S 3887APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING DIVISION APPLICATIONMERMIT
LIC NO.
INK
i SUBMI ITAL DATI
1461m
OFFICE
CONI'AC'P 111IONI:
BUILDING PERMIT INFU
❑ Consultant Fees Paid by Applicant (Initial)
BLDG ELECT PLUMB MECH
❑ ❑ ❑
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IJCENSED CIIN I'RAC'1UR;S DF,CLAHATION
1 hereby affirm that 1 and accrued ander novi.i... of chapter v (commenemg
with Section701hof Division 3 of the Businessand Professions Code, and nrylicensei`
in full force and cffcn. 'l
License CI' s Lic. « i /4.S%�
a- C
Dam comm .
QTY. ELECTRIC PERMIT FEE
JOB DESCRIPTION
RESIDENTIAL:
�gFDWL ❑ KITCHEN REMODEL
❑ADDITION GPLUMBING BF. -PITH
❑MULTI -UNIT ❑STRUCTURAL.
MODIFICATION
[I INTERIOR ❑ CHIMNEY REPAIR
IMPROVEMENT SWIMMING POLLS
❑ BATH REMODEVREPAIR ❑ DEMOLITION
❑O/T�HER
/. Y]#'Pi /':+e r
PERMIT ISSUANCE
APPLIANCES -Ii IiSIDENTIAL
ARflll'MCT 'S Dr;ChARNv
I understand my plans shall be used as public fids
PANELS
UP 1O 200 AMPS
Licensed ProfeninnW
OWNER-RUILDER DECLARA'1'IUN
I hereby afinu that 1 am exempt from be Ctuarn m's License Law for IM1e
following reason. (Section 7031.5, Business and I'rofnaiuns Code: Any city or county
which requires a Permit to consumer, alter, improve, demolish, or repair any structureI`Pl1�AC,P
prior in it, issuance. nBommues the applicant for such permit to filo a signed statement
that he is licensed pursuant u the provisions of the Contractor s license Low (Chapter 9
ons
(commencing with Section 9000) of Division 3 of the Business and Professions Cd
that he is exempt therefrom and the ha i. for the alleged exemption. Any violation of
Section 01131.5 by any applicant for a peril subjects the applicant to a civil penaltyof
201.1(XX)AMPS j
OVER p") AMPS
SIGNS ELECTRICAL
SPECIALCIRCUH'/MISC.
�-
TEMP. METER OR POLE INST.
COMMERCIAL:
❑NEW BLDG/ADDITION ❑ DEMOLITION
❑TENANT ❑ FOOD SERVICE
1'OW17R DEVICES
�=Qma
f F -O
Wim
"tore Ihe" five hundred dnllan 155101.
❑ I, as owner of the propenR or my employees with wages as their sole cnntpereation.
wilauthe%mk.andthe saactureisnm intcndWoroRemdforwle(Sec.YBW.Businesis
and Profession. Code: The Conrracmrs License law docs not apply to an owner of
property who hu inn or improves Imoner, and who does such work himself nr through
his own employees, provided tont such improventen s arc not intended or offered for
sale. IL hoesvca the building or itnpmvement is sold within tine year of completion, 'he
IMPROVEMENT
❑OTHF;N
SWIMMING POOL ELECTRIC
OU'T'LETS -SWITCHES - FIXTURES
NEW RESIDEN'T'IAL ELHCTR SQ Pf.
SQ. FT. FLOOR AREA
5/SQ. FT
owner -builder will have the burden of proving that he did not Guild or improve for pur-
pose of sale.).
❑ I, a ownerof 1hn pmpeny, :i xdusivcly c tmmeting with licensed oulmemes m
TOTAL:
sur
not 1'mf
vee th or
ees
nor pplyoanee
ldsurimpmves thereon.and
Lowowner rx who builds improves then m. nd
cense Lawdces notapplyces ownerofproPeny
QTY. PLUMBING PER T FEE
Xebec
oho contracts for tach pmjmts with a asnuacmrts) licensed pursuant m Ne Cunuanors
PERMIT ISSUANCE
License Law.
❑ Ii exempt under Sec. ,11& P C fur ihisrenson
UR- DRAIN & V - 'R EA)
Owner LureALI
VALUATION
WORKER'S COMPENSATION DECLARATION
BACK FLOW P . D IC
_
mines hereby under Penalty of perqjury one of the BdhAving declarations:
uirt'on
7IM1irvcvnd will nmimnina CeniGsmm til Gmscntmxclf insarc for Wnrkcr'x Compcm
6alinn, us provided for by Section 3900 of the Ens Code, for the perfemer-, [the
work for which This .it is issued.
