30200 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO _ BUILDING-ELECTRICAL PERMITNO. 0
BUILDING DIVISION APPLICATION/PFRMIT PLUMBING-MECHANICAL
BUILDING PROIRCT IDENTIFICATION
BUILDING ADDRESS: SANITARYNO. APPLICATIONSUBMITTALDATI
Lb
OWNF. WN PHONE: CONT k CTO R'S M^ LIC NO:
I in NIC CONTROL#
�\RCHITECT/ENGINEER: LIC NO: ADORES ❑ ko"461
CONTA PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
Hl $ ❑ ❑ ❑
LICENSED CONTRACT'OR'S DECLARATION QTY ELECTRIC PERMIT FEE
I creby affirm that I am licensed under provisionsof Chapter 9(commencing JOB DESCRIPTION
,O„OZ with Section]000).fDivision3 of me Pusineaa and Professions Code,and my license is RESIDENTIAL:
.f�., in full force and ellen. PERMIT ISSUANCE
�mak." OSFDWL ❑KITCHEN REMODEL
VUU License Class Lic.p gppL1ANCE5-RESIDENTIAL OADDITION ❑PLUMBING RE-PIPE
�<aWe Contractor
ARCHITECTS DECLARATION PANELS OMULTI-UNIT 0STRUCTURAL
�
~v� I understand J my plans xhall used art
z public c.Na MODIFICATION
UPT02MAMP5
GZ�f� - OINTERIOR ❑CHIMNEY REPAIR
�Q�F❑❑" Licensed Professional 201-IIX1U#MPS IMPROVEMENT
Oat I am exempt
from
m the Con ION
eco. OVER HMAMPS G BATH REMODEL,REPAIR 0 DEMOLITION
3K 6 I hereby alum that 11. a rept from the CommemrCode:Any c Law for the
aU which followinga.
Permit
]B)LS.Busiler, pmvrro demons rrpmrily or county SIGNS ELECTRICAL OOTHER
0. which,its hom a pennil m aims the,alien improve,demolish,nr repair say statement
thathes issuance,also requimsthe applicant for such permit Glia signal atamnrem SPECIAL CIRCUIT/MISC.
that he is licenmdpmxmmImmeprovisiona.fda C.ntact.ra Liccom l.ow(Chapler9
GG�O (commencing wish Section 7")ofDivision 3 ofthe Business and Professions Cade)or TEMP.METER OR POLE INST. COMMERCIAL:
That he is exempt therefrom and the basis for me alleged exemption.Any violation of NEW BLDG/ADDITION O DEMOLITION
Y•
Section 7031.5 hmi
yany applicant for a pertsuhjecv the applicant to a civil Penalty of POWER DEVICES
any TENANT OFOODSERVICE
Gnot mote Than five hundred dollar y employees
[]Lo the warof the pro sanctum is emplended with wages as theirsole70ntpensetinn, SWIMMING POOL ELECTRIC IMPROVEMENT
C will Jn me work,and the sanctum is not intended or.ffertd for sale(Stt.]fH4,Business ❑OTHER
�'3m and Rvfessions Cele:The Contractor's License Law does not apply to on owner of OUTLETS-SWITCHES-FIXTURES
property who huilds or improves thereon,and who docs such work himself or through
his own employees,provided that such improvements am not intended or offered for NEW RESIDENTIAL ELECTR SQ FT.
sole.IL however,the building.,improvement!,,aid within one year ufcompletma,the SQ.FT.FLOOR AREA $/SQ.IT.
owner-builder will have the burden of Proving that he did not build or improve for Pur.
pone of sale,. ( p 2 3S
O I,as owner of the prnpeny,mm exclusively contracting with licensed comntemrs to T'Lk t
construct the project(Sec.]IHS,Business hind Philistines Geed The Contmctora Li.
cense Law does not apply to an,owner of property who builds or improves thereon,and QTY, PLUMBINGPERMIT FEF.
who contracts for such projects wit a comracmr(s)licensed Pursuant to the Conuactor's
License Law. PERMIT ISSUANCE
❑I am amroptunder,Sec. ,B&P C formic remain
0O e Date ALTER-DRAIN&VENT-WATER(EA) JUL-Z ION
WORKER'S COMPENSATION DECLARATION BACK PLOW PROTECT.DEVICE r
Game,l hereby affirm under penalty of perjin,.,car me following dechou mom: Wert rv' /•t 1—ji- A1.
