S 0211APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING . in.ftc IRICAL PERMITNO,
NUILDING DIVISION APPLICATION/PERMIT • r r, urornn!cunNln r+er S 0 211
PLUMBING r rCHANI rr,N
N
CONTACT: IPHONE:
i'ht%pe-z4 avl1 Y7o
LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm Nat 1 am licensed under provisions of Chapter 9 (commencing
ODC with Seclinn]10yami Division 3nftbe Bed.examid Pmfessims Cade, and my license is
in full force and a c t.
at U U License Class Lic. g
F. 7a W Dore Contmctnr
fn un ARCHITECTS DHCL i
Z p y K 1 undemm�d my plans shall be used a public,atoms
OZ-,
F 1•" Licensed Professional
OWNER -BUILDER DECLARATION
W 6 1 hereby affirm that I am exempt firma the Contractor's License Law for the
O y U fnllowing reason. (Section 7031.5, Business and Professions Code: Any city lir county
W O which requires a permit to conswct, alter, improve, demolish. or broad, any saucture
ono, to its issuance, also require, the applicant for such permit to file a signed statement
Eby (commencing;
he is licensng with
personal to the provisions of the Contractors License Law (Chapter 9
WC) iith Section 7nlMR of Division 3ofthe Businessand Firms inns Grde)nr
S d o that he is exempt therefrom and the basis for the alleged exemption. Any violation of
NSection 703l..1 by any applicant for a permit subjects the applicant to a civil Penalty of
not marc than five hundred dollars 1$500).
9i 71 1, as owner of the pmpeny, lir my employees with wages as their role compensation,
44 will do the work, and the structure is not intended oro@ml for cele (Sec. 71114. Business
6 3 and Pruessinn.s Code: The Contractor's License Law does not apply to an owner of
property who build, or improves thereon, and who does such work himself or through
his own employees, provided shut such improv encs ore not intended or offered for
sale. ILhoerveq the laildnitminproventem is soldwithin one yearufa+mpletinn, the
mer -builder will have the burden of proving that he did not build lir improve for pur-
Nve of sale.).
❑ 1, is owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7641 Business and Profewinns Oxle99Le Contractor's I.i-
cense Law does not apply to an owner of property who builds or improves thereon, and
who contracts for such projects with a Omencmrlg licensed pursuant to 003 Commenin s
License Law,
❑ I am exempt under Sec. ,B& P C for this reason
3 SC F k rvnz-w I- W X rza a'n
❑ Consultant Fees Paid by Applicant (Initial)
,TY ELECTRIC PERMIT FEE
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL.
PANELS
UP TO 20 AMPS
SIGNS ELECTRICAL
SPECIALCIRCUIT/MISC,
TEMP. MEYER OR POLE INST.
POWER DEVICES
SWIMMING POOL. ELECTRIC
OUTLETS - SWITCHES - FIXTURES
NEW RESIDENTIAL. F.LF.CTR SQ Ef.
0
RLDG ELECT PLUMB MILCH
❑ ❑
JOB DESCRIPTION
RESIDENTIAL:
❑ SFDWL
❑ KITCHEN REMOUEI.
[]ADDITION
❑PLUMBING RE -PIPE
❑MULTI -UNIT
❑STRUCTURAL
VENTILATION FAN (SINGLE RESID)
MODIFICATION
❑INTERIOR
❑CHIMNEY REPAIR
IMPROVEMENT
E] SWIMMING POOLS
❑ BATH DEMOLITION
El0T�H
pR/E��M�ODIDIId-flREPAIR�E❑
ksz;c
work for Which obis permit is issued.
this
/\.
V&_
O.mo m emlimi.d agent I brae—
COMMERCIAL:
El NEW BLDG/ADDITION
El DEMOLITION
❑TENANT
❑ FOOD SERVICE
IMPROVEMENT
GAS -PA.SYSTEM -I INC. 40U'1' i'1'S
❑ OTHER
My Workers Compensation Insurance carrier and Policy number are:
Comer. Policy No.:
$/SQ. FT.
PERMIT ISSUANC
ALTER-IIRAIN&VENT-WA 'R(EA)
FEE
Signature of Appncanvft-mmracmr
HA] RDOUS MATERIALS DISCLOSURE
Will theappliewin or fbture building creuparn store lir handle hrzardnus material
as defined by the Cupen"no Municipal Code, Chapter 9.12, and the Health and Safety
Cade, Seetiun 25532(0)1 a,�
E3 Yet LO N'"
Will the applicant
nno or future building by the B use equipment lir devices which
emi"hazardmus air cnnmmiwmsa No efned by the Buy Arca Air Quality Management
p°"dc@
❑Yes
1 bout real hazardous materialsmaterialsrequiremems aider Chapmr fi 95 of NCali-
fomia Health & S.fcl,,Cqdc. Sections 25505, 25533 dad 225534. 1 uadensmnd chat if rho
buildingdnesnntcu o haveemnanL ohm it ix my recponsibilitym notify the rcapant
reyuire is It must he met pnonninmunce nlA1 Cf, d^I�t of (kcuYoul".
