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APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY (
CITY OF CUPERTINO BIIILDING - ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING -MECHANICAL '
BUILDING PROJECT IDENTIFICATION
PERMIT NO.
BUILDINGADDRMS:
SANITARY NO. APPLICATION SUBMITTAL DATE
d
RW
6 —'
OWN PHONE:
_
CONTRACT'OR'S NAME: LIC NO:
-T
PCCI `
NIC
❑
CONTROL a
ItC EC'IIENGINEIiR: LIC NO.
A KESS.
`
Vill
CONTACT': PHONE
ILDWG PERMIT INFO
• lia Q,
❑ Consultant Fees Paid by Applicant (Initial)
BLDG FrL CrPI B SUCH
ElMov
LICENSED CONTRACTOR'S DECLARATIONQTY
I hereby affirm that 1 am licensed under provisions of Chapter') commerce it,
ELECTRIC PERMIT FEE
JOB DESCRIPTION
RMIT ISSUANCE
with Section 70W)of Division3of the Business and Professiom Code, and my license is
in fall force and t.
RESIDENTIAL:
[]SFDWL [I KITCHEN REMODEL
APPLIANCES -RESIDENTIAL
Loans C sec�kDC—CL Commoner CYt kia;
ARCHITECTS DECLARATION
1 malcontent my plans shall he used az public records
DADDITION [I PLUMBING RE -PIPE
[]MULTI -UNIT CSTRUCTURAL
MODIFICATION
[]INTERIOR []CHIMNEY REPAIR
IMPROVEMENT 0SWIMMING POOLS
PANELS
UPT02MAMPS
Licensed Pmfessionel
201-IWOAMPS
OWNER-BUILDERexemptDECI.ARmmeteATION
1 hereby afforded 1 am exempt tram the Cottaaors: License,Law for the
fallowing massa (Section 703LJ. Business and Profession. Cade: any city or county
which requires a permit m ulcer, improve. demolish, or repair any anmcvure
❑ BATH REMODEIJREPAIR []DEMOLITION
-T- `. A•.A V.I.
DOTHER pie-Irq_.
1]�
OVER I" AMPS
SIGNS [LECfRICAI.
tD
h perp
prior to its issuance, alaorequirts the applicant for such pnrmiur fileu&igned namment
ai,a thei
that he is licensed pursuam to the pmv s of the Camacmrs License law (Chapter 9
SPECIAL CIRCUITIMISC.P�
(commencing with Section 700) of Division 3 rfthe Business and Professions Code)or
TEMP. METER OR POLE INST
COMMERCIAL,
mat he is exempt therefrom and the basis for the alleged exemption, Any violation of
C NEW BLDG/ADDITION D DEMOLITION
Secure 7011.5byeny applicant fora permit subjects the applicant me civil penalty of
not mom than five hundred dollars (S500).
I,azowner of the property. or my employees wird wages av their role compensation,
will do the work, and the structure is not intended or offered for sale (Sea. 7044, Business
POWER DEVICES
CTENANT []FOODSERVICE
IMPROVEMENT
El OTHER
SWIMMING POOL ELECTRIC
and Professions Code: The Caricatures License taw does not apply to an owner of
OUTLETS -SWI'TCt1ES-FI%TI1RE5
NEW RESIDENTIAL ELECTR SQ FT.
property who builds or improves thereon, and who does such work himself or In i gh
his own employees, provided flat such improvements are not intended or offered for
.sale. If. however the huilding or improvement is sold within one year rfcompletion,the
SQ. FT. FLOOR AREA
$jSQ. FT.
per -builder will have the burden of proving that he did not build or improve for put-
poxof.le.).
C I, as owner of the property, am eaciusively contracting with licensed contractors to
TOTAL:
mMILO the pmje0 (Sce. 704q Business and Professions Code:) I'he Contractor's Li-
censeLaw ones not apply to an owner ofproperty who builds or improves thereon,and
QTY. PLUMBING PERMIT FEE
who contracts for such projects with a contraaorts) licensed pursuant a the Contactors
ISSUANCE
ALTER - DRAIN & VENT- WATER (EA)
License law.PERMIT
C l am exempt under Sec. ,B& P C for this reason
Dam
VALUATION
�.
