S 0172APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING. ELECTRICAL PE MITNO.
CITY OF CUPERTINO PLUMBING - MECHANICAL 9 0172
BUILDING DIVISION APPLICATION/PERMIT ant nsvr. Pan leer IBbIN7FiVATION
LICENSED CONTRACTOR'S DECLARATION -
I hereby affirm thin 1 um licensed under provisions of Chulncr air
{ODC with Section]t3110)of Division 3 of Ne Businessland PrafesxionsCale. and my license is
F ly.. in full force and effect. oil
V F License Cl!Lic. N -
Date Contmc M' ��
ARCHITECTS DECLARATION
Z FO y I understand my plans .shall he used as public records
oz—
u01 Licensed Pmfeasamild
••1 OWNER -BUILDER DECLARATION
a 1 hereby affirm that I am exempt from the Commnor'a License Law for the
iy5 O
as U following remod (Section 7031.5, Business and Profession., Code: Any city or county
sft 3 B. F which requires o permit to construct, ala, improve, demolish, or repair any nwcmre
�WWti prior to its issuance, also requires the applicant for such permit to file a signed statement
CY
thm he is licensed purxuanuo the pmvisi.m.fthe Commerce. License Law (Chapter 9
�I Op (commencing
with Section 9MB.f Division 3ofthe Business and professions Cade)or
L q m Of that he is exempt therefrom and the basis for the alleged exemption. Any violation nl
YXl {e. Section 7031.5 by any applicant for v Permit subjects the applicant in a civil penalty of
of morethan rose handled dollars(SSW).
C Q ❑ I, as owner of the pmiserry,or my employees with wages us their sole compensation.
C2 will do the work. W the morGere isnot intendW or offered for sum (Sec.]M4, Business
L and Professions Code: The Conuactola License law does not apply m an mune, of
pmperry who builds or improves thereon, and who free such work himself or through
his own employees, provided that such improvements me ma intended or offered for
sale. If. however. the building or improvement is sold within one ynnof completion,the
owner -builder will have the burden of proving that he did not Wild or improve for Pur-
pme of sale.)
❑ 1, as owner of Ne pmpeny, am exclusively co are ing with licensed commdors m
construct the project (Sec. TW, Business and Professions Cade) The Contractors Li-
cense law does not apply to an owner of property, who builds or improves daemon, and
who contracts for such projects with acommciar(s) licensed pursuant to the Collimator's
License law.
❑ I am exempt under Sec. , B & P C for this reason
❑ Consultant Fees Paid by Applicant (Initial)
ELECTRIC PERMIT
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL
PANELS
UP TO 200 AMPS
SIGNS ELECTRICAL
SPECIAL. CIRCUITWISC.
TEMP. METER OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS -SWITCHES -FIXTURES
NEW RESIDENTIAL EI.ECTR SQ PT.
�Owner Date
WORKER'S COMPENSATION DECLARATION I
1 herby affirm under penalty a(perjury one of the following dedamtions
❑ (have and will muintainn Cemificaa of Gsroem mselGinsure for Wrrker's Cnmpen- I
cation, as providW for by Section 37M of the labor Code. far the pmfommence of the
work for which this permit is issued.
1 have and will =,main Worker's Compensation Insurance, as required by Section
3700 of the Lmor Code, for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance carver and Policy number are:
Cartier: Policy Na:
CERTIFICATE. OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE.
(This section need not he completed if thepermit Is for one hundred call... (SIM)
or less.)
I cenily Cham in r of the work for which Nis permit in issued, lshall
not employ any Penn n m m tt mgps uo the Woken.' Compen-
Ox cation laws of Cath ruse 1`k
7 Applicant
F7 fq NOTICE. TO APPLICANT: If, alcor m king this Cenificvte of Esemption, no .should
I•' become subject to the Worker's Compensation provisions of the Labor Cade, you must
94 forthwith comply with such provisions or this permit shall he deemed revoked.