V t1 1p
Owner Date
WORKER'S COM PENSATION DECLARATION
BACK FLOW PROTECT. ICP
/ Od
1 hereby alliin under penalty of perjury one of the follow in, declurmiom:
PAID
VENTILATION FAN (SINGLE RESID)
Data Receipt #.
I havernl will mainmin a Cenifiemeof Conmtn m self -insure for Workers Comics.
moron, ask for by Section 971X1 of the Luhor Cade, lie the performance of to
pRAINS-FLOOR. ROOF CD 1
(STORIES
TYPE C(
AIR CONDITIONERe
ISSUANCE DATE
ISSUED BY: --
work for Which obis permit is issued.
this
FIXTURES -PER TRAP
O.mo m emlimi.d agent I brae—
1 hove and will maintain Workers Compereallofte w Insurance, h required by Section
3](Nl of the labor Cody for performance of rhe work for which this permit is issued.
OCC. GROUP
GAS -PA.SYSTEM -I INC. 40U'1' i'1'S
My Workers Compensation Insurance carrier and Policy number are:
Comer. Policy No.:
GAS -EA. SYSTEM -OVER 4 (EA)
GRIiASPJINDU$q'RI. WASTF.INTERCIiI'TON
CERTIFICATE OF E%EMPd'ION FROM WORKERS'
COMPENSATION INSURANCE
BUILDING DIVISION FEES
lir less) This section need not he completed fthe permh is for line hundred dollars$RMB
GREASH'IRAP
I �I KNlill
SEWLR-SANITARY-STORM IiA 210 FT.
I certify that int dbrmanceoldowmkforwhichohispermilisiscod,lshall
nuoemplayany person ymanner `mbe/�p9mqesubjeco m the Workers'Cnmpen-
ENERGY F'' a
WN'BRIIEATER WNEM'MI-11 R
WATER SYSTEM/IREATING
WATERSERVICE
R G
O z
F
�i'�y
'cation l• fCIn, in Dun �l1'Yl Oman
ApPlica11
NOTICE TO APPLICANT: L after making this Cerilicam of Exemption, you should
become subject to the Workers Compensation provisions of the Labor Cade, you mud
funhwiohcnmPly wiNsnch provisimm�rthis permit shall he deemed rnvnked.
SOILS ITE `M11)5
NEW RESIDENTIAL. PLMB. SQ. PI'.
7 z
U 0
O WL:
y
y
U z
CONSTRUCTION LENDING AGENCY
l hereby affirm shauhem is a construction lending agency for the performance of
the work for which this permit Is issued (Sec. 3097. Civ. CJ
Leaders Name
PAID
Data Receipt p
'IOTA I.:
TOTA
Lenders Address
BUILDING FEE
SEISMIC FEE
I certify ohm 1 have read this application and slam that abuse information "c
correct.I sane,, comply with all city and county mnliwnees and,tons laws relntinsm
building construction, and hereby andiron mprcsenm"ivesnf chis city in eater eons the
QTY. MECHANICAL PERMIT FEE
PERMIT ISSUANCE
ELECTRIC FEE
above-mentioned property for inspection purposes.
(We) agree m save, indemnify end keep harmless the Cily of Cupen'mo eguinm
AI.TERORADDTOMECH.
PLUMBING PEE
liabilities,judgments, costs and expcnms which may in anyway accrue against said City
in consequence of the graining n( "his permit
AIR HANDLING UNIT (TO IIkWO CFM)
MECHANICAL Irf:E
APPLICANT U RSTANDS AND WILL COMPLY WITH ALL NON -POINT
OURCFD�ysvEG IONS.
YIT i lizz— 03-r-1 g7
AIR HANDLING UNIT (OVER IO." CFM)
CONSTRUCTIONTA%
Signature of Appncanvft-mmracmr
HA] RDOUS MATERIALS DISCLOSURE
Will theappliewin or fbture building creuparn store lir handle hrzardnus material
as defined by the Cupen"no Municipal Code, Chapter 9.12, and the Health and Safety
Cade, Seetiun 25532(0)1 a,�
E3 Yet LO N'"
Will the applicant
nno or future building by the B use equipment lir devices which
emi"hazardmus air cnnmmiwmsa No efned by the Buy Arca Air Quality Management
p°"dc@
❑Yes
1 bout real hazardous materialsmaterialsrequiremems aider Chapmr fi 95 of NCali-
fomia Health & S.fcl,,Cqdc. Sections 25505, 25533 dad 225534. 1 uadensmnd chat if rho
buildingdnesnntcu o haveemnanL ohm it ix my recponsibilitym notify the rcapant
reyuire is It must he met pnonninmunce nlA1 Cf, d^I�t of (kcuYoul".
V t1 1p
HOUSING MITIGATION FEE
H17ATING UNIT (TO Hall RICH
HEATING UNIT (OVER 100,010 BTU)
PAID
VENTILATION FAN (SINGLE RESID)
Data Receipt #.
BOILER COMP (JHP OR IW,U(E BTU)
T
BOILER- COMP (OVER 100,IK0 BTU)
AIR CONDITIONERe
ISSUANCE DATE
ISSUED BY: --
NEW RESIDENTIAL MUCH. SQ. FT.
TOTAL -1
O.mo m emlimi.d agent I brae—
OFFICE