conswet, alter, improve, demolish, to repair any sweture
poor its issuance. also requires theapideant for such Permit rile a signed statement
that he is licensed pursuant m the provisions of the Contractors License Law (Chapter 9
SPECIAL CIRCUITIMISC.
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(commencing with Section 7000) of Division 3 of [he Business anal Professions Code)or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by m,ii,hi,am farit,amotsuhjaurs their,dicanl to. civil pemoty.r
t more than five hundred dollars(S5W).
as owner of the pmpcny, or my employees wiNwagesae theirsulensmpensmion,
will
will do the work,and he swmure is not henandedaroffend fa rale (Sec. 7044, Business
and Professions Code: The Contractors License Law does not apply is m owner of
POWER DEVICES up R
SWIMMING POOL ELE
ed
OUTLETS -SWITCHES -FIXTURES'
property who builds in improves thereon, and who does such work himself an mrosgh
his own employees, provided that such improvements are no, intended or offered for
NEW RESIDENTIAL ELECTR
rule. IL however, the building or improvement is sold within one yearofcompletion, the
caner -builder will have the burden of proving mat he did not build or improve for par -
pose of sale.).
❑ 1, as owner of the property, am exclusively contracting with licensed ammmcmrs to
amolruct the Pont. (Sec. 9044, Brio ners and Professions Code:) The Contractor's U.
s
censc law does not apply to an owner of property who builds or improves thereon, and
QTY, PLUMBING PERMIT
whocotnracos forsuch Projects with a conmeou(s) licemedrommanttothe Commencer
PERMIT ISSUANCE
License Law,
❑ tum exempt under Sec. ,14& P C for this reason
ALTFiR -DRAIN & VENT- WATER (EA)
BACK FLOW PROTECT. DEVICE
Owner Date
WORKERS COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
DRAINS- FLOOR, ROOF, AREA, COND.
Ihastand will maintain a Cenilear.fConsaid 1. If -insure for Workers Co.,.-
had, as provided for by Section 37W of the I.aMsr Code, for the perfonaunce of the
work for which this pernit is issued
FIXTURES - PER TRAP
1 have and will maintain Workces Compensation Insurance, as required by Search
37W of the Labor CMe,far the performantt of the work for whichthis permit is issuedki
GAS- EA. SYSTEM. I INC. 4 OUT
ppl1y Wo kce Comp�eJ� uan lnsumnccyyyprtr nand Policy m5
C.rierSY.�—G{..war.ri� /%�•+micY No: -/1�f rLY
GAS -EA. SYSTEM -OVER 4(HA)
CERTIPTION FROM WORKERS'
COMPENSATION INSURANCE,
GREASMNDUSTRL WASTE INTERCEPTOR
(This section need not he completed tribe permit is forma, hundreddollars(5100)
a less.)
GREASETRAP
SEWER - SANITARY - STORM EA, 200 FT,
I certify that in the performance of the work for which this permit is issued, l shall
not employ any petro. in any meaner so as to became subject m me Workers' Cmmpero
WATER HEATER WVENTIELECTR
Zztion
Laws of {jlifnmia. Da
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NOTICE TO APPLICANT, If, after making this Cenificam of Exemption, you should
become subject to the Workers Compensation provisions of the Labor Cale, you mus,
forthwith comply with such pmvisions or this permit shall m directed revoked.
CONSTRUCTION LENDING AGENCY
thaubereisewd(Sec. 30 lending agency far Performance of
I for which this
work far which,his permit is issued (Sec. 3TNT, Civ. CJ
WATER SYSTEMITREATING '
WATER SERVICE
NEW RESIDENTIAL PLMD. SQ. IT.
Lander's Name
Lewers Address
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1 certify that 1 have «uJ this application and state that the above information is
correct.I agree to comply with all city and county mdinancas and state laws relating to
building construction, and hereby salmon representatives of this city m enter upon the
QTY, MECHANICAL PERMIT
PERMITISSUANCE
-above-mentioned propeny for inspection purposes.,
(We) agree to save, indemnify end keep harmless the City of Croartim against
ALTER OR ADD TO MECH.
liabilitics,judgmentx, costs and expenses which may in any way aecmeagainst said City
in asequence of the granting of this permit.
AIR HANDLING UNIT LTO In." CFM)
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE TIONS.
AIR HANDLING UNIT (OVER 10,1100 CFM)
_
EXHAUST HOOD (WIDGET)
ogna um of ApplicsntlContmctur Dat.
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupnlstore or handle harardous material
HEATING UNIT (TO IW,000 BTU)
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, See.. M532(a)Y
HEATING UNIT (OVER I00,000 BTU)
❑Yes ❑No
VENTILATION FAN (SINGLE RESID)
Will the applicant or future building occupant use equipment or devices which
air hazardous air conmmina d, as defined by the Bay Area Air Qualify Management
BOILER -COMP QHP OR IW," BTU)
BOILER -COMP (OVER 100,0001 BTU)
iatrict^
❑Yes ON.
AIRCONDITIONER
I have most the hamNous materials requimments under Chapter 6.95 of the Cali-
NEW RESIDENTIAL MECH. SQ. FT.
hands Health & Safety Code. Sections 25505.25533 and 25534.1 understood that if the
building does not currently have o tenant, that it is my responsibility to notify the occupant
of the «yuirements which must N met prior to issuance of a Certificate of Occupancy.
I TOTAL
Owner or authorized agent Data
OFFICE
FEE
PERMIT INFO
BLDG ELECT PLUMB MECH
❑ ❑ .LIQ' ' ❑
RESIDENTIAL:
❑SFDWL
❑KITCHEN REMODEL
❑ADDITION
❑PLUMBING RE -PIPE
13 MULTI -UNIT
❑STRUCTURAL.
MODIFICATION
11 INTERIOR
❑CHIMNEY REPAIR
IMPROVEMENT
❑ BATH REMODEUREPAIR ❑ DEMOLITION
❑ OTHER
COMMERCIAL,
❑NF.WBLDG/ADDITION (]DEMOLITION
❑TENANT ❑ FOOD SERVICE
IMPROVEMENT
❑ OTHER
PA, l' K
APR .1 1996
BUILDING DIVISION WEDS
PLANCHECK FEE _
ENERGY FEE
GRADING FEE
SOILS FEE
PAID
Date Receipt N
TOTAL:
BUILDING FEE
FEE SEISMIC FEE
ELECTRIC FEE
PLUMBING FEE
MECHANICAL FEE
CONSTRUCTIONTAX
HOUSING MITIGATION FEF.
PAID
Data Rcceiptk
TOTAL
ISSUANCE DATE
ISSUED BY: