30420APPLICANTTO FILL IN ID
RED
PEN ONLY
BUILDING DIVISION APPLICATION/PERMIT PLUMBING -MECHANICAL. 30420
❑ I,
❑ Consultant Fees Paid by Applicant (Initial) BLD,
I r� ❑
0042
14 OPERMIT
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I hereby affirm Thal I mai licensed under provisions of Chapter 9 (commencing
with Section 7( ) of Division 3 ofthe Business and Profevemas Code, and my license is
in full force end effect.
enu Clens L10.a
Tone-
QTY. ELECTRIC PERMIT
ISSUANCE '
'APPLIANCES -RESIDENTIAL
❑ MULTI`UNIT, ",
ARCHITECTS DECLARATION
1 understand my plansshall e used as public records
PANELS
Cp
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4477 W WO {'1
❑INTERIOR
UP'IY)200AMPS t
Licensed Professional - ''
OWNER -BUILDER DECLARATION
1 herchy from that 1 am exempt from the Contacmrs License Law for the
followingresson, Seetion7031,5, Bminewarl profession, Code: Anychy .,county
which requires a permit to ronswn, he,. improve, demolish, or repair any swcmrc
20Wrk TAMPS
OVER 1000AMPS '
SIGNS ELECTRICAL
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prior 1. its issuance, alimool ims@e applicsnt forsuch permit m file u signed instanter,
SPECIAL CIRCU [TIM ISC.
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that he is licensed pursuant o the provisions of the Conametols License Law (Chapter 9
TEMP. METER OR POLE INST.
9000
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
L q ca K
2
that he is eumM therefrom and the basis for the alleged exemption. Any violation of
POWER DEVICES
Y%1 �
Suction 7031.5 by any applicant for a permit subjects ,hc applicant to a civil penalty of
FZY
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6 3 ^
not more than five hundred dollars(SSW).
0 I, as owner of the property, or my employees with wages as their sole compensation,
will do the work, said is not intended mothered retreat, Sec. 7U14, Business
sod Pmfcasiom Code: The Contractor's License Use does not apply to an owner of
pr.pcny who builds or improv. Neuron, sod who does such work himself or through
his own employees, provided that such improvements se, not intended or offered for
SWIMMING POOL ELECTRIC
OUTLETS -SWITCHES -FIXTURES
NEW RESIDENTIAL ELECTR SQ FT.
sale. If, however, the building or improvement is sold within rte year of completion, the
-
owner -builder will have the burden of proving that he did not build or improve for pur-
pose of sale.).
❑ 1, as owner of the property, am exclusively contracting with licensed connracmrs t.
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construct he Project (Sec. 7194, Business and Professions Code:) The Contractor's Li.
cense Law does no] apply to an owner of property who bull& or improves thereon, and
QTY, PLUMBING PERMIT
who contracts for such projects with a contractor(s) licensed pursuant to the Contactors
PERMIT ISSUANCE
License Law. -
❑ I am exempt under Sec. ,B&P C for Nis reason
VENT-WATER (EA)
EDnteAISHR-DRAIN&
WONKCR:S COMPENSATION DECLARATION
BACK FLOW PNOTECf. DEVICE
I herchy elRrm under penalty Of perjury one of the 611owirg dedemtions:
DRAINS- FLOOR, ROOF, AREA, CORD.
❑Ihave and will maintain aCenificme of Cnnsen, In ulf-inure for Workers Compcn-
sation, as provided for by Sectio 3710 of the Labor Cole, for the performance of the
FIXTURES - PER TRAP
work fur which this permit is issu W.
❑ I have and will maintain Worker's C.mpersa0.n Insurance, ss required by Section
3700ufthe Labor Code, for the pedorromee ofthe work for which Ibis permit is issued.
GAS -EA. SYSTEM -I INC. 4 OUTLETS
My Worker's Compensuion Insurance carrier and Policy number are:
Cartier. Policy No.:
GAS -EA, SYSTEM -OVER 4 (EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GREASIYINDUSTRL WASTE INTERCEPTOR
(Ibissection need not be completed if the Permit is for one hundred dollars IS IW)
or less.)