WORKER'S COMPENSATION DECLARATION
ACK FLOW PROTECT. DEVICE
I hereby affirm under penalty of perjury one of the following do I pit inns:
haveand will maimalna Ccniticateof Conscat toxlf-in.mre for Worker's Compen
.tion, az provided for by Section 37W of the Labor Code, for the performance of the
INS-PLOOR,RWF. AR .GOND
STORIES TYPE CONSTRUCTION
work for which this permit is issued.
FIXTURES - PER TRAP
1 1 have and will maintain Worker's Compensation Insurance, as required by Section
JW of the Labor Code. forthe performance afthe work for which this melt it red
OCCGROUP APN
GAS-EA.SYS'IEM-I INCAOUTLEIS
My Wa p�tj�tion In mice carrier and Policy number er : G
Camey s�,I �r�� It Policy No.: �
CERTIFICATE OF EXEMPTION FROM WOR ERS'
COMPENSATION INSURANCE
� O
GAS -EA. SYSTEM -OVER 4(EA)
GRGASFJINDUS'TRI. WAS TE:INTERCEPTOR
BUILDING DIVISION FEES
(This sectors need not becompleted ifthe Permit is fortune humircd dollars(SIM)
nr lest)
GREASETRAP
PLANCHECK FEE
SEWER -SANITARY- STORM EA. 2(X) FT.
ENERGY FEE
(certify that in the ivedormanceafthe work for which thispermiti& issued, [,hot]
not employ soy person in any manner so as In hcurme subject to the WorkersCompere
IWATER HEATER WIVEN1DELECTR
GRADING FEE
salon laws of California. Date
Applicant
NOTICE. TO APPLICANT: IL after making this Certificate of Exemption, you should
.meation provisions of the labor Code, you must
WNerebjea n the Worker's Compns
WATER SYSTHM?REATING
8011,5 FEB
forthwith comply with such provisions or Nis permit shall be, deemed revoked.
WATER SERVICE
CONSTRUCTION LENDING AGENCY
Thereby affirm Nat Nerc is uconswainn lending agency for the performance of
NEW RESIDENTIAL PLMB. SQ. PT.
PAID
Date Receipt#
1 the work for which this permit is issued (Sec. 3097. Civ. CJ
Lender's Name
I
ITOTAL:
TOTAL:
Lenders Address
BUILDING FEE
I certify that 1 have mad this application and state that the above information is
correct. l agree to comply with all city and county ordinances and&rate laws relating to
huilding cemwcaon, and hereby midu rite reprtsentatives ofthis city m enter upon the
QTY, MECHANICAL PERMIT FEE
SEISMIC FEE
PERMIT ISSUANCE
ELECTRICF
ah vc-ormooned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupenino against
ALTER OR ADD TO MECH.
PLUMBING
liabilities,judgments, costs and expenses which may in anyway accrue against said City
in consequence of Ne grasdng of this permit.
AIR I[ANGLING UNIT Cf010,000 CFM)
MECHANICAL FEE
APP CANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
3L F. REGUT TIONS.
Nt.
AIR HANDLING UNIT (OVER 10,000 CFM)
CONSTRUCTION TAX
kjo
EXHAUST HOOD(WMUC)
HOUSING MITIGATION FEE
Signature 7flAppRneffaCommistor D:ne
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store orhasdle hazardous mncmd
EATING UNIT (TO 100,000 BTU)
as defined by the Cupenino Municipal Cade, Chapter 9.12, and the Health and Safety
Cade, Section 25532(u)?
D Ye` o
HEATING UNIT (OVER Map" BTI)
PAID "
Date Receipt p
FAN (SINGLE RFSID)
BOILER -COMP (3HP OR 1110,000 BTU7
B use .Air unt ordeviceswhich
Will the air contra orfuturebuilding by
I'll hueardous air ummminams as defined by the Buy Area Air Quality Management
TOTAL
BOILER- COMP (OVER I W." BTU)
District? /
C Yes
AIR CONDITIONER
1 have mailthe hazardous materials requirements under Chapter 695 01 the Cali-
frmia Health & Safety Cvi Sections 25505, 25533 and 25530. 1 understand that if the
ISSUANCE. DA/T!E //��
^% 9Y Pi
NEW RESIDENTIAL MECH. SQ. FT.
'ding does nm currently have amount. Nat it is my responsibility to notify the occupant
D --.
r I
rt'mm mswhi< mustbemerpdoraoissuasceofa Ceni(emeoftxcu
!
ISSUED BY: s
TOTAL:
O er suthonzed tug Date
OFFICE