S 0776APPLICANTTO FILL IN INFORMATION WITHIN RED LINES • USE BALL POINT'PEN ONLY
CITY OF CUPERTINO, BUILDING - ELECTRICAL.
RUILDINGDIVISION APPLICATION/PERMIT PLUM RINIMECIIANICA]
CON EACT:
❑ Consultant Fees Paid by Applieant (Initial)
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1 hereby affirm that 1 am Reed under provisions of Chapter 9 (commencing
with Section 10X101 of Division 3 of the Business and Professions Code, and my license is
In lull f ince unU CBe ➢^
License Cb, �Lic. N'
Dam Cnrmct
ARCIID'ECT'SDEC IA ON
Iunderstmdmyplun.s,hullbeusedaspublicrecons
QTY ELECTRIC PERMIT
PERMIT ISSUANCE
APPLIANCES-RUSIDF.NMAL
PANELS
Z n. O
UP DO 200 AMPS
Licensed Prnfia,iomi
2111-I IXNI AMT'S
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30.0
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Uat I minBUILDER DECLARATION
I hereby affirm that 1 am <xentpt from the Contracrois License Law Inn the
following rcomn. (Section 7031.5, Business anti Professions Cole: Any city or county
which requires a peril to construct. alter, improve, demolish, or repair any swmurc
prior to its issuance, also requires the applicant for such permit to file a signed statement
OVlilt I(XXIAMPS "
SIGNS EIdiCTRI 1. -
SPECNL Cl RCUrr/M15C.
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that he is licensed pursuant to the provisions of the Contractor's License Low (Chapter 9
TEMP. MEfERORPOLEINST.
00
y n y
QUI,
p.
y 3
(commencing with Section 7000) of Division 3 of the Business and Profession Gdelnr
that he is exempt therefrom and the basis for the alleged exemption. Any violation or
Section 7031.5 by any applicanl fur is permit subjects the applicant to a civil penalty of
t more than five hundred dollars ($500).
as owner of the property. or my employees with wages as their sole compensation,
will do the work, undthestmnum hurl intended or named! for .]a(Sec.)WJ, Business
and Professions Cada: The Contractors License Low does not apply to an owner of
property who builds nr improves thereon, and who does such woh himself or through
POWER DEVICES
SWIMMING POOL ELECTRIC
OUILIJS- SWITCHES -FIXTURES
❑ FOOD SERVICE
IMPROVEMENT
his own employees, provided that such improvements are mol intended m oure d for
NEW RFSIDENTIAL ELECTR SQ 14.
sale. If, hawever, the building nr improvement is sold within one year ofmmplation, the
mer builder will have the human of proving that he did not build or improve for Pur-
pose of sole.).
C] 1, us owner of the progeny, um exclusively contracting with licensed contractors to
TOTAL.
contract the project (See, 7044, Business and Professions Code:) The Qmtmemr's LI-
enseLow does not apply lounOwner ofproperty who builds or improves mercon, and
QTY. PLUMBING PERMIT
wha contracts for such projects with a comma ou a) licensed purmanuo the Contractor's
PERMIT ISSUANCE
License Law.
❑ Ian exempt under Sce. ,B&P C for fr....no
ALTER - DRAIN & VENT- WATER (EA)
Owner Date
WORKER'S COMPENSATION DECLARATION
BACK FLOW PIECEUCT. DEVICE
hereby affirm under penalty of penury one of the following decimations:
DRAINS- FLOOR. ROOF, AREA, COND.
I have and wil l maintain a Condictie of Consent o set f -insure for Worker's Compo
cation, as pnrvided for by Section 37M of the Labor Code, for the performance of the
FIX'I'U RE'S - PER TRAP
work for which this permit is issued,
je ban and will maintain Workers Compensation Insurance, as required by Section
370(1 of the labor Code, for the Performance of the work for which this permit is issued.
GAS - EA. SYSTEM -I INC. 4 OUTLETS
My Workers pensmi Incur nttcameraalpriicy be re:
Carrico �. Policy
GAS - EA. SYSTEM -OVER 4(EA)
CER -11P A O %EMOTION FROhf W'ORKE S'
ROMW��
COMPENSATION INSURANCE
GRPASI%INDUS'rRL WASTE INTERCEPTOR
(This aection need nal he cumpined iftne parit is for one hundred dollars(S 100)
orlex.)