GRFASETRAP
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I certify that in the performance of the work for which this permit is issued [shall
not employ any person in any manner so as to become subjectto the Workers' Compen-
motion laws of Calibrom. Data
Applicant
SEWER -SANITARY -STORM EA. 200 FT.
WATER HEATER W/VENI'/ELECT R
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t, V)
a7become
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NOTICE TO APPLICANT. If, after making this Cenificam of Exemption, you should
subject to the Workers Compensation provisions of the Labor Code, you must
forthwith comply with such amok.ions or this permit shall be deemed revoked
WATER SYSTEM FREATING
WATER SERVICE
a'
z
CONSTRUCTION LENDING AGENCY
NEW RESIDErwrl AL PLMB. SQ. FT.
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a.
Ihereby affirm that there is a comrecrion lending agency for the pcti'.namec of
the work for which this Permit is issued (See. 3097, Civ. C.)
Lender's Name
Lender's Addrss
TOTAL:
1 certify that I have read This application and statethat the above information is
0
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cotrcei, l since to comply with all eily and county ordinances and state laws relating to
building construction, and hereby authorize reireomadves of this city to enter upon the
above-mentioned pmpemy for inspection purposes.
(We) slow, t. save, indemnify end keep hafmless the City of Cupordom against
QTY. MECHANICAL PERMIT
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
'
Iiahilitia,juJgmems; rnst end expenses which may in any wayacermitiminn said City
in comes umice of the granting of this permit.
AIR HANDLING UNIT GY310." CFM)
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS.
AIR HANDLING UNIT (OVER 10,000 CFM)
Signature Of Applicant/Contmctor Data
EXHAUST HOLD(W/DUC)
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT GO I MOW BTU)
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
Code, Section W3200?
HEATING UNIT (OVER 100,000 BTU)
El Yes El No .'
VENTILATION PAN (S INGLE RESID)
Will the applicant or future building occupant use equipment or devices which
emit hN
ezaous air contaminants as defined by the Bay Area Air Quality Management
BOILER - COMP (3HP OR 19,000 BTU)
'
Disrlct7
❑Yes ❑No
BOILER- COMP (OVER 100,000 BTU)
AIR CONDITIONER -
I have read the hmu,dom materials requirements under Chapter 6.95 of the Cali.
NEW REMDENTIAI. MECH. SQ. FP.
1'omia Health & Safety Code, Sections 25505, 25533 and 25534. 1 ondenamat the, i1[be
building does rat currently have a tenant, that it is my responsibility to notify the occupant
of the requirements which trust be met no, to ismvncc of. Cenifieme of Occupancy,
-
OFFICE
FEE
❑ ❑
JOB DESCRIPTION
RESIDENTIAL:
❑SFDWL
❑ KITCHEN REMODEL
❑ADDITION
❑PLUMBING RE -PIPE
❑ MULTI`UNIT, ",
❑ STRUCTURAL '
MODIFICATION
❑INTERIOR
❑ CHIMNEY REPAIR,
IMPROVEMENT
❑ BATH REMODEUREPAIR ❑ DEMOLITION
❑ OTHER �, ags,,
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ONEW BLDG/ADDITION ❑DEMOLITION
❑TENANT ❑ FOOD SERVICE
LSQ. Fr..
FEE
AUG 21 1199A
VALAI
I 1_1. Id", -c'.11 iUU
BUILDING DIVISION FEES
PLANCHECK FEE
ENERGY FI7E
GRADING FEE
SOILS FEE
PAID
Data Recc'm M,
TOTAL:
BUILDING FEE
FEE SEISMIC FEE
ELECTRIC IEE
PLUMBING FEE
MECHANICAL FEE
CONSTRUCTION TAX
HOUSING MITIGATION FEF.
PAID
Dam Receipt p
TOTAL:
ISSUANCE DATE "
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