30678APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING -ELECTRICAL
PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL
BUILDING PROJECT IDENTIFICATION
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BUILDI/ry)G ADORP(S/S:O to I/.o J�
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SANITARY NO.
APPLICATION SUBMITTAL DATE
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OWNERS boli:.
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'HITECT/ENGINF;Ea NO:
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ADDRESSSVV:
CONTACT: PHONE:
BUILDING PERMIT INFO
❑ Consultant Feu Paid by Applicant (Initial)rys�sDQ�
ELECT PLUMB MECH
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LICENSED CONTRACTOR'S DECLARA'1'I(lN
1 hereby affrznt dial 1 an licensed under provi.�ions ol'Chirpier 9 (commencing
with Seddon ]OW)nf sion3 of the Business anJ Professions Code. and my license is
in full forte end cffec
Date.LicenG s.-�-.a---Lice 3
Date. Commnor
ARCHI'TECT'S DECLARATION
1 understand my plans shall hesed uas public records
QT -Y. ELECTRIC PERMIT FEE
JOB DESCRIPTION
RESIDENTIAL:
❑SFDWL [I KITCHEN REMODEL
❑ADDITION C1 PLUMBING RE -PIPE
❑MULTI -UNIT ❑STRUCTURAL
MODIFICATION
-
PERMIT ISSUANCE
APPLIANCES -RESIUIiNT1AL
PANELS
OZ -0
UP TO 2W AMPS
❑INTERIOR [I CHIMNEY REPAIR
IMPROVEMENT
❑BATH REMODE1 REPAIM9{,ITION
❑OTHER 7 Y�
: /
;
+C W Q
X2�d�=UF
W 3 U. N
0
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that I am exeln a from the Comractor's License Law for the
following reason.(Section ]031.5, Business and Professions Cale: Any city or county
which requires a permit to construct, ao improve, demolish or repair any arvcmre
prior m it, iswancc.also.,arm, the applicant foriamh peranofile a signed vmteme,
201-IIX10AMPS
OVER 100MAMPS
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC.
�ythat
he is licensed purstmmit) the ponivinnsoftheContmctmT License Law(Chaptcr9
TEMP. MEI' FR OR POLE INST.
COMMERCIAL:
=00
(commencing with Station 7000) of Division 3 of one Business and Professions Colle)or
esL n C
�y
E -Z Y
<]Lus
W
W
Had he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 byany applicant faro permitmbject, the applicant too civil penalty of
not mom than rive hundred dollars (551101
owner ofthe pestruc,mntyet intended withowugesas rsale(ee 7(W. Bution,
aoJ the he Coma is not intended se aw reddo ss not apply to an caner of
willdo Professions
and Professions Qsori'he Contrucors License Lowdoesnmapplytolf owner of
progeny who builds or improves themm, and who dors such work himself or through
his own employeesprovided that such improvementsam not anot intended or offend for
sale If, however, thee building or improvement is sold within one year of campletisn,tM
owner -builder will have the burden of proving dial be did not build or improve I'nr par-
C1 NEW BLDG/ADDITION ❑ DEMOLITION
❑TENANT ❑ FOOD SERVICE
IMPROVEMENT
❑ 01 HER
POWER DEVICES
SWIMMING POOL ELECTRIC
OVI'LF.TS- SWITCHES - FIXTIIRLS
NEW RESIDENTIAL ELECTR SQ FT.
,
SQ. FT. ILOOR AREA'
DEC
SISQ. FT.
pose ofl
sae.).
EJ 1. e, owner of the property, am exclusively contracting with licensed contractors to
AC
8 19
TOTAL:
construct the project (Sec. 7044. Business and Promoiom Cede:) The Commnor'. Li-
ui:?L
who) oriniproves mercon,and
who convects for such projects with a unnucloo,) licensed pamuanl m the Ctionchn's ase Law does notapply to an owner of progeny
QTY. PLUMBING PERMIT FEE
Uri C/711i�(, f
vu
PERMIT ISSUANCE 01
License Law.
1 me exempt under Sec. . B & P C far mus ammo
Owner (late
ALTER - DRAINh VIi,VT-WATER
VALUATION
WORKER'S COMPENSATION DECLARATION
BACK FLOW PROTECT DEVICE
1 hereby affirm under penalty of perjury one of the following declarations
I have and will maintain a Cenificate of Comminno self -insure for Worker'scompen-
tion, as provided for by Section 3700 of the labor Cade, for the performance of the
_
DRAINS- FLUOR, ROOF, AREA, COND.
