S 1002APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO
UGL'NS40C NfRAc OKsuLCLARAIIUN
1 hereby arum mat I sm live" etiander pmvisbms of Chapter 9 (commencing
wim Svctian](Xltl)aroivi,.ion 3oflhcBuancss ane Professions Code. aodmy Baaam is
in full fares amt e0em.
Li<enu Class Lic.x
Dmc Contractor
LUMIR NG.O - ELECMECHANICAL CALICA
PLUAIRING-NHCIfANICAI.
JOB DESCRIPTION
RESIDENTIAL_
OS' WL ❑ KITCHEN REMODEL
ADDITION ❑PLUMNING RIid'll'li
C31 1171 -UNIT C3 STRUCTURAL
MODIFICATION
0INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT SWIMMING POOLS
El BATH REMODEUREPAIR 0DEMOLITION
❑OTHER
iD A I n
PF,�N11T N0. 1 O O
`v
BUILDING DIVISION
APPLICATION/PERMIT
ARCHITECTS DECLARATION
l understand mMsed., y pi...h. Iu.publlcrecorJ.a
PANELS
U,T02m)AMPS
L
Lcensed Professional
-BUILDER DECLARATION
I hereby affirm that I am exempt from the Commcmr's License Law far the
following reason. (Section 703 1.5. Business and Professions Cade: Any city or county
which reytdma. permit in cnnswct alter, im,ra , dem..hd. m rcpmr any "o'him
its issuance, also requires Ne applicant for such permit to flcangned statement
also
that he is licensedp rmato in the provisions of due Conoctor's Livensece La (ChapterY
w'th Section ]1110) ofD' Isi .3 ofth Ba,na., adl fi,,i ...s Codc)nr
thin he is eacrop ffirmfixon and the lawas far N II g d t,,wanplimrt. Any violation of
Secorm 7031.5 by any applicant for a Permit. subjects the applicant to a civil penalty of
not tome than five hundred dollars f45W1.
0 Las owner of the Empeny,ormyemployees with %agesastheirsoleexmpensation,
wi 11 it,, the work, eaJthestucmre isnot intended omRered formle Se, 7(H4 Business
and P..lead... Code: The Contractor's License Law does not apply to an owner of
property who builds or improves thereon, and who does such work himself or through
his own employees, pravided that such improvement, aro nm intended or offered for
sale. IL however, the building or improvement is sold within one year f completi it'he
owner builder will have the burden of proving that he did not build (ir improve for pur-
pmn of 4a1c.)
1, as owner of the Sec.property, am extlus and contracting with licensed contractors to
consumer the project (Sec. ]044, Rosiness any Professions with licensed
Li-
The Contractor's to
cense Law does not apply to an owner of property who huiltE, or lmpmves therein. and
who contracts for such projects with a contractors) licensed pursuant to the Contractor's
License Law.
1 am exemptrcd Sec. B k PC far thio reason
s
2014000AMPS
BUILDING PROJECT IIIEN'TIFICA'I'ION
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC.
BUILD
GADDREYS:
o RI DIT? 010LITION
TE
❑IMPAN'I' ❑FOOD 51iRVICIi
�9Th"I� UUru111NU
1:1 OT
POWER DEVICES
SWIMMING POOL ELECTRIC
SANITARY NO.
APPLICATION SUBMITTAL DATE
NEW RESIDENTIAL LLECTR SQ IT.
SQ. FE FL( AREA
'''yyp�����eee..'
SISQ. FT.
T'
QTY- PLUMBING PERMIT FET?
O 'NIiR'SN F]F..�11
Aa PHONE:
_
CONTRACOR:S NAME:
LIC NO:
NIC
CI OLM
BACK FLOW PROTECT. DEVICE
DRAINS- FLOOR, ROOF, AREA. COND.
STORIES
'1'YPECONSTRUCTIOD
❑
If
ARCHITECI'/ENGI FMR. LIC NO.
ADDRESS:
CONTACT
PHONE: I
BUILDING DIVISION FEES
CNEASETNAP
BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant (Initial)
W OO
�1F
a_$u
W
UGL'NS40C NfRAc OKsuLCLARAIIUN
1 hereby arum mat I sm live" etiander pmvisbms of Chapter 9 (commencing
wim Svctian](Xltl)aroivi,.ion 3oflhcBuancss ane Professions Code. aodmy Baaam is
in full fares amt e0em.
