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APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
(IIIITHIN(; - 111.1[C'IRI CAI. - PERMIT NO,
CITY DI G HIVIS1'INO n [X O p
BUILDING DR'ISRJN eV'PIJCA'PION/PGRMIT i PLUMBING SIC,v. LUOQ
\r. PRIIItrfT ll)R\TIPI(:A'1'll)\'
1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing
whh Section 2010)of Division l of the Basins, and Profecsiow Code, and or, license is
in full inn. and effect.
License Class La.k
Umc Contractor
ARCIIIILOTS UECLARA'ITON
I understand a, Plans abaft he used as public recants
hiccn'O Prnlensional
OWNPR-BIJILDHR DECLARATION
1 hereby affirm that I all, exempt from the Contractor's License Law for 'he
fallowing reason. (Section 2031.5, Iodine, and Professions Code: Any it, or county
which requires a permit a) construct. alter, innprove. demolish, or music any ,fracture
prior In its issuance, also requires the applicant for such perdl to file a signed statement
that he i, licensed pursuant,'fie provisions of the Contractors License Law (Chapter 9
(commencing with Section 2001) of Division 3 of the [twines, and Professions Cade) lar
that he is exempt therefrom and the hasis for the alleged exemption. Any violation of
Section 21131.5 by any apto,rur fur a pennil subjects IM applicant to a civil penally of
nal nitre than five hundred dollars S5kb.
❑ 1, a, owncnd@e property, or lay niployces with wages as their sole cafnpcnsullan.
will do the work, and the IrG c is nut Inlendcd or nlfisrcd lot - 15,,.2010, ILlsincss
and Profusions Cre1c: The Cnmme..... Licenw Law docs not apply b an owner of
property who builds or improves thereon, and who docs such work himself or rfimugb
his own anp, h,ce providetl that such inmpr enecaux are nm intended or offered Poli
Sade. If, hawcvct The building or Impmvemcre is sold within one year ofrnmpletion, the
c h Ida IIh have b len fp gthat h JJ m bald or improve for P r
pose u.
I1
f the
p pent cl . ly contracting withlicensed contractors to
constract the project (S c 2000 Businessdprofessions C.le)The Contoutor's Li.
icarse durs not applyT f property who builds or improves lhemnn d
wlio tart% for inch Projects with'r,mevtnr(dlicensed Pit rsuva, Tn the Cunmooalr
I.ic, w I-101.
❑Inmv wnynm cr Scc .[I A P C to, this
�— WORKER'S COMPIINSAI ION DECLARATION
1 hereby affirm under Penalty of perjury one ,l the following declunnionm
�iI have and will maintain a Cemficam of Cnnwtn
nself-insure tor Worker's Complain
provided for by Sermon 3200 of 0e Inhor CeAc. Por The performance of 0c
ck for which This permit is issued.
0 1 have and x'ill maiumin Workers ComN-tion Insurance, w, returned by Section
3210n1 the I. Code.f The pcdnnnancc oDhe work for which this permit is issued.
My Workers ani xau sumncu carrier Policy
Currier:
Policy Nu.:
CERT F O}�jIi%�' 1Jf��(1 RUM
['(iMITNSATI(WYfJSIJRANCF.
( fit, eecf( rdnol hecit npicMi it'he Pllout is fill arc anJrcddollarsgIIXq
or less.)
I cerf ity that in theperfiennnce of the work for which this Inernmif is Issued, I shall
nal employ any pe,,a in any mmmer s, m b. bacon subject In IM1e Workers' Crnnpen-
wrion Lows of Cslih,rle. Dec
Applicant
NUI ICI; TO Al-PLICANC IL afar making this Certificate of Exemption, you .should
becmne subject m me Worker's Compensation provisions of the paha Code, you room
lonhwith courtly with such pct, isiow or this permit shah be deemed revoked.
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❑
STORIIS
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IIXTURFS-PISH
GAS - ISA.. TISM. IN C. a OUTLETS
GAS - EA. SYS 'IfN TVI: 0(EA)
GRPAS ]IYUIJS'TRL WAS 11: IWERCEPrOR
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BITtPERMIT INFO
BLDG
PLUMB MECII
❑ Consultant Fees Paid by Applicant (Initial)
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/
L[d�
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ENERG'I
)'I'Y ELECTRIC PERMIT'
FEE
JOB DESCRIPTION
RESIDENTIAL:
c❑1 SFDWL
),ADDITION
C MULTI "UNIT
)KITCHEN REMODEL
)<
(-1 PLUMBING RH-('IPF,
[D STRUCTURAL
PERMIT'ISSUANCIS
APPLIANCES-RESIDEN[A],
PANELS
SOILS F
MODIFICATION
UP'I'O 20 AMPS
WATER SERVICE
ElINTERIOR
IMPROVENIE 1'
❑HATH REM
❑ 01 HER
C3 CHIMNEY REPAIR
CSWIMMING POOLS
C DEMOLITION
200-IIXXIAMI'S
OVER HXXIAMPS
NEW RIES B), SIIAI. I'hMB, SQ, En
SIGNS EI.ECI'RIC
TOTAL:
NUILDING P i
SPECIAL CIRCU- 11,' .
