31508IN INFORMATION WITHIN RED LINES • USE SALL POINT PEN ONLY
CITY OF CUPERTINO_ - BUILDINGELECTRICAL T Pnamt t nn,, � � � O
BUILDING DIVISION APPLICATION/PERMIT I PLUMBING -MECHANICAL
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ARCHITF.CI'/ENGINBER: LI
G
ADDRESS:
❑
DRAINS- FLOOR, BOOR, AREA, COND.
CONTACT,PHONE:
TYPE Ci
BUILDING PERMIT INFO
GAS - EA. SYSTEM- I INC.4 OUTLETS
GAS - EA. SYSTEM -OVER 4 (EA)
❑ Consultant Fees Paid by Applicant (Initial)
BLDG ELECT PLUMB MECH
El ,LTJ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby afford that l am licensed under provisions of Chapter 9 (commencing
withSemion7000)af Division3ofthe Bucinennnd Professions CMe.endmylicenseis
full hormonal effect.
License Class Lic.p
Datc Contactor
QTY ELECTRIC PERMIT FEE
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6 W
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W 3 EES F
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ENERGY FEE
JOB DESCRIPTION
IAL
Sri Ll KITCHEN REMODEL
❑ ADDITION [I PLUMBING RE -PIPE
❑MULT-UNIT []STRUCTURALyOl
MODIFICATION
[I INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT
[J BATH REMODEURBPAIR [I DEMOLITION
❑ OT ER
g/a�'4 g•(1/i<
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL
ARCHITECT'S DECLARATION t
I understand m plans shallh used as publiccords,
PANELS
I a"n
l UP 70200 AMPS Ii
Licensed Professional
OWNER -BUILDER exempt front
1 hereby alTrm That 1 em exemq from the Contractor's License Lew for the
following meson. (Section 703 1.5, Business and Professions Code: Any city or county
W01 hlch r�Ylmi B pemdl In CnnsWCl, alter. ImprUV[, dem011sh, nr Rp81I Br1y rlNClum
prionoits issuance. also requiresthe applicant for such menninofleaeignW me¢mem
201-1000AMPS
OVER !"AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUITIMISC. j
IALM It Ott ntt
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that he is licensed pulsnano the provisions of the Contractor's License Law(Chapter9
tt
TEMP. METER OR POLE INST.
COMMERCIAL' I
❑ NEW BLDG/ADDITION ❑ DEMOLITION
El TENANT ❑FOODSERVICE
IMPROVEMENT
❑OTHER
00q
Is. e LL
•'^,� Ix•
N
QLas
..
Ilapandro
(commmingwiNSedion7(100)of Division3nfthe BusinessmdProfenionsCWe)or
(But he is exempt thercfiom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for o permit subjects the applicant o o civil penalty of
t more than live hundred dollars ($5fgl).
owner of me rt, or emloces with woes as their sale compensation,
❑ prop< y Y P Y 6 pcnsa
dosforside
will dothe wons Codes he Con rr tot intended minuendLaw not ply to an Business
License Law does nal apply s if owner of
Cade: The Cos thereon,
erty who
who or improves thereon, and who don such work himself through
his
POWER DEVICES
SWIMMING POOL ELECTRIC
)IOUTLEfS.SWITCHES -FIX7VR8S �a
SEISMIC FEE
ELECTRIC FEE
PERMIT ISSUANCE
ALTER OR AORTO MECH.
own ogees,
his own employees, provided Net such improvetmnu art not intended or offered for
f
NEW RESIDENTIAL E1.EC7R SQ Ff.
MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,000 CPM)
sale. If. however. the building or improvement is sold within one year of completion, the
Signature of ApplicaMC.nrracbr Doe
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or form building occupant store or handle hazardous material
as defined by the Canadian Municipal Cede, Chapter 9,12, and the Health and Safety
Cede, Section Vi532(a)7
❑Yes 0 N
Will the applicant or future building avcupeat use equipment or devices which
emit haxaN.ua air mmaminsnts as defined by the Bay Area Air Quality Management
District?
F7 Y. [:1 No
I have rend the hmallous materials beguilement under Chapter 6.95 of the Cali-
funds Health & Safety Code, Sections 25505.25533 and 25534. 1 understand that if the
building does not currently No
ntly have a (sat it is my responsibility notify the occupan
of the requirements which must he mel prior to ismonce of a Certificate of Occupancy.
SQ.PnrlpRgREA
VSQ. Ff.
HEATING UNI 'p(TO 100,000 BTU)
owner -builder will have the burden of proving that he did not build or improve for pun-
HEATING UNIT (OVER 100,000 BTU)
Y' p0 7
VENTILATION PAN (SINGLE RESID)
BOILER -COMP (JHP OR 100.000 BTU)
pard of sale.).
