S 1697APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CCPRRTINO BUILDING -ELECTRICAL PE IT NO.
TUILDINGDIVISIpN 9'9'IaL' PIAMBINC-MECHANICAL, 1697
ER SC PHONE
JARIIIITECT/ENGINEER:
'RACI'OR'S NJ "wrifli. LIC O:
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NIC
❑
CONTROLN
hIC NO: OODURE�SS'
1-1j.s5
N'AC . PHONE
ILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant (Initial)
BLDG ELFT PLUMB MUCH
1:1LICENSED
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CONTRACTOR'S DECLARATION
1 hereby nation that I (tin licensed under provisions of chapter 9leommencing
with Socuon ]IX0)ofDivision3 of the tlminess and fesvioos adean my license is
to full l'nracrosl t. ZD ,
Lt°cn tae' N
Date Cnnl2ctnr
ARCHITECT'S DECLARATION
I underswnJ my plans shAl he used as public records
QTY ELECTRIC PERMIT FEE
JOB DESCRIPTION
RESIDENTIAL
❑SFDWI, ❑ KITCHEN REMODEL
❑ADDITION C1 PLUMBING RE-PIPE
URAL
❑MULTI -UNIT ❑MODIFICATIO
MODIFICATION
11 INTERIOR ❑CHIMNEY REPAIR
P17RMI'1' ISSUANCE.
APPLIANCES -RESIDENT'JAI.
PANELS
Oil T0201AMP5
=Fe,O1�
IMPROVEMENT E] SWIMMING POOLS
Licensed Professional
201-11100AMPS
Y23
C Q
O e. U
LLJ
not I w -exempt fir m Ce Cmura(1N
I hereby alRrm that I am exempt from the Commctor's License Law for the
maintains ...In. (Section 7031.5. Rusincss aad Professions Code: Any city or cnumy
which requires n permit tO "w"On", tire, improve, demolish, or mpair any structure
prions is issuance. also requires the applicantfor such permd In file o signed statementSPECIAL
❑BATH REMM FSP])$ CD�yYI01.1T10
❑OTHER
OVER 1000AMPS
is SIGNS ELEC1 RICAC
CIRCUI FIM ISC.
...3...777
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C0�Ikomami
qq oy
Ulm,
FZY
SQp
that he is licensed pmemor es the provisions(it 'the Contrucior's License Ltw(Chapter 9
ng with Seaton 7008 of Div W. 3 of the Businessand Professions Cade)ar
that he is exemp therefrom and the basic for the alleged exemption. Any violation of
Section 70315 by any applicant for a permit subjects the applicant est a civil penalty of
man than live hundred dollars (5500). ns
C1, vsownermfthe 1wan hi myempbyeeswith wage -s rale( (See.001.Rmtion.
will daahewmis and the Business
TEMP. METER ON POLE INS,COMMERCIAL
❑ NEW BLDG/ADDITION ❑ DEMOLITION
❑TENANT ❑ FOOD SERVICE
OTHER IMPROVEMENT
[I OTHER
POWER DEVICES
SWIMMING 11001, ELECTRIC
3
he Contixnot s License Law doestafferval
not apply to an
and Property wh b Code r The Contractors License Lawarksnotapplytolf Owner of
his own who builds or improves thereon. and who dors such work himself orthroughf
his own employees, prnviMd ohm such improvements arc nm imendil or uttered for
sale. If. however the building or improvement is sold within one year ofcompletion, the
OUTLE3:S-SWI'I'CHIS-EIX'rURFS
NEW RESIDENTIAL ELGL:'R 5
SQ. Ff. FLOOR AREA LSQ. Ff.
nerhoilder will have the burden of proving that he did not build or improve for pur-
Top
pos, of sale.).
contemn to
C 1, as mater of the pmpeny, am exclusively contracting with IimnsWone
onswct the peyect (Sec. 7B4q Business and Professions CodcU'I he Cnntrmm�v's I-
use Law does not apply m an owner of property who hadd, or improves thereon,and
P1 A '
p D
SJ
QTY. PLUMBING PERMIT �F
who contracts for such pmjens with a comm chos) licensed pummuuo the Contractors
PERMIT ISSUANCE
License Low.
C 1 too cxa upt under Sec. , B & P C for this reason
flI �q/'Ia
n'
MAY
ALTER - DRAIN & VENT' - WATER (EA)
VALUAT
Owner Dam
CITY
WORKI!R'S COMPENSATION DECLARATION
1 herchy aRrm under penalty of perjury one of me following dechersim s:
HACK PLOW PROTECr. DEVICE
Ur-. LUrcn l uvU
STORIES
OCC. GROUP
TYPE CONSTRUCfIOt
,
APN
�Ihave mJ will,naimaima Cerifiem-d Conseuno,elf-insure for Worker's Compen-
as provided for by Section 37M of the Labor Cade, for the performance of the
trk for which this permit is issued.
