99100041APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELBCTR
BUILDING DIVISION APPLICATION/PERMIT r PLUMBING. MECHAI
CONTACT:
❑ Consultant Fees Paid by Applicant
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LICENSED CONTRACfO SDECLARATION
• I hereby affirm that I in, licensed anti provisions ol'Chapter 9 (commencing
with Section)000]of0ivision3nOhc liuxinee, and Prnfesdnns Cndc,andnry l'menseis
in full knee and ONO,
License Class Liar.
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Dmn ms
QTY. ELECTRICPERMIT
.�� pliliMll'ISSUANCE ,
APPLIANCES - RESIDIiNTIAI.
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AR 1 fi PS DECLARATION
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I' II a public records
PANELS '
UPTO 200AMPS '
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OWNER -1 IL DER DECLANATION
1 ereby emrm tum I am scmpt from the Comreanls License Law for the
following, ,crista (Section 7031.5, Business and Professions Calc: Any city or county
201-IIkM1AMPS
OVER I(XO AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC.
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which mquimn a pt to construct. alcor, improve, demolish, or repair any "onto e
prie, in its xsuancgtdadregmdma the applicant lot such pnnfli m rile u signed amtentent
tum he is)F,,rwdpursuant to the pmvialonsoftho Contractor's Lactose Law (Chapter9
OHO
W
o y'
o Buness and Professions Cody or
ion)g'Uivision3ofthsi
(rommencing with SenMB ol
that he is exempt Nercfmm and the hadis for rhe alleged exemption. Any violation of
Section)031.5 by any applicant for a permit sahjects the applicant to a civil penalty of
3'I7MP. METER OR POLE INST
POWER DEVICES
LL13
not more than rive hundred dollars (1510).
C] 1, as owner of the propeny, or my employees with wages as their sole compersdumn,
erel for sale Sec. Busin
will it,, the work, and thestrucmm is not attended oroRess
and 1'rofeesions Code: The Comments License Law does not apply at ".owner of
properly who build, or improves oon. Bad who does such work himself or through
his own employees, provided That such improvements aro not intended nr offered for
SWIMMING POOL ELECTRIC
OUTLETS —SWITCHES _ EIXTURIiS
.NEW RBIDEN'1'IAL ELEC7R SQ ET.
side. II.however. the building orinmmvellow is sold wi thin ono year of completion. the
i
wnerrhui later will have the burden of proving that he did not hui Id or improve for pur-
'
TOTAL:
pow ofxdeJ.
1, as owner of the propeny, am exclusively contracting with licensed conuacmn to
induct the project (Sec. 7044. Business and Professions Chep The Contramors Li.
«ase Law does net apply m son uwnerof propeny who builds or improves thereon.and
QTY. k, PLUMBING PERMIT
whomittmms fo,meh pmjectiwith aemademn licensed Pursuam in the Committees
FERMITIS ANCE
License law.
1 oro exempt made, See. . N p P C for this reason
ALTC AWI &VENT—WATBN (PLA)
net Tom—
WORKER'S COMPENSATION DECLARATION
BACKFLOW.DhVICIi '
I hereby affirm under pcnulry of perjury one of the lidlowing declarations;
FlI have and will maintain a Cenilicmeaf Consent to selbin.mm for Workers Compen-
DRAINS—FLO R( FANEA. GOND.
sation, as provided for by Section 37110 of the Labor Cade, for the performance of the
work for which this permit is issued
ITXTURES —PER TRAP
I have and will maintain Workers Compensation Insurance, as required by Section
3)Wof the labor Cache, for the performance of the work for which this pemdt is issued.
GAS—FA. SYSTEM -I INC. 40 97LUS
GAS—EA. SYSTEM-OVE (EA)
My Workers Compensation Insurance tamer and Policy another are:
Cormo: Policy No.:
GRF.ASUINDUSTRI ASTE IN'I'ERCF.PTOR
CERTIFICATE Olr EXEMIMON FROM WORKBR.S'
COMPENSATION INSURANCE
GREASETRAP
n
(Phis auction need not he a.ntplemd ifthepermit is loon hnndreJdo11ms($100)
SEWER — ND'ARY—STORM EA. 200 Ff.
