99100011APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY + ,3ZZ7 Q 00 11
OFFICE
CITY OF CUPCi RTINO BUILDING - ELECTRICAL
PERMIT NO.
BUILDING DIVISION APPIACATION/PERMIT PLUMBING -MECHANICAL.
- BUILDING PROJECT IDENTIFICATION "+
13UILDINGA pDRESS:
SANITARY NO,
AT ION S A1. DATE
' 5c^eni I Iu Na le
�6_�
'NHI<'S NAME:
.GN`PHO�J�n
COMfRACTOR'S NAME?: LIC NO:
NIC
CONTROLp
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pcj �l-�1 ✓
❑
T /ENGINEER: LIC NO:
ADDRESS:
CT: PHONE:
' BUILDING PERMIT INFO
(,n C. or- �S � I �n
Ifull
❑ Consultant Fees Paid by Applicant (initial)
BLDG ELE PLUMB ECI
LICENSED COME RACI'OR:5 DECLARATION
1 herehy allirm that 1 am licensed under provixiuns mf Chapter 9 remain nein.
Section Division 3 ofthe Business and Professions Code, and mylicause
and effect.
1 icense Class Lae. #
Date Contractor
ELECTRIC PERMIT ' '
.. T1. FEE
5<-J
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00ERMIT
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B DES IPTIO
RESIDE
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❑SFDWI. ❑ KITCHEN REMODEL
❑ADDITION El PLUMBING RE -PIPE
C3 MULTI ❑STRUCTURAL
MODIFICATION
MF.NT SWIMMING POOLSOWNER-BUILDER
�,INTHR10R CHIMNIiY R[I'AIR
MOD EPAIR DEMOLITION
ISSUANCE
APPLIANCES - RESIDENTIAL
ARCHITECTS DECLARATION
I undemmnA nfy plxn.e shall accused us public rearrdx
PANELS
UP TU 2Bt1AMPS
Licensed Professional
DECLARATION
1 hereby anfour that I am exempt from the Contractors License Law for thea
following reason. (Section )031.5, Business and Professions Cale: Any city or county
which requires a pamnit to construct, alma improve, demolish, or repair any smsam
prior to tslssuenca,nlso,csfuresthe applicou for suchpanni o, filen signed smmmmn
that he is licensed pursasnFto the provisions of the Contractorsl icense Low (Chapfer9
2ol-I(XpAMPS
OVER IINlAMPS
SIGNS ELECTRICAL
SPECIAL ClkCl11T/MISC.
TEMP. METER OR Po1.1?INST.
COMMERCIAL:
Qo
(commencing with Section 7")of Division 3 of the B firms, and Profession.. Cade) or
n
that he ix exempt hurefrmn and the basis for the alleged exemption. Any violation of
❑ NEW BLDG/ADDITION ❑ DEMOLITION
4•
1 w
;yQ
I
13�
Section 7031.5 bymy applicant fora perch,ulneds thcappliaam tea civil panallyaf
not more than five hundred dollars ESSEX).
❑ 1, us owner mf the property. nr my empinyeca with congas as thei...c eirmperecoun,
will do the work, and the structure is not intended or offered for snle(See 7044, Businmy
and Professions Cade: The Contractors License Law docs not apply to an owner of
property who builds or improves thereon, and who docs such work himself or through
POWI?R DEVICFS
[I TENANT ED FOOD SERVICE
IMPROVEMENT
ElER's
SWIMMING POOL ELECTRIC
OUTLETS - SWITCHES- FIXTURES
Q
his own employees, provided that such impmventents are not intended or olferad for
NEW RESIDENTIAL ELCCTR
sale.If, however, the building or improvement is sold within one year of completion, the
owner -builder will have the burden of proving that he did not build or improve for
OCTRAR`S. 199 Ed FT
J1.
pose of salol.
❑ I, as owner of the propemy, am exclusively contracting with licensed conaria, to
ci nswa the project (See. 7BaL Business and Professions Code:) Tire Contractors Li--
-
censeLawdoesudapplymanownerof property whn builds or improves thereon,and
who contracts for such projects with u contracaa(s)licensed pact at I. the Cootacors
j PLUMBINOPERMIT
Y
P hUr ISSUANCE
License Law.
under Sec. B & P C for this rens
&VENT'- WATER (HA)
.MEE(}EIfexempt
e DateALTI?R-DRAIN
/�Jt, VALUATION
BACK FLOW PROTECT. DEVICE
WORKER'S COMPENSATION DECLARATION
I herehy ukrmnd
iuer penalty of perjury one of the following dedurmions:
!//U
O
DRAINS- FLOOR, ROOK AREA, COND.
