S 0977APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE SALL POINT PEN ONLY
CITY OF CUPF.RTINO BUILDING - F.LKMRICAL 1112RMIr NO.
BUILDING DIVISION APPLICKI'IOWPERMIT IyLu\te^NGL-r.SIKGflN,c r" r I so S 0977 977
DDRFSS:
❑
I V(O`J
❑ Consultant Fees Paid by Applicant (Initial)
BUILDING (PERMIT It
nl.l ELECT PLUMB
D0Z
Y1 O p
F
W
LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing
1A of Division 3 ofthe Business and Professions ale. and my license is
with Section 70110)G
in Nil force and eO'cct
License Cana Lic.N
Date Cnmrumm
QTY ELECTRIC PERMIT FEE
JOB DESCRIPTION
'OWL ❑KITCHEN REMODEL
Ll ADD)LON ❑ PLUMBING RLbPIPF.
T1 -UNIT ❑STRUCTURAL.
MODIFICATION
[I INTERIOR [I CHIMNEY REPAIR
IMPROVEMENT SWIMMING POOLS
❑ BATH REMODEVREPAIR ❑DEMOLITION
❑OTHER
PERMIT ISSUANCE
APPLIANCES -RESIDENTIAL
0.❑M11Ul
F O m
Z O ?
OZ ,
ARCHITECTS DECLARATION
I understand my plans shall be used as public records
PANELS
UP To 20d AMPS
Fes~
6
O 0. U
Licensed Rmdessional
bwNER-BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Common,., License Law Latina
following reason. (Section ]091 5, Hmnca iand Professions Code: Any city no county
201-10MAMPS
ER Into)AMPS
G ELECTRICAL
3 0.
�j tYO�
t1 a py
�yNSection
Qnot
Wand
which requires a permit to construct, alien Improve, demolish, or repair any saucmrc
prior to in isatimum. also requires the applicant for such perminnlileasigned stanmtent
that he is licensed pursuant mtheprovisionsnfthe Contr tor'el.icenae Luw(Chapter4
(commencing with Section 7")of Division] of thc Business and ProfessionsCdO or
that he is exempt therefrom outlaw basis for the alleged exemption. Any violation of
7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
more than five hundred dollars ($500)
] 1, as owner of the prupemy, or my employees with wugesas their.sole compensation,
will do the work, and fhestrucmre is not intended oroffmcd far salc(See 70, 1, Business
Professions Cord,; The Cmttraoors License Low does not apply to an owner of
property who builds or improves thereon, and who does such work himself or through
his own employees, provided that such improvements are not intended or offered for
sale. If. however the building or impmvcntcnt is sold within,) yemofeompletimn,the
entmilder will have the burden of proving that he did nm build or impmvc for par -
.� / n
LCIRCUIT/MISC.
TEMP. MR-: O LE (NST.
IT
7
❑ N/EW BL A I/I(0*4,EMOLITION
�rs COD SERVICE
IM 1s�41FFMM::
❑OTHER
POWER DEVIC
SWIM M ING POOL ELECTRIC
OUTLETS -SWITCHES -FIXTURES
NEW RESIDENTIAL ELECOI SQ ET.
SQ. FP FLOOR AREA
S/SQ. FT.
D
'�i6g2
w nl'the property, am axewaivel, enntmen, with licensed co uraci x m
crear the project (Sec. 9043, Business and Professimta Code'J'I'he Conooutnr's l.i-
sel.aw dues not apply to an owner of property who buil]., or improves thereon.and
who emnwee for such project with a r mtmeturm) licensed Pursuant to the Commemrs
QTY. PLUMBING PF. -KNIT FEE
�s
/V.
PERMIT ISSUANCE
License Law.
❑ 1 am exempt under Sec. . B & P C farina ..an
VALUATION
ALTER - DRAIN & VENT -WATER IEA)
tam > J
r
` WOR KER'S COMI-17NSA'1'1 CI.ARA'1'ION I
f (hereby ul maintain aCenahyofparjary oneonsem ofthefnllureftn arkee ions:
[]Ihave and will of Ce WorkersCompcm
BACK FLOW PROTECT. I]IiVlC,li
DRAINS -FLOOK. ROOKARIiA,CONED.
