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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY G q I i n Q (--JI Q
ERTINO BUILDING - ELECTRICAL
ISR)N APIIACATION/PERMIT PLUMBING - MECHANICAL
BUILDING PROJEcr IDENTIFICATION
Y' I'r NO.
S:
FAFIZ_
SANITARY NO. APPLICA SUH L DATE
//-�
PHONE:OR"
MF.: LIC NO:
NIC
❑
CONTROLN
CIIITCCT/13NGINHER: LIC NO:
AppRySS: i
CONTACT': PHONE:
❑ Consultant Fees Paid by Appliwnl (Initial)
BUILDING PERMIT INFO
BL ELECT PLUMB MECH
❑ ❑ ❑
Ey
LICENSED Ii a CONTRACnderpDECLARATION
I norcbr alum t 1 ant ran Bu ural, pmvixvanx ofChapter 9 kamme«ing
wirhSmion ](MXB a the Busincv- ndnxions Cr,Jca Ylicense is
io full force ands c
Liccn I -. Lic. x
Ace
Cnmrvc.
IT
ARCHIiCI'S DE,.
unJccuvnJ my pl;un shall R used is public rcrorJs fig¢"'
QTY ELECTRIC PERMIT FEE
JOB DESCRIPTION
RESIDENTIAL:
0SEDW1, ❑ KITCHEN REMODEL
❑ADDITION [IPLUMBING RE -PIPE
❑MULTI -UNIT C1 STRUCTURAL
DIPICATION
❑INTERIOR >41 MNEY REPAIR
IMPROVEMENT SWIMMING POOLS
❑ BATH REMODEIJREPAIR ❑DHMOLH ION
El Off
I'IiRMI'1'IS5UANCE
APPLIANCE'S _ RESIDP.N'1'IAl.
Up10PANELS
t]'T21X)AMI'S
Gcnnsad Prof ... lana
OatI ree n,coe,1!R the omm,oRNI ION
follbre— idiom that 1 cacmpt hone urbc Cnnvactoo Iwccmc Iy o fou the
whnwlhiguiresa (Section ]1111,5, t, alms and improve, detohCWc:Any dry orammr
which requires n permit err umx.ma, sem. improve, h permit
er mit, or ymr any mm oset
thathe its icowd e.uknngo theics thuiki... otfor such p, vLEense Law(statement
Law (Chapter
that he Inch, h Section
rorhepf Disina nftha eHu%iee%x and Professions
,hot he is ci gwlthmminn]IXXp ufDivixinn9 he alleged a,ss.nd Professions Cadc) or
,hot he is csempr rM1emlmm and the basis fnr mu alleged exemption. Any violation of
Section 70315 by any applicant fora permit subject, the applic..t,. a civil pc..try of
not mote than five hundred dollars CSS M.
MI. as owner o(the prnpca,. or my employees with wages as their sole compensation.
will Jo the work, and the saoctan is not intended or offered for sale (Sec. ]DW. Business
and Pmfauions Cod, 'Me Contractor'x License Law does not apply to an owner of
pmledy who builds or improves thereon, and who does such work himself or through
his own employees, provided that such improvements arc not intended or offered for
sal,If. however, the building or impmvatem is%old within one yearofcamplichim. the
owneolnuilder will have the harden of proving that he did not build or improve for put -
pow of sated.
❑ 1, as aver of the pm. 70,1 ore exclusively contracting wird licensed ThatCconuaaots i-
emtewa the es not (Sec. NH1 owner of and rty who bei Cede:) The Contractor's Li-
c mlaw tvforschplymvnownendpmperty imphaves; hereon.
who <ommcrs for such pmjems with a umavaot(s) licensed purxuvm m the Contruaoh
License law.
❑ I am exempt under Sm. ,B& P C for This reason
211-I0HIAMPS
OVER 1011UAMPS
SIGNS Ir.I,IiC'1'RICAI.
51'P:CIAI.CINCUI'I'/NIST.
'TEMP. ME'H!H OR I'OLI!I .'I'�
COMMERCIAL:
❑NEW BLDG/ADDITION ED DEMOLITION
CD TENANT ❑FOOD SERVICE
IMPROVEMENT
❑ OTHER
POWER DEVICES
SWIMMING POL ELECTRIC
OUTLETS -SWITCHES -FIXTURES
NEW RESIDENTIAL ELECTR SQ ET.
��STJ'FCFCOOR� ��� LSQ. FT.