8011811 -COMP (OVER I(NI,(I0p U'1'U)
I
ISSUANCE DATE
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ambxcvely convecting with licerned coanacton to
wnf Ne propertylusi
❑1,a.ero
Q�`'
project, (Sec. 7044, Business and Prusiom Code:) The Convnma's Li-
o onmrue, the profa
fwAC.o1,
.Vld GI y99
me Lowliness not apply to an ownerofpmpedy who huilds or improves thereon, and
QTY. PLUMBING PERMIT FEE
{p
I'VM
who pursuant contracts for such projects with a cormaclods) licensed pursuano the Contractors
Li -=-.pa
e Law. pt ander Sec. B&PCfor//Nisn
Lr exemreaxo
C11
CI7 i Ur ��FCn 111V(,
PERMIT
ALTER- DRAIN & VENT - WATER (E
�'P. ATp Z'—Tn"dZ"Ft
.............
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. WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penaby of perjury one of the following declarations:
❑ (have and will maimuine Cenificum ofCansenl to self -insure for Worker's Compen-
sation. as provided for by Section 37M of the Labor CWC, far the perfamtancc of the
work for which this permit is issued.
❑ 1 have and will maintain Worker's Commensal ion romance, as required by Section
3700.f the Labor Code, for the perfornrancc of the work for which this permit is ismed.
My Worker's Compensation Insurance carrier and Policy number me:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Tons seoi.n need not Ix completed i(the pemut is forone hundred dollen ($10E
.,less.)
this crniiare W rles'Comon-
not employ any person in any manner so as m hx.me subject the Workers Campen-
Foy any pmolat in in any performance the work as to
ration lows of California. Dole
Applicant
BACK FLAW PROTECT. DEVICE
DRAINS- FLOOR, BOOR, AREA, COND.
STORIES
1
OCC GROUP
TYPE Ci
FIXTURES -PER TRAP
GAS - EA. SYSTEM- I INC.4 OUTLETS
GAS - EA. SYSTEM -OVER 4 (EA)
GREASMNDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
GRP.ASETRAP
PLANCIiP,CK II3P.
SEWER -SANITARY -STORM EA. Ff.
ENERGY FEE
WATER HEATER WNENT/ELECTR
GRADING FEE
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abecome
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NOTICE TO APPLICANT: IL after making this Certificate of Exemption, you should
subject to the Worker's Compensation provisions of the Labor Code, you most
forthwith comply with such pmvisi.m or Nis permit shall be declined revoked.
CONSTRUCTION is. ION LENUINGAGBNCY o
lher which hilhenhere issued x. 30 len ding agency for the pertoomavc of
Nework for which this meteor is issued (Su. JIp7, Civ. CJ
Lenders Name
WATER SYSTEM/TREATING
SOUS FEE
WATER SERVICE
PAID
NEW RESIDENTIAL PLMU. SQ. FT.
Dam Reeeiptp
TOTAL:
Lcndn'. Address
TOTAL:
ccnify, that I have read this application and sta¢ Na d¢ above information is
sourest. l agree to comply with all city and county ordinances and stoic laws reusing to
buil ding construction, and hereby osbnrizdo,pri,entatives of this city m auto, upon the
above-mentioned por,my for inspection purposes.
(We) agree to save, indemnify and keep hamdess [be City of Cupertino against
liabilities,judgments, costs and expenses which may in any way accrue against said City
in masequence of the gaming of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS.
QTY, MECHANICAL PERMIT FEE
BUILDING FEE
SEISMIC FEE
ELECTRIC FEE
PERMIT ISSUANCE
ALTER OR AORTO MECH.
PLUMBING FEE
AIR HANDLING UNIT(TO 10.000 CPM)
MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,000 CPM)
CONSTRUCTION TAX
Signature of ApplicaMC.nrracbr Doe
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or form building occupant store or handle hazardous material
as defined by the Canadian Municipal Cede, Chapter 9,12, and the Health and Safety
Cede, Section Vi532(a)7
❑Yes 0 N
Will the applicant or future building avcupeat use equipment or devices which
emit haxaN.ua air mmaminsnts as defined by the Bay Area Air Quality Management
District?
F7 Y. [:1 No
I have rend the hmallous materials beguilement under Chapter 6.95 of the Cali-
funds Health & Safety Code, Sections 25505.25533 and 25534. 1 understand that if the
building does not currently No
ntly have a (sat it is my responsibility notify the occupan
of the requirements which must he mel prior to ismonce of a Certificate of Occupancy.
EXHAUST GOOD(WMUCT)
HOUSING MITIGATION FEE
HEATING UNI 'p(TO 100,000 BTU)
HEATING UNIT (OVER 100,000 BTU)
PAID
Date Receipt M
VENTILATION PAN (SINGLE RESID)
BOILER -COMP (JHP OR 100.000 BTU)
TOTAL:
8011811 -COMP (OVER I(NI,(I0p U'1'U)
AIR CONDITIONER
ISSUANCE DATE
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NEW RESIDENTIAL MECH. SQ 17T
OFFICE