STORIES
TYPF,CONSTRUCI'ION
Labor Code.
for mi Section 3]W of The Labor Gale, for The performance of the
for bynetion 37M
anion, as hick this
work for which This permit is issued.
FI%TURIS -PER TRAP
❑ 1 have and will maintain Workers Compcnsmion Insurance, as required by Section
37W of the lrMa Code. for the performance of the work for which this permit is issued.
GAS-BA.SYS'IEM-1 INC.30UTLITS
OCC. GROUP APN
GAS -EA, SYSTHM-OVER 3(EA)
My Worker's Compensation Insurance carrier and Policy number am:
Center: Policy No.:
GREAMUINDUSTRL WAS' 1'E INTERCEPTOR
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
BU I r DIVISION FEES
GRFASETRAP
PLANCH FE
(This section need not be completed dam permit is forone hundred dollars (SIM)
or less.)
SEWER - SANITARY - STORM EA. 2W FT.
FE
I cemifythat inam perfuncen.eof the work for which this permit is issued, l shall
nal employ tiny person in any manner so as to become subject at the Worked Compen.
WR'I'ER I MATER WNENT/IiLEMR
G PE
Z
C)
.�.a
a ,
Q
Z
cation Laws of Cali famia. Date
Applicant t
NOTICE TO APPLICANT: IL after making this Certificate of Exemption, you should
become subject m the Workers Compenspt is pmvisions of LuMr Code, you mail
forthwith comply with such pmvisions nr this Permit shall he Jmmed revoked.
CONSTRUCTION is acONLENDINGAGENCY
herebyichthi lh ethere issued( ectionlending agency 4a the perfommnce of� the work(nr which this permit is ianuud (Sm. 909]. Civ. C.) Lenders Name
WATER SYSTEM/TREATING
WATER SERVICE
E
Dam ci pUOI
NEW RfSIDF.NTIAL PLMB. SQ. PL
PN1RC'YFEjj
TOTAL_>ki
FEEcord.
PF.above-mentioned
1OTA1.:
LendersAddress
I comity that I have mad this application and state that the above information isG
l agree m comply with all city and county ordinances and state Laws refiningm
building constmction, and hereby authorize representatives ofihi.s city to enter upon the
QTY. MECHANICAL PERMIT FEEU
PERMIT ISSUANCE(W)
'EEALTER
property for inspection purposes.
agree m save, indemnify and keep hornless the City of Cupertino against
ORADDTOMECILNG
tF.NRSTASAPPLICANT
AIR HANDLING UNIT (T(Y III,IXXICFM)
C FEE
UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT'
SOURCE REGULATIONS.
D
AIR HANDLING UNIT (OVER 10.0100 CFM)
CON.STRU TAX C)
Signature of AppiicamfContmetor Out
BX14AUST HOOD(W/DUC)
HOUSING MITIGAT FEF.
HEATI NO UNIT (TO 100,M0 BTU)
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupamsore or handle hazardous material
as defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
Cade, Section 2553200?
HEATING UND(OVER IIXI,IXXI If I V )
VENTILATION PAN (SINGLERESID)
❑Yes ❑Nn
PAID -
Date Receipt X
�
Will the applicant or future building occupvm ux equipment or devices which
,it ha,momm, air contaminants as defined by the Bay Area Air Quality Management
.00(
BOILER-COMPOHPOR 1 WBTU)
- TOTAL :
BOILER - COMP (OVER I0000011'1'1)
enseictP
❑Yes 0 N
AIR CONDITIONER
ISSUANCE DATE
1 have read the hachous maerials requirements under Chapter 6.95 of the Cali-
NEW RESIDENTIAL MECH. SQ. ET
'
famia Health & Safety Code. Sections 8505. 25533 and 8533.1 understand that if the
buildingdoes not cunendy have a teed.,. That it is my responsibility to sonify the eve -pint
of dee requirements which most he met prior to issuance of a Cemifcate of Occupancy.
ISSUED BY:
TOTAL.
Owner or nathorieed agent Date
OFFICE