29662APPLICANTTO FILL IN INFORMATION WITHIN RED LINES • USE BALL POINT PEN ONLY
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DIVISION APPLICATION/PERMIT
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❑ Consultant Fees Paid by Applicant (Initial)
BUILDING PERMIT INFO
BLDG ELECT . PLUMB MECH
E:1
❑ ❑ ❑
J.ICENSP.DCON] Rd underSoviCons of CON
I hereby vfrirm that I a3, licensed i n ss provision oris Code. 9lrommensi is
ideas,
ith Section 7(qX ] Business and Professions Code. and my license is
full I'nrce anA v s ,
Liceme Class q
Date Comrecmr
ARCHITECTS DECLARATION
lundersmn my plane shell be usedm imblicrenuds
QTY, ELECTRIC PP.RMI'I' FEE
JOB DESCRIPTION
RESIDENTIAL,
❑S WI. KITCHEN REMODEL.
❑ADDITION ❑PLUMBING RE -PIPE
❑ MULTI -UNIT ❑ STRUC'NRAI.
MODII9CATION
11 INTERIOR ❑CHIMNIiY REPAIR
IMPROVEMENT
❑ BATH RG JRE(f,k(t DE ITION
OTHER ]�
��
PERMIT ISSUANCE'
AI'PLIANCIIS- RISIDF.NTIAL
PANELS
UI'T0200MPS
Licensed Pmfexsional
OWNER-BUILOF.R DECLARATION
1 hereby aree eRnn that I am exempt from the Contractors License law for the
following reas,n. (Section 7031.5, Business and Profusions Cede: Any city or county
which requires a permit to cnmWet, alter, improve, demolish, of repoir any flrucmre
prion, its issuance, also requires the aWlicam for such permit to rile a signed statement
that he is licensed pursuanno Neprevisionsofthe Contractors Licenselaw(Chupter9
(commencing with Sectien 7") of Division3 of the 9nsines.send Per l'u..most ,Ju)or
mm be is exempt therefrom and the basis far the alleged exemption. Any violation of
Section 7031.56y any applicant faro permit xuhjensthe applicannoacivil penalty of
t .,,,urban rive hundred dollars ($500),
01, as owner of the propert, or my employees with wages as their sole compensation,
will do the work. and the stmctoba is not intended oroffeted forxle(sec. 71WI. Business
and Prnfes.slons Code: The Contractor's License Law does not apply to an owner of
Property who build, or improves thereon, and who does such work himself or through
his own employees, provided that such improvements are not intended or offered for
aideIf. however the faudingm improvement is cold within one yearn(completion, the
ownenbuildey will have the burden of proving that he did not build m improve fill puri -II
poxf s
oole.).
1, as owner of the property, um exclusively contracting with licensed contractors to
construct the project (Sec. 7040, Business and Profusions Cosi The Convactnr'--
-
arrive, Lavadayes not apply to an coviscrofiomploy %hobuild% orimparoves thereon, and
c xLawdoesnotapplytoanownerofpmpenywhobuildserimprovesthereon,and
who connects for such projects with a conmumm rn
ons) licensed pursuant the Comemrs
License Law.
I am exempt under Sec. - , B & P C for this rerun
2111-Iofg1AMP5
OVER It") -
SIGNS F.LEL4RICAL
ELECTRICAL
SPECIAL CLRCUIT7MLSC.
TIIMP. MIgNk OIt POLE IN$T.
COMMERCIAL:
[I NEW BLDG/ADDTTION DEMOLITION
❑TENANT ❑FOODSERVICH
IMPROVEMENT
❑OTHER
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS - SWITCHES -FIXTURES
NEW RESUNiNT1AL ELECfR S
� RIM
SQ. FT. FLOOR AREA
FEB
Igoe
CITY UrUU4, fll�U
ESQ. Fri.
TOTAL:
QTY. PLUMBING PERMIT FEE
1'IikMl'L'LSSUANCE
ALTER -DRAIN & VENT- WATER (EA)
Owner Use
VALUATION
, C60
WORKER'S COMPENSATION DECLARATION
I hereby affirm under Penalty of Perjury one ofine following dedamliom:
LJ nmlmulnuCeniriculeof C,nswlt lost(-ittsur, fnr Wnrku's C,..,ar-
astion, es provided for by Section 17M oldie Llan Cade, for m
the perforance of the
work far which this permit is issued.
0 I have and will mad train Workers Compensation Insurance, as required by Section
3700,E the L'Mtr Code, licr the performance of he work for which then permit is issued.