Li<enu Class Lic.x
Dmc Contractor
QTY ELECTRIC PERMIT FEE
JOB DESCRIPTION
RESIDENTIAL_
OS' WL ❑ KITCHEN REMODEL
ADDITION ❑PLUMNING RIid'll'li
C31 1171 -UNIT C3 STRUCTURAL
MODIFICATION
0INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT SWIMMING POOLS
El BATH REMODEUREPAIR 0DEMOLITION
❑OTHER
iD A I n
PERMIT' ISSUANCE
APPLIANCES - RESIDENTIAL
Q
'-Z
'Z,.Q
ARCHITECTS DECLARATION
l understand mMsed., y pi...h. Iu.publlcrecorJ.a
PANELS
U,T02m)AMPS
t?F{y
6oiHOWNER
CCw 6
O C. V
3 O y
'prinna
V'}
aC�(Coninamning
d e IY
X^a'
=6
a3 m
Lcensed Professional
-BUILDER DECLARATION
I hereby affirm that I am exempt from the Commcmr's License Law far the
following reason. (Section 703 1.5. Business and Professions Cade: Any city or county
which reytdma. permit in cnnswct alter, im,ra , dem..hd. m rcpmr any "o'him
its issuance, also requires Ne applicant for such permit to flcangned statement
also
that he is licensedp rmato in the provisions of due Conoctor's Livensece La (ChapterY
w'th Section ]1110) ofD' Isi .3 ofth Ba,na., adl fi,,i ...s Codc)nr
thin he is eacrop ffirmfixon and the lawas far N II g d t,,wanplimrt. Any violation of
Secorm 7031.5 by any applicant for a Permit. subjects the applicant to a civil penalty of
not tome than five hundred dollars f45W1.
0 Las owner of the Empeny,ormyemployees with %agesastheirsoleexmpensation,
wi 11 it,, the work, eaJthestucmre isnot intended omRered formle Se, 7(H4 Business
and P..lead... Code: The Contractor's License Law does not apply to an owner of
property who builds or improves thereon, and who does such work himself or through
his own employees, pravided that such improvement, aro nm intended or offered for
sale. IL however, the building or improvement is sold within one year f completi it'he
owner builder will have the burden of proving that he did not build (ir improve for pur-
pmn of 4a1c.)
1, as owner of the Sec.property, am extlus and contracting with licensed contractors to
consumer the project (Sec. ]044, Rosiness any Professions with licensed
Li-
The Contractor's to
cense Law does not apply to an owner of property who huiltE, or lmpmves therein. and
who contracts for such projects with a contractors) licensed pursuant to the Contractor's
License Law.
1 am exemptrcd Sec. B k PC far thio reason
s
2014000AMPS
OVER IINX)AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC.
.<
TEMP. ME I ER OR POI -17 INS' I'.
o RI DIT? 010LITION
TE
❑IMPAN'I' ❑FOOD 51iRVICIi
�9Th"I� UUru111NU
1:1 OT
POWER DEVICES
SWIMMING POOL ELECTRIC
OU'TLE'TS- SWI 'ICHM-FIXTORES
NEW RESIDENTIAL LLECTR SQ IT.
SQ. FE FL( AREA
'''yyp�����eee..'
SISQ. FT.
T'
QTY- PLUMBING PERMIT FET?
PERMITISSUANCE
AT TER - DRAIN .& VENT- WATER (EA)
�\
(�anc Date
♦♦ VALUATION
WO�F MP; SATION DE CATION
Ihereby aRp pvirml of perjury one cfalbswing declarations
❑ Ihava and will muimam aCmificme ofCnnsmn mself-in...efm Worker's C.... en-
cation, as provided for by Section 377 of the Lakin Code. for the psmame nce of the
work far which this permit is i ... or
❑ I Love and will nunoun Worker', Compursmian Insurance, m required by Section
370 of me Labor Code. for the performance of be work for which this permit is issued.
