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APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO . BUILDING-ELEC'UtICAL.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL. -'
" BUILDING PROJECT IDENTIFICATION
PERMITNO. O O
BUILDINGADDRESS:
221ofo LINA vls7'� i'L.
SANITARY NO
APPLICATION SUBMITTAL DATE
I _-Z.�j-q,
OWNER'S NAME:.�tt PHONE:
1 w)o•V a TSArJ
RA.JCTOR:S NAME: LIC NO:
L N e�r
NIC
IDfJ�
CONTTR��kOL # —a�''
11
10 ✓✓���D
ARCHITECTIENGINEER: LIC NO.
e)wIb 1� 2 cala7ra
ADDRESS:
CONTACT: PHONE:
DAp/I� p�}� �p� �3[j
❑ CnnsullantFeesPaid byApplicanl(Initial)
BUILDING PERMIT INFO
BLDG ELc� PLUMB MECH
'yup\
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I ten lidensed under provi,kno l' Chapter 9 fent eing
with Section 700pbuf Division 3 of the Business and Professions Cade, and my license is
in full force and effect, '
Lt... Class Lic.#
Date Contractor
QTY. ELECTRIC PERMIT FEE
JOB DESCRIPTION
RESIDENTIAL
❑SFDWL TCHEN REMODEL
❑ADDITION PLUMBING RE -PIPE
❑MULTI -UNIT ❑STRUCTURAL
MODIFICATION
❑INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT
[] RATE REMODEUREPAIR [] DEMOLITION
[] OTHER
PERMIT ISSUANCE
-
- - ^ �
APPLIANCES -RESIDENTIAL
I L
ARCHITECTS DECLARATION
1 understand my plums sholl be used ux public records
PANELS
UPT0200AMPS
Licensed Professional
Oar I and BUILDER DECLARATION Conte
1 hereby affirm OW 1 ten BUILD R the OLicense Lew for the
following reason. (Section 7031.5, Business and Professions Code: Any city or coumy
which rectums a permit to consumer, aper, improve, demolish, or repair any structure
priortoitsismance, also requires the applicant for such person to file a signed statement
that he is licensed pursuant to the provisions of the Cmametors License Law (Chapter 9
(commencing with Section 700 mf Division 3 of Business and Pbum.slon., Code).,
not he is exempt therefrom and the basis for the alleged eumption. Any violation of
Section 7011.5 by onyapplicant fora permit subjects the.pnlicanuo. civil penalty of
not more than rive hundred dollars ($500)'
C)Las ownerof Nepropeny,ormy employees with wages as theirsolecompenmlion.
will do thework, and the stmclure is not intended contacted forsele (Sec . 7014, Bus
and Professions Cure: The Contractor's License Law doe, not apply to an owner of
his own who builds or improves thereon, and who rims such work himself or through
his own employees, provided that such improvements arc not intended or offered for
sale. If, huweverJhe building orimprovmnem is xnlJ within one year (if complmion. the
ow,ner builder will have the burden of proving that he did not build or improve for put-
pox manic.).
I, as owner of the property, am occel.,wely convecting with licensed contranm. to
14
consumer the project (Sec. 70, Business and Professions Crde:) The_ L.
cone law does not apply to an owner of property who builds or improves thereon, and
h cmdructsfnrsuchi, jects wish t commen.d.) licensed puaumnun the Contractor's
¢en a Ww.
e, rapt fonder see. , B & P C booms reason
-
201-I(NM AMPS
OVER 1000 AMPS
SIGNS ELECTRICAL
-
SPECIAL CIRCUIT/MISC.
TEMP.ETER OR POLL INST,
COMMERCIAL:
❑ NEW BLDG/ADDITION ❑ DEMOLITION
'[]TENANT ❑ FOOD SERVICE
IMPROVEMENT
[]OTHER
POWE VICES
SWI I LELECTRIC
OUTLLTS -,S ES -FIXTURES'/—
NEW RPSIDENTI L SQ F-n
SQ. FT. FLOOR AREA EdQ. Fi'.
P-411) p
%
.1/J
AN 2 `2 R
c
C�Ty ��- '
�UF
VALUATION
-
T
QW,, PLUMB G 9 R PEE
PERMIT ISSUANCE
ALTER-DRAIN&VENT-WATER(EA)
_
Owner to
WORKERS COMP ATION DECLARATION
1 hereby omrm under penalty of perjury one of the following declarations:
❑ I hoveand will mainainaCendirewmConsemto self-n.urefor Wmker's Camper.
section, as provided for by Section 3700 of the labor Cade, for the perficam nce of the
work for which this permit is issued.