❑ I have and will maintain a Cenillcam ofConentto self -insure for Workers Comon-
sation, as provided for by Section 37W of the Labor Craft. for the perfomance of the
STORICS
TYP ON
work for which this permit is issued.
FIXTURES - PER TRAP
'
[DI have and will inaimuin Worker's Compensation Insnrnnce, as required by Sect inn
37M of the Labor Cowie. for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance cancer and Policy number are:
GAS -EA. SYSTEM -I INC. 4 OUTLETS
UP
APN
Comm, Policy No.,,
GAS - PA. SYSTEM-OVER4 (EA)
CERTIFICATE OF EXEMPT]ON FROM WORKERS'
COMPENSATION INSURANCE
(1'hls section need not be confpleted ifthe pennon ix formic hnndreddollos(SIW)
or less.)
GREASP/INDUSTRL WASTE IMERCEYfOR
it LDING DIVISION FEfS
CREASE TRAI'
PLANCHECK PIiF
SEWER -SANITARY -STORM EA. 20114.
Z
1, 0
I comity that in the performance office work for which this permit is issued.I shall
not employ any parson m any mo bo
anner sat as ecome subject the Workers' Co mpury
sation Luwv mf Celifomia. Date
Applicant
ENERGY FEE
WAfIHi HEA'fl?R WNENTO?LEC'IR
GRADING FEE
NOTICE'TO APPLICANT: If, after ma•ing this Certifmme of Exemption, you should
becouc xahject m the Wurkcr's Compensation provasa..... of the Labor Crude, yon must
comply sif ,mala pmvisicia, ,,his permit shall he deemed revoked.
WATER SYSTEM/TREATING
WATER SERVICE
w to
yforthwith
SOILS FEE
�Q
F
U
y1
CONST'RUCT'ION
uction LENDING AGENCY
rwhichirm that there isaenmshee3 lending agency for the performance of
k for
Be work fur which Nis permit is issued (Sec. 3097, Civ. C.)
Lenders Name
PAID
Data Recdpfk
NEW RESIDEMfIAL MIME. SQ. FT.
TOTAL:
Lender's Address
'fOi'A L:
rectify bar 1 have read this application and vhim that Ne above information is
-
BUILDING FEE
h
comecv l agree to comply with all city and county ordinances and state laws relating o
huilJmg construction, and herehy authomercpresemurivoa of this city to enter upon
QTY.
MECHANICAL. PERMIT FEE
SEISMIC FEE
above- vacationed property for inspection purposes.
(We) agree to save, indemnify and keep hamnless the City of Cupertino g net
.RMIT ISSUANCE
ELECTRIC FEE
ALTTCIt ORnDUTOMECIi.
PLUMBING FEE
habiline,judgmcnto, wetland expcnxes sohichnfay i nnny w.yaroeagnin,oxid'by
in consequence of the Scanning of this pamnir
AIR HANDLING UNIT(TO Ig00) CFM)
MECHANICAL FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE. REGULATIONS.
AIR HANDLING UNIT (OVER 10,000 CFM)
CONSTRUCTION TAX
Si, aturc ofApplicant/Cmar or [Dare
HAZARDOUS MATERIAIS DISCLOSURE
EXHAUST 11001)(W/DUCD
HOUSING MITIGATION FEE
HEATING ON] f(I 0 100.000 BTU)
Will me applicant nr future huilding tcenpamtxom or handle hamNous romenul
as defined by the Cupamino Municipal Code, Chapter 9.12, and the Health and Safety
Coda, Section 25532(x)!
HEATING UNIT (OVER 100,000 BTU)
❑Yes L] No
ordeviceswhich
Will the air contaminants
tarfurore huilding by
occupantuseAir
emit M1feardmus air cnnmminantr as delinul by the Bey Arca Air Quality Management
Distract?
❑Yes E] No
PAID --
Dao Recei
VENTILATION FAN (SINGLE RESID)
BOILHR - COMP (3HP OR IIX1,001 BTU)
BOILER - COMP (OVER 100IXq I{TU)
AIR CONDITIONER
S
re, n p
I have mad the huardons materials is under Chapter 6,95 of the Cali-
I CE
NEW RESIDENTIAL MECH. Sp, FT.
25533
forms health & Safety Crde, Sections 25505. 25533 and 25534. I understand Nat if the
building docs nnf aumwdy have u tenant, Nnt it ix my rcxrymsibillty hr notify theaecupom
ofthe mems which most n pnondswanee rfa Cemifice¢ of flecupane.
,NXnot or authorised agcm Mata
TOTAL:
ISSUI?Il I3Y:
OFFICE