My Workers Compensation Insurance comer and Policy another are:
Currier: Policy Na:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Phis section need not he completed if the xvion is Torahs hundred dollars (SRX)
or less.)
Ie,any that in the purfnnnueco a, ,, ork Naomewake this perthe in Worker, Caniha0
not employ any Person in any manner so us m Hearne subject to the Worker' Compen-
C)z sainn Laws of Culifomio Date
z O Applicant I
M NOTICE TO APPLICANT: If, after making this Cenificam of Exemption, you should
a' become subject to the Workers Compensaino provisions of the laky Gule, you must
W forthwith comply with such provisions or this permit shall he deemed revoked.
Q
Uz CONSe.isa tumor ;holeGAGENCY
rwhich affirmifa thereissued Sce. 30lending agencyin, the prbnmonmof
UQ I far
(L h the walk far which this cennit is issued (Sec. 309], Civ. CJ
O Lenders Nunm
,r Lenders Address
1 cemy that 1 have read this applkarnn and sum that the .Nice infnrmauan is
FF...�,1
F -i %1 correct. 1 agree m comply with all city and county ordinances and state laws relating to
UZ building construction. and hereby authorize representatives of this city to enter upon the
akon mentioned propcny for inspection purpose,.
(We) agree to save, 'indemnity and keep harmless the City of Cupertino against
inanywayaccmeagairad,udCity
asequence of stenting of tis permit
. 1 sRSTANDS ANU L COMPLY WITH ALL NON -POINT
SOURCE TIONS.
BACK FLOW PROTECT. DEVICE
DRAINS- FLOOR, ROOF, AREA. COND.
STORIES
'1'YPECONSTRUCTIOD
FIXTURES -PER TRAP
GAS - EA. SYS'I M- 1-I INC, 4 OUTLETS
OCC. GROUT'
APN
GAS - EA. SYST'IiM-OVER 4 H;A)
GREAS191NDUS'I'RE. WASTE INTERCEPTOR
BUILDING DIVISION FEES
CNEASETNAP
PLANCHECK FEE
IiNERGY FEE
SI?WEN-SANITARY-S'IORM EA. 2!X114.
WATER HEATER WNENT/ELI!CfR
GRADING FEE
WATER SYSTEM/fREA'TING
SOILS FEE
WATER SERVICE
PAID
Il'te Receipt
NIiW RESIDENTIALPhMN SQ IT.
'fU'IAL:
TA :
Ly
T;
QTY. MECHANICAL PERMIT FEEO
E
PERMIT ISSUANCE
'may
AI,TERORADDTOMECH.in
FEEAPPLICANT
LFF.EAIR
A
AIR HANDLING UNH'(1010.010CFN)
HANDLING UNIT(OVER 10.0N) CFM)
T ION TAXSign
sof Applies car Date
DOUS MATF,RIALS ITIS , . URF.
Will the applicant on future building occupant ar handle Economic material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health tray Safety
Code, Scctian 25532(.)?
E] Y, ❑Nn
WIII the applicant or future mildin t use equipment or devices which
` pp gnccupun .Air
:mit ha.ideas air nmmminants az JeBsed by the Bay Arca Air Quality Management
s ❑Nn
Iread the homnlnus mwcriak rcquiremmatx wider Chapter 6.95 of the Cali.
dr Safety ed,. Section 25505, 2553 and 25534. 1 malemtand Nat if the
Ldms
nm cummtly have a mount, that it i.s my rcsprmsibility to notify the occupantmmts which must be met prior m is„tanto of a certificate ofOcmpancy.
EXHAUST HOOD(W'/DUCT)ITIGATION
Cai
HEATING UNIT(T'O 100.(X10 BTU)
11 17A ING UNIT(OVER 10.000 BTU)
PAID --
. Dam ceipt k
VI3NTIhA'HON PAN (SINGLE RESID)
BOILER-COMP(3HPOR IW.000ITID
TOIAL
ROILP.R- COMP(OVEH 1010,000 BTU) _
AIR CONDITIONER
ISSUANCE DATE
1ssuED BY:
NEW RESIDENTIAL MECH. SQ. FT.
nmiree actor Date
'I 1.:
•