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APPLICANTTO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY 1/ OP 100 1 -7,2
NO nIUMBING -MECHR CA
IT[' DI C DIVISION
BUILDING DIVISIpN APPI,ICATION/PERMIT PLUMPING. TIDEWIFIC
BUILDING PROJECT IDN'.NTIFICATION "
I'
UILDING ADDRESS: �{ .{' �['
O \ S! 1
I'WNER
SANITARY NO.
APPLICATION SUBMITTAL. DATE
'�_(?�
'SNAME. PHONE:
CONTRACTORS NAME: LIC NO:
NIC
❑
CONTROL
CHITECT/HNGINEER: LIC NO:
ADDRESS: •7 I/ ♦I TIQ p�, �r
7 /�
171.14
❑ Consultant Fm Paid by Applicant (Initial)
covracr: PHONE :
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
❑ ❑ W1 ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby oRnn that I am licensed under provisions of Chapter 9 (commencing
with Smtiun]IXq)n(DivisinnJ of the Rosiness and Professions Caie. ane my Lcenae is
in full force an�/lw�fq��� //j�
Licen.c mess +�--A(A_1G_ Lies
I Due Cnrypy
QFY ELECTRIC PERMIT FEE
JOB DFSCF.IPTION
R SID NTIA ,
❑ SFUWI. ❑ KITCHEN REMODEL
❑ADDITION C1 PLUMBING RE -PIPE
❑ MULTI -UNIT ❑ STRUCTURAL
MODIFICATION
❑ INTERIOR [:)CHIMNEY REPAIR
IMPROVEMENT SWIMMING POOLS
❑BATH REMODEL/RP.PAIR (] DEMOLITION
El OTHER
1
PERMIT ISSUANCE
'S APPLIANCES — RESIDENTIAL
ARCHITECTS DECLARATION
I undersand nay plana shall he used as public records
I
PANELS
IIP TO 41X1 AMPS
Licensed Professional
UW NI?It-ItU11.DER DECLDECLARATION[I'
I hewhy anion that I um exempt from Lha Coannai r'. License Law fir the
ct ]1131 R s J I f L d :A y roomy
whin 6 permit
which y pe till Ir. I II, p "
d .h reP' an,
t y.,tare
proolo itsiso requires thappli,sinl it permit tofile a,,red,norstan
that he is licensed pursuant t the l I the Ct ntmaoes License Law (Chapter 9
(commencing with Section 7000) or Division 3 of the Business and Professions Coda or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
oat more than five hundred dollars ($500).
❑ I. as owner of the property, or my employees with wages as their sole compensation,
will da the work, and the straaum is not ins meal monered Outside (Sec. ]BM. Business
and Professions Calc: The Com uctur's License Law does not apply to an owner of
property who builds or improves thereon, and who does such work himself or though
his own employees, provided that such improvements am not intended or offered for
sale. If, however, the building or imprm'enstent is sold within one year of completion, me
ter -builder will have the burden of proving that he did not Wild or impmse for Pu-
❑ 1, as owner of the pe
mny, em exclusively contracting with licensed contractors m ctors
conna th
rve fortiori (Sm. ]B4f, Business and Professions
Cede:) The CanuamoJs cens,
who commas far such projects will, a cononclons) licensed Formal to the Contractor's
License Law.
E]I am exempt under Sete. B & P C for this reason
201-1W0AMPS
OVER 1000 AMPS
SIGNS[ -
ECIRICA1.
SPECIAL CIRCUH'/MISC.
TEMP. METER OR POLE, INST.
COMMERCIAL
❑ NEW BLDG/ADDITION ❑ DEMOLITION
❑TENANT ❑ FOOD SERVICE
IMPROVEMENT
❑ OTHER
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS — S W ITCHES — FIXTURES
NEW RESIDENTIAL, ELECTS SQ
Q. FT FLOOR AREA
$ISQ. Fm
TOTAL:
QTY, PLUMBING PERMIT FEE
PERMIT ISSUANCE
ALTER — DRAIN & VENT — WATER (EA)
rter, Date
VALUATION
p 73• so
WORKER'S COMPENSATION DECLARATION
1 hereby affirm matter penalty of perjury one of the fallowing declarations:
I have and will maintain a Curti Ileum of Consent to for Workers Compen-
sation, as provided lin by Section 3]0) of form
Ilse Labor Cade, for the performance of the
won k liar which [his permit Is issued.
