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APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO PLUMBING - INIESH a1CAL PI7RM111T NO. (� n
APPLICATIONIPERMIT rI UM-ROIECfl!cxANIcC
BUILDING DIVISION nen nwa Pa011!C1' IDBN'1'IF'ICATION 1, O
If
PHONECO
/ co IIiF r
'LIC NO: DURESS
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PHONE:
❑ Consultant Fees Paid by App
LICENSED CONI RACTOR:S DECLARATION QTY.
I hereby affirm that 1 am licenced under provisions of Chapter 9 (commencing
with Section 780X) of Divi%ion 3 of the Business and Professions Code andmy licenx is
in full force and elle'L % 6f5"v6
License Clnxs o
Uvm CommctaA_
ARCHITECTS DECLARATION
1 understand my plum shall M uuA as public m%orJs
Llernwed Po, esvional
OWNER -BUILDER DECLARATION
I hereby :JBnn that I ammnpt from the Centmemr's License Law far the
following reason. (Section 7831 5 �Busins- and Prete,-ions Crile: Any city o, county
which requires a Wm, to a r,mc , aIle,, improve, demolish, or repair any su atom
prior to its issuance, also mquire.s the applicant for such permit to file a signed smmmem
that he is licensed pursuant to the pnrvision.s of the Contractors License law (Chapter 9
(commencing with Section 7000) of Division 3 al the Business and lomfe..lon, Cade) or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant . o civ 11 penally of
not more than rive hundred dollars ($500).
D 1, as owner of the propcny, or my employees with wages ox their sole cuntpcnsatior.
will do the work, and the stmcmm is net intended oro@ted or sale (See. 70W. Business
and Pmfcsslons Code: The Cnnvuml,d Liccrew Lill dues ml, apply u+ no owner of
property who builds of improves thereon, and who does such work himself or through
his own amplaycus, provided that such ampoweallms am not intended or o8cred for
tuts. If, hnwsver.lhe building or intp.vcmcm is sold within one year of cnmplminn, the
ov,mer-huildcf will have he burden l,f proving that he did not build or improve for put.
pes o1salcd.
h as owner of the property, all, exclusively contracting with licensed consonclicars to
mswct the Project (Sec. 7141 Buainus, and I'mfcxsinns Code Ove Commcnn's Li -
clow Law does not apply to an owner of pmpcny who builds or improves thereon, and QTY.
will, "aa'w,s I'nr such projects with o amuucuu(s) licensed parm ant to the Contract,,,,
Liccn%c law.
D l am exempt ander Sm. ,B&P C for this anion
.
\IC No
ELECTRIC PERMIT FEE
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL
PANELS
UPTO 200 AMPS
SIGNS F:LECI RICAL V
SPECIAL CISCO I'I/MISC.
1 EMP M ETER OR POLH INS'R I
POWER DEVICES ,
SWIMMING POOL ELECTRIC
OUTLETS - S W ITCHES - FIXTURES
NEW RESIDENTIAL ELCCfR SQ Fr.
7i.V .nim 7nf.gY
Owner Date
. WORKER'S COMPENSATION
on DECLARATION
1 hand I, affirm under pewhyofperjuryone tof othefallowing decWork,,,
o
Q (have and will maintains Cenifica¢of Consconn.rdf-insurcliaWnrker'sC'ompmt-
souon, us provided fn r by Se tion 3700 If the Lu bar Code, for the dome. of the
work fer which this permit is issued.
D I have and will maintain Worker's Centpenation Insurance, as required by Section
3701Bf the Luber Coale, far the perfarmun,c it the work for which this permit is illmd.
My Workers Compensation Insurance carrier and Policy number am.
Cturicr; Policy Na'.
CERTIFICA IE 01: EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(ThiswaBonneelnatbecomplend ifilic emtitisforonehundmldollan(511X8
orlessJ
1 ccnify That in the performance Ill the work Int which this permit is issued, l shall
not cmplay any Penne in any mesons, sl, as to become subject. the Worker: Compcn-
z -lion laws of Califnmia. Date
C)
O Applicant t
rn NOTICE APPLICANT: If, alto making this Certificate of Exemption, yen should
F-' Iw o mm -abject to the Workers Compensation provisions of the Labor Codes you must
W� forthwith comply with such prnvhinas n, this pemil shall be decmW mvokaL
noA CONSTRUCTION LENDING AGENCY
Ue I hemhyfT
armthanhem i%alion commaleadingamacy for Ne performance of
LL the work linwhich This permit is is-ucd (Sce 3W7. Civ. C)
O Lcnder's Name
D.1 Lenders AJJrcas
M. I ccnify that 1 have mad this application and %fate that the mauve imorm.lil,n w
F' y ciarreci. tagme to comply with all city and county ordinances ands.¢laws miming. QTY.
