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CITY OF CUPERTINO BUILDING. uLRCrRlcTi,
RUII,DING DIVISION APPIACATION/PERMITPLUMBING-MECHANICAL
BUILDING PROJECT IDENFIFICAI'ION
PIs Tr NO.
1440
4TMILDING ADDRESS: p
10325' 8" [ANE
SANITARY NO.
APPLICATION SUBMI'I'fAL DAT Ii
O NiRINAMp:Loi NE-
Q NMit-qD3 }
CONI'ItACI'OR" AMI:: LIC NO:
N/C
❑
GDNI'Rot. N
ARCHITECT/ENGINEER: LIC NU:
ADDRESS:
COM'AC . PHONE:
BUILDING PERMIT INFO
BLOC ELECT PLUMB MECH
❑ Consultant Fees Paid by Applicant (Initial)
El El El
LICENSED CONTRACTOR'S DECLARATION
I hereby all!.... that i i G<er,ed under prodoioar of Chapter 9 (ammnanAng
QTY. ELECTRIC PERMIT 17EF.
JOB DESCRIPTION
PI7RMIT ISSUANCE
with Section 7000) sit Division 3ofthc Business and professions Code and my license is
in full functional effect.
RESIDENTIAL'
❑ SI-DWL ❑ KITCHEN REMODEL.
APPLIANCES-RESIDBN'I'I Al.
License Class Lic.K
m
Dme Commor
❑ADDITION El PLUMBING RE -PIPE
❑MULTI -UNIT ❑MODCNRAL
ATION
CHIMNEY
[-I INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT DSWIMMINGPOOIS
ARCHITECrs DECLARATION
I understandmy plansshall be used as public records
PANELS
UP'i'02(O AMPS
Licensed Professional
201.1000AMP$
OWNER -BUILDER DECLARATION
1 herchy ni int that I iun exempt rmm Ife Conuucmr'N License Law for Lha
following reason (Section 7031.5. Business and Professionals Code: Any city or county
❑BATHRE )D R'PAI F.M ITION
❑OTHER y
OVER IBIN)AMPS
SIGNS ELECTRICAL
Which requires a pe,mo to non9auel, akar, improve, demolish a repair any swcturc
prior to its issuance, else requires the spPlicun, for -ch pennirto lie a signed aenemem
SVECIALCIRCUIT/MISC.
the, he is licensed pursuer, et the pmvininec of the Coal .. nr's I-wenm Law (Chapter 9
(commencing with Section 71X0)of Division 3 afthe Business and Professions Cnle)or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
TFSIP. MITER OR POLE INST.
COMMERCIAL:
El NEW BLDC/ADDITION DEMOLITION
Sro,ion 70315 by any applinim forapermit subjects the apPlionrto a civil penalty of
N)WHR DEVICES
El FNANT ❑POODSF,RVICH
ire oat than five It dreddollurs($500f
eroflhepmperty. or my employtts with wegcn as their sole compensation,
ill dm the work, and the stricture is not intended aroffared for sale (Sea. 7044, Business
IMPROVEMENT
❑ O'TIIER
SWIMMING POOL. RLECTRIC
/tIVEE
and Pmiesvbns Cock The Contractor's License Law ares not apply to an owner of
OUTLGI:S-SWITCHES -FIXTURES
NEW R&MIA NTIAL ELECI'R SQ lel'.
tannery who builds or improves themon, and whir ares such work himself or Ihmugh
his own employees. provided that such Improvements are not intended or offered for
safe. ,[however. the building or imprnvemcut unsold withlnune yv:roo ,d nplefon, the
SQ.IT. IILOOk AREA
$ISQ.IT.
ner-huilder will have the burden of proving that he did not build or improve for pur-
pttw of sale J.
trope y, ten excessively ctmuacons wllh:)canned conimemre i-
I, its owner of that n
TOTAL:
rtywhoomCWd)TheComracaor,Li-
pati at heproject(See.o an Business and
seLaw apply toa,owner whobuildvorimproves
Conta,and
QTY. PLUMBING PERMIT
ah.cispropeny
the
who nnnrums for such pmjccN with o cnntrannr(s) IiacnseJ pursuant m the Cnmmcmr's
esfor.
PERMTIISSUANCE
License Law.
G/I am exempt under Sec. ,B& P C fnf this reason
f
ALTER -DRAIN & VENT - WATI3k (IiA)
VALUATION
D. 3
WORKER'S COMPENSATIONDECLARAl ION
3 U Affil
HACK FLOW PR(TI'IiC.. DEVICE.