, 1 huvc and will inalnlain Worker's C ..... pennalan bomorce, as required by Ssmfn n
]ll if the Lubar Calc, Our the perfnrnaummcol'the work for wiich[tthhis permit iIoowdd
MYWnrke It yc yk tyY RtKIaOLJmc;ite pon No. K����b1&
Cartier: C • l /11P1G �1J
Clik'rIIICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
('this section neednot W completed If thepermit is foronehun&ed dollars ($IN)
or lex")
I certify that in the performmuuof the work for whichlhis permit is issued, [,hall
not employ any person in any Insurer so as to become subject to the Workeri Compen-
,akin Lawsof Cahfomis. Date
Applicant
BACK FLOW PROTECT. DEVICE,)
DRAINS— FLOOR, ROOF, AREA, CND.
STORIES
OCC. GROUP
TVI'E CONSTRUCTION
APN
FIXTUR17S — PER l'RAI'
GAS— EA. SYS' 1'1?M. I INC. 4 OUTLETS
GAS—EA SYSTEM OVER
GREASEIINDUSTRL WASTE INTERCEPTOR
GREASETRAP
BUILDING DIVISION FEES
PLA' CK FEE
SEWER -SANITARY -STORM EA. 200 FT.
ENE Y EE //�����
ns 1A_\
r WATER [IGTER WNENT/F,LF' R
GR mlgG HE
U
NOTICE TO APPLICANT: IL after maAing this Certificate of Excmpion, you should
become subject the Worker's Compensation previsions of the Labor Coyou must
m de,
foMwithcamplywithsuch prvislonsorthislanmmlt shall bedeemedwsaked.
CONS TRUCHON[.ENDINCAGENCY
I nor by which is a mere is..ed(Sm.3 lending7,Cagency for perrommanw or
the der's for which this permit is issued (Sec. 3119]. Civ. CJ
Lender's Name
Ixnder'Address
I certify Na 1 have rood this application and sole mm the aMve information is
mrtca.l.gmemnamply with.aB city and a,umy nminances and smmlaws relating to
building e mrtctim, and hereby imbrue tepresenmtivesof this city menterupnn the
mom -o ,mioned pmrc l for instate ion poroses
(W'0 agree to s' e, indemnify and keep Wanless the City of Cupertino against
IiahilitIva,juJgmcnu ass' cxptenace which may in any way ucweagainat mid City
ameeyuenec of e ofdi'
APPLICANT I DS AND LLC WITH ALL NON -POINT
SO CE U 1'
WATER SYSTEM/fRGTINC
SO E n
I (ICT 9 '—I
WATER SERVICE
I�yy
P D
t Dam Recdptx
NEW RFSIDE.NI'IAI. 1'LMB. SQ. FTI
—TOTAL:
TOTAL:[
BUILDING FEE
QFY. MECHANICAL PERMIT FEE
I
SEISMIC FEE
PERMIT ISSUANCE
ELECTRIC FEE
ALTER OR ADD 10 MECH.
PLUMBING FEB
AIR HANDLING ON] I(L(XX) CFM)
MECHANICAL FEE
AIR I[ANGLING ON] '1'(OVER IO,rot CFM)
CONS TRUCOON']AS
omni A,hcaal/C mar Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicunlnr future building orcmpam,nee or handle hasrdo., material
as dented Fy the Cupertino Municipal Cale, Chapter 9, 12. vad the Health and Safety
Cade, Section 25532(al:'
❑ yes, s'n
Will the applicant or )mm ubuilding use equipment or devices which
sit hmarm doair containment, as defined by by the the Bay Area Air Quality Management
Diwia?
❑Yea Y1 No
/h�y av a rmcrials requirement oatenChapter 6.95 ofthe Cali-
, S um'' .25533 J 2553x. I undersand that if IM
have tenant255Xity unpurify derstand arupam ofdrc tP mi eofa Cenifcate of Care
b o
EXHAUST HOOD(W/DUCT)
HOUSING MITIGATION FILE
BEATING UNIT (TO I00.0m)STU)
HEATING UNIT (OVER I00.1X10 BTU)
PAID Date Be _ -
'1 AL:
VENT 'If.ATION FAN (SINGLE. RIS 10)
HULLER —GGMP (3HP OR IW.000 BTU)
BOILER — COMP (OVER 100,000 BTU)
AIR CONDITIONERISSUANCE
DATE;fomia
ISSUED BY:
NEW RESIDENTIAL. MECH. SQ. FT.buildiI
Owner or emhorirW egem Dale
TOTAL:
OFFICE