S 2755APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPFRTINO BUILDING -ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING- MRCIIANICAL
BUILDING PROJECT IDENTIF'ICA'rIIIN
PIiRMI'r NO.
S 2755
BUILDING ADDRESS:
SANITARY NO.
API'LICAI'I(IN SUBMITTAL DATF
ZZ ! /
OWNIi0 AM1tE; PHONE:
s i u s J yi _/
CONTRACTOR 'SNAME: LIC NO:
_NIC
❑
CONTROL To
iARCBITECTlENGINEER: LIC NO:
ADDRESS:
CONTACT: PHONE
BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant (Initial)
BLDG ELECT PI H/ MECH
] ❑ II,J' ❑
DECLARATION
LICENSED ..btCONTRd made,
I hereny afimt mm [,all licensed aaeer proviai.aa .r enapmr 9 (camtmmcing
QTY. ELECTRIC PERMIT FEE
JOB DBSCRIPTION
PERMIT ISSUANCE
with Section 70 mol Division 3af NC Business and Potassium Code,mdmy licumen,
in lull force and effect.
RESIDENTIAL;
[I SFl C KITCHEN REMODEL.
APPLIANCES -RESIDEN'I'[AT,
License Clan Co
Dmcnte tor
CAIANTLON (_1 PLUMBING RE -PIPE
[IMULTI-UNIT []STRUCTURAL
MODIFICATION
CINTEkIOR El CHIMNEY REPAIR
IMPROVEMENT 0SWIMMING POOLS
7C
ARCHITELTS DECLARATION
1 understand my plans shall M used as public records -
PANELS
UP T02W AMPS
Licensed Pndessi... I
2014000AMPS
OWNIiN-BUILDER DECLARATION
1 hereby anion that I am exempt from the Contractor's License Law for the
following reason. (Section 703 1.5, Business add Professions Cede: Any city or county
following
REMODEL/kEPA1R CDEMOLITION
C Cr[HER
OVEN East
SIGNS ELECTRICAL
which acquire a permit to conswm, alter, improve, demolish, or repair any or mare
SPECIAL CIRCUIT/M ISC.
prima, its issuance,also requires the applicant for such perru o filen signedstmemem
that he is licenced pursuant o the provisions of the Contractor's License Law (Chapter 9
17^
(commencing with Section 7001yof Division 3 of the Business and Profession, C0lOor
TEMP, METER OR POLE INST.
COMMERCIAL' It
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
C NEW BLDG/ADDI'r10N C DEMOLITION
S«don 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
POWER DEVICES
_
❑TENANT ❑ FOOD SERVICE
t more vthan ermf handrcd dollars (SSW
with ono,,mi their sole onntpcnsntion,
r] I, ns owner of fl the pmpeny, lar my employeesge
will do the work, land the structure is not Intended or offered forselo (See. 7144, Isminesx
IMPROVEMENT
COTTER
SWIMMING POOL ELECTRIC
OUTLETS-SWITCHES-17M URES
and to Tic siona CoJC:'File Contractors Liecree Law dues not apply I un owner ill
'
NEW RESIDENTIAL ELECTIt SQ I'L
property who halide or improves thereon, and woo does sact, w,ak himsdf or dm,ngh
his own employees, provldul that such improvements aro not intended or olmeed In,
.sale. IL however, the building or improvement isyold within one year of completion, the
SQ. PC. FLUOR AREA
USQ. ET.
lar -builder will Imre the hunlen of proving the he did not build or impnwc lin par-
-m of solo:).
fah us owner of the property, nm exclusively endearing with licensed commuctu s to
TOTAL:
1 _Imct the project (Sec. 704Q Business and Professions Cdlep The Contractor's Li.
cannot tow docs not apply In on owner of property who builds or improves thereon, and
QTY. PLUMBING PERMIT FEE
who contracts file such projects with a contmemod licensed punaanno the Corrientes
License low.
I amexconra kr. .B&PCfonhis mason
PERMIT ISSUANCE pJ
-51
gUse
ALTER -DRAIN & VENT - WATER (IiA)
VALUATION
BACK FLOW PRtTfECI'. DEVICE
IF Wm TI DECLARATION
'Oty
on
1 hereby affirm under penalty of pc jury one of the fallowing declarations:
under of rat
❑ Ihave and will maintain aCenifcme.fC...cutwself-insom far Worker's Compen-
smion, as provided for by Section 3700 of the Labra Code, for the performance of the
DRAINS- FLUOR, ROOF, AREA, COND.