1lhave and%ill maintain a Ceniftcte ofComem to self-insure for Workers Compen- DRAINS-FLOOR,ROOF,AREA,COND. ^ � —STORIES - TYPE CONSTRUCTION
ammo.,as Provided for by Section 3]00 of to Labor Code,far the ped'arramee.fine
work for which this pennil is issned. M(TURES-PER TRAP
I have and will maintain Workers Compensation Intuitionism,as rtquirtd by Section -
3'/W of the Labor Code,for the Performance of the work for which this permit is issued. GAS-EA.SYSTEM-I INC.4OUTLETS
pCC.GROUP APN
My Workers Compensation Insurance calmer and Policy number arc:
Carrico Paiey No.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASOINDUSTRI,WASTE INTERCEPTOR
(This section need nm be completed dune permit is loran hundred dellars($100) BUILDING I VISION FEES
ur less.) GREASETRAP ' PLANCHECK FEE
I certify mal in the performance aloha work for which this permit it issued,l shall
notcmPloy uny parson in any manner so aemhecrnne suhject to the Warkers'Cnmpen-
SEWER-SANITARY-STORM EA,200 PI'. ENERGY FEE
C z train.Laws of Celif.mia.Date WATER HEATER W/VEN/EL[LTR
Q Applicant - GRADING FEE
N NOTICE TO APPLICANT If,after making this Certificate of Exemption,you should WATER SYSTWITREATING
became subject m the Worker's Compensation provisions of the Labor Cade,you must SOILS FEE
Wforthwith comply with such pmemaims orchis permit shall be deemed rev.ked. WATER SERVICE DV
7 z - CONSTRUCTION LENDING tion lending
NEW kIiSIDENTIAf.P1.MB. SQ,FT, PAID
UQ 1 hereby work
dolhat them.iti issued Se .ion len ding agency for performance of ons Receipt If
U. F rework for which tin permit in issued l$ec.31197.Co,CJ
0U
Lender's Name TOTAL:
It1 Lembar's Address TOTAL:
I
y certify that 1 have rcaJ mit application and shite thin the about information is BUILDING FEE �
pz correct.I agree to comply with all city and county ordinances and state laws mulingm QTY, MECHANICAL PERMIT FEE
V Z mildingconstructionundhereby amhromerepremoutivcs oflhiscity meala.,or the SEISMIC FEE `
above-mentioned prnpeny fill inspection Imposes. PERMIT ISSUANCE
(We)agree m save,indemnify and keep hamdess the City of Cupci inh agolnat I ELECTRIC FEE
Iiabilitiee,juJgmcma,cons cx meswhich may in any
way accrue against said City ALTER OR ADD TO MF,CIi.
inconics,ju gamaleg mg ix pemrin. PLUMBING FEE
APPLIC T UNDE 'AN S NO WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
SOURC EGULATI S. MECHANICAL :E
u: AIRHANDLING UNIT(OVER 10,000 CFM)1AAA CONSTRUCTIO TAX -
Signatti Applicant v
nactor - Da EXHAUSTHOOD(WMUC)
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIG ON FEEN
ill the applicant or future building occupant store or handle hazaous material HEATING UNIT(TO 100,0011 BTU)
to alalia d by the Cupcnino Municipal Code,Chapter 9.12,and the Health it Safety
Cabe,Section 2553200? HEATING UNIT(OVER 100,000 BTU)
❑Yea ONo
,VENTILATION FAN(SINGLE RESID) PAID
Will the applicant or future building ant use a tem or devices which Dam Recct #'
PP lby the it Air BOILIiR-COMP OHP OR 100.1X1(1 BTU)
mit Dhe istrict? s air conlaminoms as defined by the Bay Area Air Quality Management
DiaviclP TAI:
❑Yes ON. BOILER-COMP(OVER I00.000BTU) /
I have read the humNous materials mncimnentz under Chapter 6.95.fine Cali- AIR CONDITIONER ISSUANCE DAT
forma Health&Safety Code,Sections 25505.25533 and 25534.I understand mat if an, NEW RESIDENTIAL MECH. SQ,PT
building does not eminently have a tenant,that it is in,u,nomsibility m notify the occupant
of to exprimments which twat he,mea prior to issuanm site Certificate of Occupaoey.
Owner car amhmised agent One A I ISSUED BY:
OFFICE