MECIIANICAL PERMIT
FEE
SF15h11
'(EMP. METER OR POLE L .
3 .'3
COMMERCIAL:
❑NEIN BLDG/ADDITION
❑TENANT
IMPROVEMENT
❑DEMOLII'[ON
CFOOD SI7RVICE:
POWER DEVICH-S/I
C 93:
'SWIMMING MIO(. ELI:.
ALTER OR ADDU MECH.
C OTHER
PLU.
OUTLETS - S W I'IC I I ES - iziX"TU R
CONSI RUCTION (.ISN DING AGENCY
I hereby alirm that there Is a conore on lending agency forthe perfornorce of
the work for which IN, pconit Is issued (Sec. 3092, Ci, C.)
Lenders Nmne
Lender's Address
1 emit, thus I have read (his appllca eaa and Smut I[in l IM1e Gawe Intlmnulimn Is
mar. I agree to comply with all city and county ordinances and nate laws refusing e, QTY,
huilAing canarmion. anJ hereby:mnhorim rcpnexmaivcs of (his city 1, cnmr upmm the
ahwomentioned property for inspection tlople".
(We) agree to sa,e. indemnify and keep hmnlcns the City of Cupertino against
liabilities. Judgments, costs and cs,,lws which may m any will recuse listener said City
. nscyucnce of the scanning of 'fit, lermil.
APPLICAKI' UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
mgmmne... n.....- I
HA%Alt DOUS MAI'HRIALS DISCLOSURE
Will the npMicam,r Carer, 111dioge,,r,au surtcnr handle I ... -1 us mmedal
no delincd by the Cupertino Municipal Code, Chapter 9.12, and he Health land Sal cty
Code. S,eion 25532(a)o
❑Yes ED No
Will the applicant or future building eareple, tett eyuipmet or Devices which
I aut hmardous air contaminants as defined by the Bay Arca Air Quality Management
❑Yes ❑No
I have readthe tricolor, I d y ts tinder Chapter 695 ofth Cal
I-
I'ur' II III SfctyC I S I :25511525531 1255141 d o 111,11
bit ill k t m Ily11 III I y b'Ifyt Ty 11 ," I'lnI
,r doe rat " tE 1)S I vemetal ..L Yu,fr�r'
NEW REST UEN'ITALI:LISCI'H 1017111-1 I
PLUMBING PFRMIT FEE
ISSUANCEE1�
DRAIN R vI�N"I'- W M ER (I?A)
DRAINS - OOH ARNfkCONU'
STORIIS
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'1'YYE CONSTRUC
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I
APNI
IIXTURFS-PISH
GAS - ISA.. TISM. IN C. a OUTLETS
GAS - EA. SYS 'IfN TVI: 0(EA)
GRPAS ]IYUIJS'TRL WAS 11: IWERCEPrOR
BUILDING DIVISION Dia
CREASE TRAY
PLANCIIEC,
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SEWER -SANI'T'ARY - S'I ORM HA, 21X0 14.
ENERG'I
T
WATER HEAW/VENTAILECTR
GRAD
E
WATER SYSTISMfFRI;A'I'INC
SOILS F
'
WATER SERVICE
PAID
Date
Receipt a
NEW RIES B), SIIAI. I'hMB, SQ, En
TOTAL:
NUILDING P i
b �
MECIIANICAL PERMIT
FEE
SF15h11
P iE
3 .'3
YERMIT ISSUANCIi
EL C
C 93:
O
ALTER OR ADDU MECH.
PLU.
.G
O i
s
AIR HANDLING UNITOO d.0f0CFM)
MEC
At. IT
3 r
AIR HANDLING ON] '1'(OVER 10,000 CFM)
CONS RU I[ON'D
EXHAUST ITOOD (Wlln)C1)
HOUSI
,fill' TI . ION PEE
HEN] INC, UNIT(1'0 10)(1 It IU)
HEATING IJNI'I' (OVI.R 1XI,ISX) BTU)
PAI A,
Date
X�
eceil N
VENTILATION CAN ISINGLIiRESNI
BOILER - COM(' (311P OR UXE.01) BTU)
BOILIR-COMP (OV ER 1001X10 BTU)
AIR CONDI'DOMiR
1' - ISSUANCE
1�,/ T
5a
ISSUED BY:
DATE
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NEW RVSHAPNI'IALMISCH. SQ. FL
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