Q
CONSTRUCTION uctNDING AGENCY
Li I for
rwhich tmthmron i isaced(See 30lending agency forthe performance of
the Leaders work
for which this permit is issue) (Sec. J(19], Civ. CJ
U Leader's Name
r {IL Lender's Address
f... I, 1 candy thin I have real thisapplication
an county c sma that the above information In
F N coiled. l agree el comply with all city mM county ntdinanas tris xmm laws relating to QTY.
U z building constmctinn, and hereby authorize representatives of this city manor upon the
above-mentioned Ptolemy for imPemion Pugmoaes.
(Wa) agree m rove, muttony and keep harmless the City of Capetian against
liabilities,judgmems, cos andespcnuswhicIt may in anyway accrue against said City
in consequence of the g ting. this permit.
APPLICANT GNEi 'AND, AND WILL COMPLY WITH ALL NOT -POINT
HAZARKOUS MATERIALS DISCLOSURE
Will theapplieam or fumm building occupvm nine or handle huzarclnus material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 25532(0'I
❑Yes *0
Will the applicant or future Wilding attapanl use equipment or devices which
emit hazardous an cortmompnts as defined by the Ray Area Air Quality Management
District?
❑Yes No
Ihove the �zallous mvmrmil requiaments under Chapter 6.95ofthe Cali-
fo�1�4'�Iu,1{th fatlI�IrICadc, Taboos 25505. 25533 anal 25534.1 understend thin if 'he
M1ouldir� dJc� of mrteptly have a tenam, that it is my responsibility In ready�the rccupant
( u
,w must M nm prior m issuance of a Cemif�m mf �I up�ncy.
PLUMBING PERMIT
'ERMIT ISSUANCE
\OPER- GRAIN & VENT - WATER (EAI .
LACK FLOW PROTECT. DEVICE
)RAINS- FLOOR, ROOF, AREA, COND,
FIXTURES-PERTRAP
GAS -EA. SYS]T?M-I INC.4 OUTI.FrS
GAS - EA. SYSTEM -OVER 4 (EA)
GREASFIINDUSTRL WASTE ING LRCEFTOR
GREASEIRAP
SEW ER - SANITARY - STORM EA. 2(N) FT.
WATER HEATER WIVENT?LECfR
WATER SYS1 ENUTREATING
WATERSF;RVICE .
NEW RESIDENTIAL PLACE. SO. FT.
MECHANICAL PERMIT
AUGER OR ADD TO MECH.
AIR HANDLING UNIT (T0 10,000 CFM)
AIR HANDLING UNIT (OVER IMight CFM)
EXHAUST, HOOD VIMUC I
HP.ATI NO UNIT (TO 100.0110 BTU)
HGTING UNIT (OVER 100.0011 BTU)
VENTILATION FAN (SINGLE RESID)
BOILER -COMP (3HP OR 1011.000 BTU)
BOILER - COMP (OVER 100,W0 BTU)
AIR CONDITIONER
N EW RESIDENTIAL MECH. SQ. FL
OFFICE
G
BUILDING PERMIT ENI°O
HLDG ELF, PLUMB MECH
❑ ❑
FEE JOB DESCRIPTION
RFSIDFNTIAL'
❑SFDWL ❑ KITCHEN REMODEL
❑ADDITION ❑ PLUMBING RETIPE
El MULTI -UNIT ❑STRUCTURAL
MODIFICATION
❑INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT 0SWIMMING POOLS
❑ BATH REMODEUREPAIR ❑ DEMOLITION
El OTHER
COMMERCIAL:
❑ NEW BLDGIADDITION ❑ DEMOLITION
;NpNT ❑FOODSERVICE
PROVEMENT
❑ OTHER
S (1D�VEA VSQ. F117.JU11011 zcv
FEE I! SI
I / (Jf CUr�MI'INO
ey
►11400.
STORIES -'
TYPE CONSTRUCTION
V�
OCC.GROUP
APN
BUILDING VISION PEES
PLANCHECK I•
ENERGY PER/
PAID \i _D �—
Di' Rtteipt N
BUILDIN 'EE
EFF? SEISMIC E
ELECT CFEE
PLUMB G FEE
MF.CHA ICAL FEE
CONSTR ION TAX
HOUSING M GATION FEE
PAID
Data pt N
TOTAL'.
ISSUANCE DATE