STORIES 11
TYPBCONSTRUCTION
work for which this permit is issued.
FIXTURES -PER TRAP
C 1 have and will maintain Worker's Compensation Insurance, as required by Section
3700of'me Lahor Code, for t he performance of the work for which this permit is iovied,
OCC. GROUP
APN
GAS-EA.SYSTEM-I INCAOUTLRIS
My Workers Compenxal.n Insurance tamer and Policy number arc:
Caner: ' Policysi
GAS - EA. SYSTEM-OVIiR 4(ILA)
CFffI'IFICAFE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GREASE/INDUSTRL WASTE IN] ERCIA"IOR
BUILDING DIVISION PILES
(This section nceA nut ha aumpletW ifthe permitis for nuc hunJmd Jullms (41(X)
lar less)
GN P.ASP.TRAP
-- -"
PfANCHECK FEC
Iedir that inflepedannanoenfthe work forwhich thispennit is issued, l shall
not employ any proom in any manner so as to become subject m the Worker. Compen-
ration Laws.f Califomia. Date
Applicant
SEWER -SANITARY- STORM EA. AN) PI'.
ENERGY FEE
GRADING FEE
^^
WATER HEATER WNENT/ELECI'R t v ,J
NOTICE '1 O APPLICANT-. If, after making this Certificate of Exemption, you should
become subject to the Workers Compensation provisions of the Labor Code, you must
WATER SYSTENIFUREATING
SOILS HE
WATER SERVICE
forthwith comply with such provision, or this permit shall be thenad devoted.
CONSI'RUCI'ION LENDING AGENCY
I hcrehyaffirm that hem iso comwmioa lendinfOommey home perforance of
NEW RESIDENTIAL PLMB. SQ. FE
PAID
Dam Rnxipnp
the work Iia which this permit is issued (Sec. 3097. Civ. C.)
Lenders Name
TOTAL:
Lenders Address
A : t
BUILDING LITE
1 eri ify that I have revel this application and stem It the above information is
QTY. MECHANICAL PERMIT FEE
SEISMIC FEE
000cLJ agree to comply with all city, and county mdirai and sura I.wsrchnin6lo
building eonamction, and hereby routinize representatives (if rhis city to enter union the
PERMIT ISSUANCE
ELECTRIC PEE
abo-mentionedpr.pcny far Insetelinn purposes.
(We) agree mxum, hde crit y and keep hanaless Wo City of Cupenlno against
ACfERORADDTOMECII.
PLUMBING PEE
liabilities,judgnrents, ematend expenses which may inany way tmcmc rudatsaid City
in consequence ofpm grading ufthis permit.
in
AIR HANDLING UNIT(TO 10,010CFM)
ANIC
APPLICANT UNDER. ANDS AND WILL COMPLY WITH ALL NON -POINT
.
SOURCf: NGC .ATI ?"
'3 .,1 //��
7l
AIR HANDLING UNIT (OVER 111.001 CFM)
CO UCTI
EXHAUST HOOD(W/DUC1)
HOUSING ITL NFEE
naw,eafApplicanFCommcm (late
HAZARDOUS MATERIALS DISCLOSURE
Will the applies., ., far.. buildingoecupmt smreorhanJle haznnluux..led.]
. {
HEATING UNIT (TO 101,0N) BTU) �\ 0
as def ncd by the Cupertino Municipal Code, Chapter 9.12, end the Health land Safety
Code. Section 25532nd!
s rs
1 (HEATING UNIT (OVER jugh had BTU
0 Yca GK
Will the air contd or future building bytheoccupant use ea Air Qu 9f devices which
emit hvurd.us air cnnmminanu m defined by the Bay Arca Air Quality Munagcmem
❑Yes LSo"
PAID
Receipt Is
VENTILATION FAN (SINGLE RESID)
BOILER - COMP THP OR 10),010 IT I If)
TAS
BOILP.R- COMP (OVEIi I(Nl,(NIB BTU) )
AIR CONDITIONER
I have real the hneardous muteriuls requirements under Chapin 695 of the Cali-
ISSUANCE DATE
NEW RESIDENTIAL MECH. SQ, FI'.
famin I lcaltb & Saml, Cole, sections 25505, 25533 and 25534, 1 undersumd that if the
lumbugdswsnm cu ar yuvcatena.,, do layresprnsihiltry mani ry the �xuupnnt
—A
7
of me rcgalremcm pi t t i none ofa Certalrasa, nnf cunancy.
'
3
wn a loan ed agent Date I
TOTAL:
ISSUED BY:
OFFICE