I cenify tum in the perfmmunceofthe work far which this pcnnit is issued. Is hall
not employ any person in any meaner so as to become subject to the Workers' Compen-
WATP HEATER W/V['NfIF.LECfR
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scion laws of Califomia. Dam
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Applicant
NOTICE TO APPLICANT. 11, after making this Certificate of Exemption, you should
WATER SYSTEM/1'RFAI'[NO
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become at ertto the Workers Compensation Provisions of the labor Code, you must
forthwith comply with such provisions or this permit shollM deemed revoked.
WATER SERVICE
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CONSTRUCTION LENDING AGENCY
I hembyoffon thanhere iso end vuucoca lerningagency for the perfammeeof
the work on which this permit is issued (Sec. 3097. Ci, C.)
Leaders Name
NI:W RESIDENTIAL PLMH. SQ. Fri.
TOTAL.
Lenders Address
I cenify that 1 have read this application and cute that the abate information is
coned l agree to comply with all city and county ordinances and state laws relating to
huildingeonsarrookn, sndbemby actinium representatives ofthis citymetneruponthe
above-mentioned Property for ins clinn purposes.
QTY, MECHANICAL PERMIT
PERMIT ISSUANCE
(We) agree m cove, anile tify and kap harmless the City of Cupertino against
liuhilities,juit nes, vocational pe s which may in any way accme against said City
ALTER OR ADD TO MECH.
In rrnscqu fthe n x ,mit.
API'I,IC 'f U D (S' A AN ) WILL COMPLY WITH A I. N -POINT
SOU .G L S
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(
Alli IIANGLING UNIT (TO 10,000 CEM)
AIR HANDLING UNI T(OVER 10,000 CFM)
"HAUST HOOD(WMUCT)
grata A lie mmmeto Date
HAY.ARU S ATERIALSDISCLOS REIt
illthe applicam ar fu trc tilling occupantemremhunJle heranlous material
Its defined by the Cupeninn calla( Code, Chapter 9.12, and the Ileehh und Sa(ety
Cale, Section 25532(a)'I -
HEATING UNIT (T01(0.11f101{TU)
HEATING UNIT(OVER 100,(0() B'UI)
VfiN'I'II Al FAN (SINGLE RESIU)
❑ Yes n
's
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Will the applicam or fn ore hailding co=upon( use equ ipmetn or Aevices which
omthrnlou'4lranmvnimmis as delved by the Boy Arru Alr Oaality Munu genmm
District?
❑ Yes
,
IIDILER—COMP('1fIP OR If111,f11100T1n
H3LLILER—COMP(OVCR Exholibru)
AIR CONDITIONER
Rsmin li S ty i of
(chore redo as rials require33 uader Chapter t 1
'3505, 25511 arM 25534.1 uncle d th f the
but nil t k that it is my nesponsibiliryton ty the cupom
cote u. be (taimmissuaneeofa CAjycat
NEW RESIDENTIAL MSCI{. SQ. FT.
J OF
FEE
N/C ONE
BUILDING PERMIT
BL T:L PLUM
JOB DESCRIPTION
RESIDENTIAL:
❑SFDWI.
❑ KITCHEN REMODEL
❑ADDITION
❑PLUMBING RIi-PIPE
[I MULTI -UNIT
[I STRUCTURAL
MODIFICATION
❑INTERIOR
El CHIMNEY REPAIR
IMPROVEMENT
El SWIMMING POOLS
❑ BATH REMODEUREPAIR
❑DE.MOLITION
❑ OTHER
COMMERCIAL:
El NEW BLDG/ADDITION El DEMOLITION
�A
Rf1ENANT . ❑ FOOD SERVICE
❑ OTHER
S/SQ, FI'.
FEE 467 ST
I V/V S
OCC GROUP t AI'N
� 3l6 -02
BUILDING DIVISION PEES
PLANCHECK FEE
ENERGY FEE
GRADING EEE
SOILS HE
Da R c Pt #
I'
n n rar ,
4
UILDING SEE
Ft.F. SEISMIC FEE L)
L,{,7s�CTR40.bEL__ _ _
PLUMBING FTE
MECHANICAL
CONSTRUCTION/AX
HOUSINGMIT CATIONFEE
PAID
Date Receipt#
TOTAL:
3
ISSUANCE DATE
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