U Z buddingenn-wetion. and hereby outhodre representativesofin% city memo, upon the
ab oc-nmetioned p.peny for inspection purponeto
(We) agree IB Save indemnify and keep hunnlcs- the Cay of Clar inl, agoing
liabilities, judgments, coxes and expenses which may in any way accme against said City
in n-r,oxacc of the gcoming of this permit.
A PPLICA NIUNDERSTANDS AN II WILL CUM PLY WI'1'llAl.l. NON -POINT
SOURCE RI iOULAGONS,
Signatureaf` Applicam/Contrac� Dale
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building necupunt .store or handle homodnus m:ncrial
is debt net by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 25532(a):'
Vc% ❑ No
oil Will the applicant or future building acurym use equipment or devices which
emit humrdnus air conmminam.. as detlmd by the Bay Are. Air Quality Management
Di-tdct?
❑Yea 0 N
1 have and the halMdnus materials requirements under Chapter 6.95 of the Cali.
bonds Health & Safety Code. Sections 25585.25533 and 25534. 1 understand that if the
building docs not vurrcnlly have a.n:mt, that it is lily resp nsdail'ny a+notify the occupant
ofihe mquirerreard, hichma,l he all prior no issuance of a C t(kvuput y.
rib i P
Owner ora Jagem
PLUMBING
PERMIT ISSUANEE
ALTER- DRAIN le VENT-WATX (EA)
BACK PLOW PRUIECT DIIVICE
DRAINS -FLOOR. ROOF, CO NI .
FIXTURES - PER TRAP
GAS - EA. SYSTEM-] INC.4 OUTLETS
GASB -EA. SYSTEhLOVER 4 IEA)
GREASMNDUSTRI. WASTE INTERCEPTOR
GREASETRAP
SEWER-SANI'[,%BY-STOEM EA. 20(1 IrT.
WATER HEATERWIVRNTIELEC'IR
W'A'I'IiR SYSTEMITRENIFING
WN'I7R SERVICE
NEW RESIDENTIAL PLMB. SQ. FT
MECHANICAL. PERMIT
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT (TO 11.000 CPM)
AIR HANDLING UNIT OVER 10,(0) CFM)
PXHAUS'I' HOOD (WIDUCI')
HEATING UNIT(To 100.000 RTU)
HEATING UNIT (OVER 10.0410 BTU)
VENTILATION FAN (SINGLE RESID)
BOILER - COMP p11P OR 118.008 BTU)
BOILER -COMP (OVER [(Xy000 PTU)
AIR CONDITIONER
NEW RESIDEN'I]AL MECH. %FI'.
OFFICE
57'2Q"
❑ I 997/
BUILDING PERMIT
❑— ❑Q— LJ
JOB DESCRIPIION
RESIDENTIAL
13s�-�7�oS
C SFDWL
D KITCHEN REMODEL
DADDITION
❑PLUMBING RB -PIPE
❑MUITI-UNIT
❑STRU(.rURAL
SQ, IT. FLOOR AREA
2y Iy
9S'Y
7 l�
MODIFICATION
❑INTERIOR
DCHIMNEYREPAIR
1NIPROREMEN'I'
C] SWIMMING POOLS
C BATH REMODEUREPAIR
El DEMOLITION
C OTHER
MECHANIC A +E
/silt(!
CONSTR ON TAX
2
N
/Z
NEW BLDG/ADDITION [I DEMOLITION
EI TENANT ElOOD SERVICE
IMPROVEMENT
C OTHER
13s�-�7�oS
BUILDING
DIVISIIIN PEES
PLANCHECK PER.
Sk 5
ISNIiHGY FEE
I/Jk/sI.
SQ, IT. FLOOR AREA
2y Iy
9S'Y
7 l�
ASQ. 14.
i+
FEE
236
VA LUA PION
_ 00
2
N
/Z
PAID $Tf7
Dam Receipt
13s�-�7�oS
BUILDING
DIVISIIIN PEES
PLANCHECK PER.
Sk 5
ISNIiHGY FEE
I/Jk/sI.
GRAVING FEE
SEISMIC FEE
SOILS PER.
PAID $Tf7
Dam Receipt
'TOTAL.:
2!36 Q6 -Y
BUILDING FEL'
FEE
SEISMIC FEE
ZX
ELE:CTRI •
236
PLUMB]. FE
2
MECHANIC A +E
'2
CONSTR ON TAX
X
HOUSINGMIT-Al'RINITH
2y^
PAID
-
Date Receipt k
T(YIAL:
f
ISSUA CIE DA]F
ISSUED BY:
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