MAR
I hereby aRnn under penalty of perjury one of the following decla slione
SIDR^I LtS
v, `„ �NV -
TYPE CONS rO DICTION
I haveund will maintains CenifinnoofC conn, selbubtre for Workers Co.r,r.
sminn, as provided for by Scetirn13700 of the Lobar Coda, I'ot the perfnmtanre of 'he
work far which this permit is issued.
DRAINS- FLOOR_, ROOF, A It EA, COND,
IBXTUR&S-PER TRAP
1 have and will maintain Worker's Compensation Insurance, as required by Senimn
9700 o1'I he Labor Code, for t ha perronnance of [lie work for which this permit is i'ond,
GAS- EA. SYSTEM. I I NC. 40UTLEIS
OCC. GROUP
APN
My Workers Compensation Insurance came, and Policy manlier are:
Canicc Policy No.:
GAS -EA. SYSTEM OVER -1 OW
GRIASI%INDUS'I'k1, WAST(? INTERCEPTOR
CliRI'IFICAI li OF CX 17M PITON FROM WORKERS'
COMPENSATION INSURANCH
BUILDING DIVISION FERS
fl'hiv section need not he completed if the permit is fofone hundred dollars($100/
nr Pus)
GREASEI RAP
PLANCIIF.CK I'EB
SEWER -SANITARY-STORM EA. 20()FT.
ENERGY FF.0
I cenirythat lathe parQumanccol M1awnrk lorwhich@Ixpannitlx issued. hill
not employ any Person in any manner so as to become subject to the Workers' Compen.
WATER IIBAI'ER W/VENT/ELECTR
GRADING Flili
sminn Laws of California. Due
Applicant
NOTICE TO APPLICANT: IL after corking this Ceriferac of Exemption, you should
become subject to the Workers Compensation provisions of the labor Cede, you must
WATER SYSTEMTREATING
SOILS FEF.
lisnhwith comply with Nuch laro,monx o, his permit shall he deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby afOmnhat there is a construction lending agency for Ilia performance of
WATER SERVICE
PAID
Dube 'nM
NHW RESIDENTIAL PLMB. SQ. Pr
OTAL:
the work for which this pennh is issued (Sec. 9097, Civ. C.)'
lander'. Name
1'.
Lenders Address
BUILDING FEL?
I anify atm I have rod this appnadnn inti state that me Neve Tnfnrnu0on is
counsel. l agree to comply with all city and county ordinance% and state laws relining m
building construction. and hereby amhnsin representatives of this city m enter upon the
QTY. MECHANICAL PERMIT IEE
SEISMIC FEE
111HRMIT ISSUANCE
IiLEC'I'If IC 11
above-memtiened propercy for inspecdmn purpexcn.
(We) corm hu act, inden nd fy and keep harndc, the City o1'Cupeninn again,,
liabilities,judgments. costs and a.....which may in any way income .gained said City
. nICANIce UNDERSif the TANDS
of AND WILL
APPLICAN'I'UNDI3RSTANDS AND WILL COMPLY WITH ALL NON -POINT
ALTER OR ADD TO MIiCI I.
PLUMBING Ilili
A11t HANDLINOIINIT (TO III0N1CPM)
MECHANICALPB.
SOUR( E ULATIONS.
AIR HANDUNGUNIT(OVER I0,00CFM)
CONSFRUCTIO TAX
O
Signaturce' ppucamUC moucur )ate
EXHAUST'HOOD(W/DUCT')
HOUSING MITI TION FEE
HA' RDOUS MAI E INS DISCLOSURE
Will the applicant our future buildingtecupatnstarcnr handle havallous minimal
;is defined by the Culeninn Mmucipnl Coda, Chapter 9.12, and the Beath all Safeny
Cafe, Section 25532(x)?
HEATING UNIT (TO 1110,00 BTU)
HEA'ONG UNIT (OVER 10,00 BTU)
FAN(SINGUH RFSID)
E) Yes ❑NoVEN'MLATION
PAID -
Dme keeeipt M ,
BOILER -COMP (31111 OR 10of BTU)
Will the applicant or future building mcceprnl use equipment or devices which
emit harardnes air do amimuct, as defined by the Bay Area Air Quality Management
TOTAL: -
District?
❑Yex F1 No
BOILER-COMP(OVER INot)(101310)
AIRCONDITIONER
ISSUANCE DATE
I have readthe hvanlous materials¢quitnmenls under Chapter 6.95 of the Cali-
NEW RF,SIDENf1AL. MUCH. SQ. Pr.
Gratia Health & Safety Coda Sections 2550.5, 25533 and 2.5534. 1 undersond Ilan If the
building does not ct rendy have a tenant, that it is my resrymsibilay to may the occupant
of the requirements which must be not prior to issuance of a Certificate of Occupancy.
ISSUED BY:
TOTAL:
Owner or nmhurited agent Data
OFFICE