STORIES
TYPE CONSTRUCTION
PIXTURES-PERTRAP
3wo,Inrwhieh1unennitisismed.
have and will maintain Worker's Compensation Insurance, as mquired by Section
.,the labor Code. for the performance ofthe work for which this permit is issued.
OCC. GROUP
APN
GAS - EA. SYSTEM -1 INC. 4 OUTLETS
My CarrierrtefK'/ptgnytti sec <anic Policy No.: Policy 7"
r`��
GAS- EA. SYSTEM OVER 4(FA)
CBk'I'IPICATE Or EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE -
GREASI%INUUSTkI. WAS 'I'E INTERCEPTOR
BUILDING DIVISION FEES
(This cation to not be completed ifthe permit is for one hundred dollars 1$1 W)
m less)
GRP.ASBTRAP
PLANCHECK FEE
SEWER - SANITARY - STORM EA. 210 FE
ENERGY FEE
I cenifythot irlhe pindurmanccofdie work for wbichmix pc car, is ioued. Isbell
oat math, any pe,wan in any mnnner w a, o become .abject to the Workers Compea-
WATER HEATER WNFNT/ELECTk
GRADING FEE
zZ anion laws of Caliburn, Dam
O Applicant
WATER SYSTEM(PREATING
S014ti HE
y NOTICE TO APPLICANT.If. aper making this Certificate of Exemption. youshmill
become sabjxua the Worker's Compensation provisions of the Labor Code, you must
WATER SERVICE
wry forthwith comply with. such provisions or this Knout slwll M deemed revoked.
d
7z CONSTRUCDONLENDINGAGENCY
L) Q Ihcmby afprtn that there is oconnruction lending agency for the pedommnce of
14 F-' the work for which this permit is issued (Ser. 3097, Civ. CJ
0 _codes Nmnc
lender's Addres
I certifym m 1 have read this application and .nate mm the above information is
Fh correct. l agree to comply with all city and county ordinances and state laws relating to
O Z-0 buildingcansoretion, load hereby aumnrire apremmmives ofthi,citym enlerupon the
PAID Dam Receipt
NEW RESIDENTIALPLMB. SQ. FT.
IT)Ts\L:
TOTAL:
BUILDING FEE
QTY. MECHANICAL PERMIT FEE
SEISMIC FEE
PHRMII'ISSUANCE
ELECTRIC PEE
above-nmann ned properly for m,gemion purposes'
(We) agree to save, indnnuily and keep haless me City of CenerJnn against
rm
ALTER OR ADD TO MECH.
PLUMBING FEE
Iiabilitin.judgmena, cops and expenses which may in any way acme against said City
in conscyuence of the granting of thi. Permit.
AIR HANDLING UNIT' (TO 10,0110 CPM)
MECHANICAL FTili
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE kF.GULATIO:VS.
AIR HANDLING ON]T(OVER 10.010 CFM)
CONSTRUCTION TAX
Signals. mf ApplicanUConaactor Dam
HAZARDOUS MATERIALS DISCLOSURE
EXHAUST HOLD(W)DUCII
HOUSING MITIGATION FEE
HEATING UNIT (TO IW.(KK) BTU)
Will the agpllcmaor future building occugum score ar handle haminka,m,no,nal
as defined by the Cuprtino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 255321})'1
HEATING UNIT (OVER 100.1100 BTU)
❑Yes ❑Nn
Will the applicant or future building occupant use equipollent or device, which
mit hmallous air contaminants as defined by the Bay Area Air Quality Management
VENTILATION FAN (SINGLE RESID)
PAID
Dom Receipt M
BOILP.R-COMP (311P Ok IOQ01)U RTU)
'TOTAL:
BOILER -COMP (OVER I WAW BTU)
District?
❑Yes Fl No
AIR CONDITIONER
1 have road The harroo materials m is under Chapter 6.95 of the Call-
quire
ISSUANCE DATE
NEW RESIDENTIAL MECH. SQ. FP.
forma,dre,&Safety Code. Section 25505 33and 25534.1 In unity td mat if me
caldo
buildingdms Uy hav mwnt,U t yortiii Certiycate me mcupant
o(thr�/�P�JL�2w uissuanc Certificate ol�,cSu�1 nay.
.
-
ISSUED BY:
TOIAI-I
Owners, aomorvell agent , 11D.n.
OFFICE