I have and will maintain Worker's Comlwmation Insurance, as required by Section.
37(X1 Of he laths�TCale, for the rformance of the work for which rhos permit ix izx Of
y fee gttlp �yi`r F ce c e, and Poli t e O /xr1
Car ri r. VVV ���� CPolicyN Ute
DRAINS - FLOOR, ROORA .CON
FIX'PURGS - PER TRAP
GAS-IA.SYSIEM-I INC.4OU'I'LHTS
GAS -1!A. SYSTEM -OVER
GREASf%INDUSTRI. WASTE INTERCEPTOR
CF.R71IFICATE OFfi iMfT10N FROM WORKERS'
COMPENSATION INSURANCE -
BUILDING DIVISION 11MS
GREASE TRAP
PLANCfIECK FI!E
(Hussecvien need son he completed lfthe pwout is forone hundred dollars(5100)
or less.)
SEWER -SANITARY-STGRMEA. 20OFE
ENERGY FEB
I certify that in the p wformance, ofthe work forwhich this pera it is issued, l shall
urn employ any loess's in vny manner>n as m hcomc subject m the Workers' Compen-
WATER HEATER WNENTIELECTR
GRADING PER
,Z
Lk1
Q
UDThereby
Us fir
smion Laws of Coliforms. Data
Applicant `
NOTICE TO APPLICANT: IL after making this Certificate of Exemption, you should
bec mic subject to the Workers Compensation provisions of the lather Code. you most
forthwith comply with such provisions lir this permit shall be Jeered revnkeJ.
CONSTRUCTION LENDING AGENCY
aBlrtn that thea ixemmwetion lending mgenay fm doe performance of
the work for which this permit is IssuW (See. 3097, Civ. C.)
lender's Nam
Lenders Address
WATER SYSTEM)TREATING
SOILS FEE
WATER SERVICE
PAID
me ReceiptN
NEW RE5IDEN'1'IAh PLMII. SQ. FT.
TOTAL: -
TOTAL:
0 LUk1
U,Z
a UTJ ING It E
I certify that 1 have read this application and state that the above information is
worst. l agree to comply with all city and county ordinances ail state laws relating to
buildingamstmetion, and hereby authorize npnsentatives ofthiseity to cater upon the
above-mentioned proprty for inspection purposes.
(We)agrecui ma. indemnify and keep harnlcs the City of Culemino ug.iao
.QTY, MECHANICAL PERMIT FEF.
SEISMIC !8
PERMIT ISSUANCE
ELECT IC IIiG
ATTER OR ADD TO MECH.
PW ING FEE
hadities,judgntend, costs and expenses obch may in any way aceme againstsaid City
in asequence of the granting of this permit.
AI R IIAN DLING UNIT(To I(Mayl CFM)
Mf.HANil AL FEE
APPI UNDERSTAND NO WILL COMPLY WITH ALL NON -POFD
S RCE REC LLAT ♦ zzi
AIR HANDLING UNIT'(OVER 10,000 CFM)
NSTRUCTION FAX
SlIlIF111IFFOLAHdoucanometer r
EXHAUST HOOD(W/DUCT)
OUSING MITIGATION FEF.
HAZARDOUS MATERIALS DISCLOSURE
HPXI'ING UNIT(TO 110,000 HTU)
_
Will the applicant or future building occupant stormshandle hazalloismnmdal
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Cite, Section 25532(0)7
❑Yes CNn
HEATING UNIT (OVER 11116013 BTU)
v
PAID
to Receipt N
VENTILATION FAN (SINGLE RLSN)
Will the applicant or future buildmng tccuptm use equipment or devices which
<rrttppI hazardous air contaminants as defined by the Buy Area Air Quality Management
rlct 7
C Yes (j NO
BOILER-COMP(3HPOR 100.000 BTU)
TOTAL:
BOILER -COMP (OVER 100.00 BTU)
AIR CONDITIONER t
ISSUANCE DATE
I have read the haeardoes materials requirements under Chaprtrd95ofthc Cali-
NEW RESIDENTIAL MECH. SQ. PT.
forms Health & Safety Code, Sections 25505, 25533 and 8534. 1 uMenmtul that if the
building docs not earmndy have a tenant. that it is my responsibility m notify the occupant
of the requirements which must he nret prior m issuance of a Certificate of Occup rvx .