NOV - 81999
' VAIAA'HON
/S—
TOTAL:
QTY PLUMBING PERMIT FEE
PERM[ r ISSUANCE
ALTER -DRAIN & VENT- WATER RA) B
while Date
WORK17R'S COMPENSATION DECLARATION
1 hereby of inn under renally of perjury one nl the following Jeclarutians:
❑Iand will m- lairaCenifcamoI Cnnmm„self-inmm fnr Workermpen- 's Co
ni m provided for by S«0oo Gf0 of the Labor Coda for the performance of .he
d fnr which tela tenni, is taxi W,
I ava.hid will onaimam W..ke,sC.nlnpcnxarinn Insurance. as mtmfed by Section
JA of tl Labor Cndu.l.n tl n'lihnwnac nf.ha work fnr him Tic lxsuW.
It,, j��j
My Wo ncr and Po1up,
Carrie. Polley /
C17R'1lITCAV: (tl I!MPION FROM WORKERS'
COM PENSAI'ION INSURANCE
(This,Ichor need not be complemd ifinmi
e part is fornhie hundred dollars(H W)
or less.)GREASETRAP
I artily thm thine pedomemccolmm work fnr which this .i, is issued, l shall
not employ any Person in any manner so as to become subject m the Workers' Compete-
sntion laws or California. Dam
Applicant
BACK FLOW IROITC1'. DEVICE
DRAINS- FLOOR. ROOF, AREA. COND.
TORIES
S'E
TY]CONSTRUCTION
p
•b �•qO
FIXTURES - P,R'rRAP
GAS -IIA. SYS'TIIM-I INC.40U'TLETS
OCC. GROUP
AI'
GAS- EA. SYSTEM OVER 4(EA)
GREASIUINDUSTR I. WASTE INTERCEPTOR
BUILDING UI VISION f13ES
PLANCHF,CK PEE
SEWER - SAN[ "1'ASY-STORM EA. 2)PT.
ENERGY FEE
WATER DEALER W/VENT/ELECfR
GRADING FEE
NOTICE TO APPLICANT: If. after making this Certificate of Heir ion, you should
become subject to the Workch Compensation provisions of the Lahr Cotle you must
Forthwith comply with such povi,imv urnspermit shall lcdcemcd ormlad.
” CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a conxwetioncraing agency for the performance of
the work for which this permit is issued (See. 3(5], Civ. C.)
Under's Name
WATER SYSI'EM/fREAI'ING
SOUS FEE
WATER SERVICE
PAID
Dae Receipts
NEW RESIDENTIAL PI.MB. SQ. FT.
TOTAL:
1<ndf,AAJdra,
TOTAL:
1 r.mi mat 1 have mad this ii,liOnion and limiter the abava Infonnmba is
correct, I agree to a....IF wen all dtr ane u,umy orJinvnces and sum laws rtlning m
building construction, and hereby millorire reprcmnarives of This ciry m enter upon the
above-mentioned property Tor impaction purposes
(We) agree to cave, inJunnify and Peep h:mhlesx the City of Cupertino against
Ilxbili.ies.juJgmthis, cosanJex ensa which umymonywayaccmeagainnsaid Ciry
i the gmntin• I... permil.
APPI c AN ca N J T DS AND WILL COMPLY WITH L ON POINT
SOI C' 'OD
BUILDING FEE
QTY MECHANICAL PERMIT FEE
SEISMIC FEE
PERMI I' ISSUANCE
ELECTRIC FEIi
ALTF.H (IRAUDIO MIiCII.
PLUMBING FEE
AIR HANDLING [ING ('TO If (XX) Cl
MECHANICAL PEE
AIR HANDLING UNI'1'(OVER 0,ShCFM)
CONSTRUCTIONIAXS
Signature of Appll:un/ nuucmr Data
MAI PEALS DISCLOSURE
Will the applintm or I milling occupam slim or handl, hac,Mn o nimerial
.as delis d by the Culeninu Municipal Coda, Chapter 9.12, and he Health and Safety
Crile, Section 25532(,)!
❑Ycv [ r
Will mea reamy ildin t use c
hman)ous ally ronrIlncd by 1hcuBay Arta AirnQualiry Manngcmcm
YcsIhavertadthe h6alsrt uimmenuuMcrCha
q purr6.95ofmeCali-
fnmia Ileah & Safety 25505. M533 and 255311 undersuuul ma if the
builJin «s me rerly has ¢sort rha it is my mxpon. 'I'mnmify he «c m
of,, t t m met prior mosvvnce ifiat o p'
13X1{RUST IIOODIWIDUCTI
HOUSING MITIGATION FEE,
IlFAI'INC UNIT H 0 1W.SX) BTU)
HEATING UNIT (OVER I(R.1XI0 BTU)
PAID
Date Receipt x'mil
VENTILKHON IAN (SING LP. RES ID)
BOILER -COMP CHP OR 100,00f) BTU)
TOlUiatricif
BOILER-COMP(OVER I00.(XIUBTID
AIR CONDITIONER
ISSUANCE DATE
ISSUED BY:
NEW RESIDENTIAL MECH. SQ. FT.
Owner or amnnn ugen Dae
TOTAL:
OFFICE