My W 11 of m 'lino nd Policy nyt1pptt�yec y
Carier� 01: GX NUMOcy Na:J WORKERS 0 3/
Cil IPIC OMPE EXEMPTION FROM WOkKERS'
COMPENSATION INSURANCE
<Tbis eemion need not bealmplemdit the penult is far one hundred dollars ($10())
or less.)
I certify that in the perfomwncc of the work forwhich this pcmtit is issued, Lshail
nm employ any person in any manner s, as nl become subject to the Workers' Camper-
smor l.aws.f Califorrom Date
Applicant
BACK FLOW PROTECT. DEVICE
DRAINS -FLOOR, ROOF,ARHA,COND.
STORIES
TYPE CONSTRUCTION
FIXTURES - PER TRAP
GAS- EA. SYSTEM. I INC. O OUTLETS
OCC GR UP APN .
IffMaI GDIVISION PETS
e��-'A.SYSTEM-OVP.RO(EA)
GREASFIINDUSTRL WASTE INTERCEPTOR
GREASETRAP
PLANCIIIi
SEWER-SANITARY-STORMCA.20o FT.
ENER .
WATER HEATER W/VENT/ELECTR
GR
NG F'E
NOTICE TO APPLICANT: Jr. after making this Certificate of Exemption, you should
become subject to the Workers Compensation p000li os of the Labor Cole, yen must
forthwith comply with such provisions or this permit shall be thermal revoked.
CONSTRUCTION LENDING AGENCY
that there is.
k for sued(Se 30 len ding agency far the performance of
the work for which this permit is issued (Su. 30197, Cie CJ
Lender's Name
WATER SYSTEM/TREATING
SOI
S l
WATER SERVICE
PAID
_ Dom Receiptq
NEW RESIDENTIAL PLMIt. SQ, FT.
TO'PAL:
Lenders Address
1 certify that I have bard this application and atom that the above infnrmminn is
corect.Iogree tocomply with all city and c,umy ordinances trod stun laws rclming to
building cunshandiom, and hereby authorize tcpresenmayes of this city or enter open the
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Co,knine ll,iut
liabilaies,judgmems,cosls and expenses which may in any way uecrueagvinstsaid City
in consequence of the granting of this Permit.
APPLICANT UNDERSTANDS>VD WILL COMPLY WITH ALL NON -POINT
SOURC ECJ Aq' .S.
TOTAL:
BUI )ING FEE �a r
QTY, MECHANICAL, PERMIT FEE
SEI MICFEE
O
PERMIT ISSUANCE.
EL CTRIC FEE
ALTER OR ADD TO MECIL
PLUMB FEE
AIR HANDLING UNTT(TO 10,M) CFM)
MLCHANICA �IiG '
AIR HANDLING UNIT(OVER EO,tNp CFM)
CONSTRUCIlO AX
Signature mf Applicant/C,otra Dole
HAZAR S MATERIAL$ DISCLOSURE
Will the applicant or fuwrt building eccupanumre or hvmlle hazardous motorial
as defiled by the Cupertino Municipal Cole, Chapter 9.12, and the health and Safety
Code, Section 2.5532(a)? s
❑Yes ❑No
Will the it clan'nt or furore building y the Ht use equipment or devices which
air uomvnitmms as defined by the Hay Area Air Quality Management
DislriclR � a ITOTAL:
Yes E]Nn
I have real the hvnrdous materialsrc requirements under Chapter of the Cali-
a l
tom if the
fominHealth gdoesneSafety Code, Sestina25505,iss5J]and25530.I to notify the
of Ne requirtmema which mut be mu prior m issuance of a Cenlriu¢,f Occupancy.
of thong does net n,whitcurrently have remnant, that it is m responsibility nmifOccupancy.
EXHAUST HOOD ONMUCI')
HOUSING MITIGA ON F[L
HEATING UNIT TO 100.000, BTU)
HEATING UNIT (OVER 110.1100 BTU)
-
PAID
Ouf�o eceipt a
VENTILATION PAN (SINGLE RISID)
BOILER - COMP (JHPOR ICC.glO BTU)
BOILER- COME (OVER 110.000 BTU)
AIR CONDITIONER
ISSUANCE DATE
.
wL/
ISSUED IIY'
NEW RESIDENTIAI. MECH. .SQ, FT.
_
Owner eT i uNunxcd agent Date
TOTAL:
OFFICE