❑ 1 have and will maintain Workers Compensation Insumnce, as required by Section
3700of Ne Labor Code, for the perfonnmrce of the work for which this permit is issued.
My Workers Compenaution Insurance carrier and Policy number arc:
Carrier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not Mcompleted ifthe permit is for one hundrcddnllars[81(X1)
in less.)
I mnifydon inthe perfonimmea.f the work for which this permit is issue, l shall
not employ any person in any mecnm
manner to as tm ha abject m the Workers' m Caice.
..tion laws mCalifornia. Data
Anglicism
BACK FLOW PROTECT. DEVICE
DRAINS- FLOOR, ROOF, AREA, COND.
STORIES
TYPE CONSTRUCTION
FlXTURFS - PER TRAP ctoo
GAS-EA.SYSTEM-1 INC.40UTLETS tk �•
OCC. GROUP
APN
t
GAS - EA. SYSTEM -OVER 4 (EA)
GREASMNDUSTRL WASTE INTERCEPTOR
9UILUIN DIVISIO ' ES
GREASE TRAP
PLANCHECK FEE
SEWER -SANITARY -STORM EA. 200 Pf.
ENERGY FE
WATER HEATER WNHNT/ELECTR
GRADING -F
NOTICETO APPLICANT: IL after making this Certificate of Exemption, you should
became subject to the Workers Compenmtion provisions of the IaMu Code, you must
forthwith comply with such provisions or this permit shall be domed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a convection lendingagency for the performance of
the work for which this permit is issued (Sec. 301 Civ. C.)
No.
Licorice, Na
WATER SYSTEM)TREATING
WATER SERVICE
SOILS E
PA '
On Receipt#
NEW RESIDENTIAL PLMB. SQ. FT.
-
TOTAL.:
Laver.Address
BUILDING iE
1 certify that 1 have read this application and sate that the above informaion is
correct. I agree to comply with all city and county oninancm and sate laws miming to
y auonpmsenatives of Nis city aenterupnn the
btildingeonshucnan, andhereannoannounce, m
above-mentioned propcny for inspection pm saver.
(We) agree to nave, indemnify and keep harmless the City mf Cupertino against
Iiabilities.judgmenu. costs and expenses which may in any way accme against said City
ceofthentingof this permit.
incouseeuenga
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS.
QTY. MECHANICAL PERMIT FEE
SEISMIC E
PERMIT ISSUANCE
ELECIRI FEE
ALTER OR ADU TO MF.CH.
-
PLUMB PEB
AIRHANDLING UNITI'O IB,(MCFM)
MECHANICAL E
AIR HANDLING UNITIOVER I0,000CFM)
CONSTRUCIONT
Signature of ApplicanVContractor - Date
HAZARDOUS MATERIALS DISCLOSURE
Will tbe.pplic.m or future building rwcupnot domo, handle hcondousmmemil
as defined by the CLpenin, Municipal Cale, Chapter 9.12, and the Health and Safety
Code, Section 255320?
[-I Yes ❑No
Will the air contaminacant or nts as Air Qualitnt or y
building by the nt Bay se Area
emir hazardous air cnnluminonrs as defined by the Bay Amu Air Quality Mtnagemenl
.nagees ant
District?
❑Yes ❑No
I have read no ha srdous materials reciuirements under Chapter 6.95 of the Cali.
rami. Health & Safety Cade, Saaon 25505. 25533 mm 25534.1 understood duet if rhe
loathing does not contend, love n tenant, that it is my responsihility tu notify the scup..,
of the restatements which must he mer prior to issuance of a Cenifcate of Occupancy.
EXHAUST HOOD(W/DUCT)
HOUSING MITIGATIO E
HEATING UNIT (TO IaL00o BTU) `
HEATING UNIT (OVER 100.000 BTU)
PAID
no. Receipt#
VENTILATION FAN (SINGLE RESID)
BOILER- COMP QHP OR 100,01X) BTU)
TOTAL:
BOILER - COMP (OVER 100," BTU)
AIR CONDITIONER
ISSUANCE DATE
ISSUED BY:
NEW RESIDENTIAL MECH. SQ. IT
Owner or authodred agent I D:nc
TOTAL:
OFFICE