DRAINS - PLO R. F, i GOND.
STORIES
'TYPE CONS I' RUCTION
MXTURES - PER TRAP
Cl [have and will maintain Workcr's Compensation Insurance, e, required by Section
3701of the Labor Code. for IM1ePeormance of the work for which this Perot is issued.
OCC. GROUP
APN
GAS- EA. SYSTEM. I INC. 4 OUTL•
My Wnrk�tys Cnmp 7txmlo nsuruncc 'u+rlcroli Notley n�
Cameo: a !;1 folic No.: S
GAS - EA. SYSTEM -OVER 4 (EA)
GRPASFIINDUS'fRL WASTE INTERCEPTOR
CERIIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
BUILDING DIVISION FEES
(ThLssecliouncelnol beet lend Oheperitis(or enc hundred dollars 0100)
or Ices.)
GREASE TRAP
PLANCHP.CK FEE
I certify Oats inlhe perforromemoffle work for whichlhis permit is issued. I shall
not employ, any Person in any manner so as to become subject l9 the Warocin Compcn-
SEWER -SANITARY -STORM EA. 210 FT.
ENERGY FEE
WATER HEATER WNEN UELECI'R
GRADING PEE
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stein Laws of Califorom Dae
Applicant
NOTICE TO APPLICANT: If, ufmr naking thin Certificate al Exemption, you should
visionsofthc Lar Codc.you mon
Femme subject mthe Wnrknr's Compensation proh
forthwith comply with such provisions or this permit shall W deemed revoked.
CONS '1'RIICI'ION LENDING AGENCY
thereby infirm that here is a construction lending agency for the Performance of
the work (or which this permit is issued (Sec. 31107, Civ. CJ
Lender's Name
WATER SYSTEMOREATING
WATER SERVICE
SOILS FEE
PAID Date Receipt
NEW HESIDh:N'1'IN,PLM11. SQ. FT
TOTAL:
TOTAL: O
Lender s Address
I certify Out I once mad tblx upplladnn and state that the aMrve Imoralion is
conecr, l agree to comply with all city and ammy ordinances and sate Dws relating In
building construction. and herahyatimurize mpmscntativas ofthis city to enter upon the
BUILDING FEE
QTY. MECHANICAL PERMIT FEE
SEISMIC FEE
PERMIT ISSUANCE
ELECTRIC FEE
abe,c-mentioned progeny for inspection purposes.
(We) agora to save, indemnity and keep hatless the City of Cupertino against
PLUMBING FEE
liahll'nics, jadgmm�ts. corn and expcn.ms which tnay inany wayaccmntgalmisald City
in "ion, ence of the graining of this permit.
AIT ER OR ADD TO MECH.-b
AIR HANDLING UNIT TO 10,1000 CFM)
MECHANICAL FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS.
AIR HANDLING UNIT (OVER I0.000 CPM)
CONSTRUCT ION TAX
k'rle k3,l -'L;-99
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Signature n(Applicant/Cmuoul Date
EXHAUST HOLD WMU(T)
HOUSINGMITIGATION FEE
HAZ RD(IU3 MATERIAIS DISCLOSURE
HEATING UNIT TO 100,M) BTU)
Will the applicant or futurcbuilding occupant store or handle hazardous material
se delmel by the Conewmo Municipal Code, Chour, 9.12 and the Hcallh and Safely
Cods. Section 3592(a)R
HEATING UNIT (OVER 100,000 BTU)
U
VF.NTH_zVH0N FAN (SINGLE RESID)
0 Yet JJZNo
/
Will the applicant i future building oeenpud yuse A equipment or devices which
mimics., nus air umlaminunts as defined by the Bay Area Air Quality Managanenl
PAI
Dam Receipt «
tlOILI?R-COMP (3HP OR IfNI,(NX) BTU)
.S 5(])1 (]
1 R9 CC?'9
BOILER- COMP (OVER 100.100 BTU)
I
DisaicC
❑ Yes kNo
AIR CONDITIONER
Ihuvereiut the hmaNnux ntamriuk mgnirnncntl under Chvpmr!!)5 of the Cull-
forma Health & Sdity Cusbc Sailors 25505, 25533 and 25534. 1 understand that if the
ISSUANCE DATE
By
NEW RESIDENTIAL MECH. SQ, ET
building does not comedy have a tenant, that it is my respmsileloy to notify the occupant
of the requirements which must W mel Poor et issuance of a Certificate of Occupancy.
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'1 (YfAL:
ISSU
Owner or authori¢tl agent Dam
OFFICE