GMASETRAP
SEWER - SANITARY - STORM G. 200 FT.
0motion
O
I cenifylhat inlhe performance of the work far which this peril isismed, l shall
oat a npray any person in any manner m n to beosme subject It the Workers Counter-
laws of California. Data
APPlicunl t
WATER IWATI?R WNENT/ELECTR
(n
abecome
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U O
IL Hthe
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NOI ICH TO APPLICAND IL after making this Certificate of Exemption, you should
subject m the Workers Compensation provisions of the Labor Cole, you must
forthwith comply with such provisions or this tremor shall hedeemed revoked.
CONhemis aI oust LENDING AGENCY
hthis that isured(Sec. construction lending agency for the performance of
by which
work
work for which thin penult is issued (Sec. 3119], Civ. CJ
Lender's Nunn
WATER SYSIEMaREATING
WATI?R SERVICE
NEW RESIDENT JAI. PLMB. SQ. FI'.
Lender's Address
TOTAL
I candy that 1 have retia Thi: y ind our and slam mar one above infossro nbnn Is
ennem.l agreetocnmply wont all cityunJ county nminances and smmlaws rclmingto
building construction, and hereby tathon. representatives of this city to enter upon the
QTY. MECHANICAL PERMIT
PERMIT ISSUANCE
r
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep huntress the City of Cupertino against
ALTER OR ADDTO MECH,
Iiabtlitie.s,judgmems,cosns andexpioses which mayinany way annicagainst acid City
in consequence of the gmming of this permit.
AIR HANDLING UNITff010.000 GFMI
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS.
AIR HANDLING UNIT (OVER IB (PN)
'
Signature o(ApplicandComr+ctor Data
EXHAUST HOOD(W/DUCr)
HAZ RDOUS MATERIALS DISCLOSURE
Will the applieon or furore building ..,a, store or handle h rramom material
IIIiAT WG O I011
UNIT T .
as aefineJ by the Cupertino Municipal Cole, Chapter 9.12. and the Health and Safety
Code, Section 25312(n17
AIN' UNIT (OVER 1110,gp01 BTU)
❑Yes 0 N
Will the applicant or future building occupant use equipment or devices which
mit hazardous air commuinoms as defined by the Bay Arca Air Quality Management
VENTILATIONFAN(SINGI-kE.SIDyt v
B011:1?R-COMP,OHP Olt IIXI,11(I(1 BTU)
BOILFR -COMP (OVER 100,000 BTU)
District!
❑Yes No
AIR CONDITIONER
I have read the hammo,ana tuts nounernents under Chapter 6.95ofnhe Cali-
NEW RESIDENTIAL MECH. SQ. IT.
fomin Health & Sunny Cal" Sections 255115, 25533 and 25534.1 understand that it Ta
building docs nm aunemly Itnve a term, that it is my responsibility to notify the occupant
OFFICE
FEE
FEE
PFJif [ NO, 0776 776
.NITARY NO. APPLICATION SUBMITTAL
13-,16/c;0107
NIC CONTROL If
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
1:1❑ L ❑
JOB DESCRIPTION
RESIDENTIAL❑SPDWL
❑ KITCHEN REMODEL
❑ADDITION
El PLUMBING RE -PIPE
❑MUI,TI-UNIT
El STRUCTURAL
MODIFICATION
El INTERIOR
11 CHIMNEY REPAIR
IMPROVEMENT
SWIMMING POOLS
❑ RATA REmoDEIJREPAIR
❑ DEMOLITION
❑ OTI18R
/
COMMERCIAL
El NEW BLDG/ADDITION
❑DEMOLITION
❑TENANT
❑ FOOD SERVICE
IMPROVEMENT
❑ OTHER
SQ. FI'. FLOOR AREA
BUILDING DIVISION FEES
PLANCKECK IEE
ENERGY Phr,
GRADING PEI?
SOILS IEE
PAID
Data
M
?I:' sr:I?F.L PEE
a s.J
I HOUSING MITIGATION FEE I I
PAID
Data RemiptX