S 1521APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING -ELECTRICAL PE IIT NO
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING -MECHANICAL 1521
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_
FEE
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BUILDING PERMIT INFO
I BLDC -ELECT I'L IM MECH
11 El E]X ❑
JUI DItSCKIFI'ION
CONTACT. PHONE:
D SFDWL
D KITCHEN REMODEL
❑ Consultant Fees Paid by Applicant (Initial)
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I,ICEN513D CONTRACTOR'S DECLARATION
liy affihal I am licensed under provisions of Chapter 9 (commpnciug
I activity T
with Sedion7bXB of Divisi(n3)fine Business and Professions Code, mldnty license is
full force and each.
License Clens Lie.
Dam Commcmr
QTY ELECTRIC PERMIT
PERMIT ISSUANCE
APPLIANCIS- RESIDIiNTIAL
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ARCHITECT'S DECLARATION
Innn herat nrylden-h ll hcmcd ,Eahlic records
PANELS
UP TO210AMPS
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Licensed professional
OWNER -BUILDER DECLARAHON
1 hereby affirm that l am exempt from the Contractor's License Law far the
following reason. lSeian9031.5. Business and Profs 'ons CWe: Any oily or county
which hateira n permiva esmevue, iJmp improve, denmdish, or repair any sl++rf„ which reyuitcs a permit m amteonet. tame, improve, demar.h. or Mair any rwcwre
pit It, it, i .... me. also requires the vppliam for such permilto file a signed statement
taw he is licensed pursuant to the provisions of the Contractor License Law (Chapter 9
with Nation 9000)ufUivisiu 03ofthe P uniness and PLL Code),),'TEMP.
that he is exempt therefrom and the basin for the alleged exemptionAny violation of
Seeiou 91131.5 he any applicant for a permit subjects the applicant to a civil penalty of
than Eve hundred dollars (5500).
❑I, ns �wnerof the prmpeny, or nrycmpinyec.withwagez a. theirs�leenopeumion,
will An the work. nnJ the snucmrc is not imcnded..olYcrcd far .1.(Se:. 91141. Holmes,
and Professiohn Cale The Conten...... License Law does not apply man nwncr of
properly who builds e, improve. thereon, and who J«s such work himself or derangh
2111 -II NIAMPS
OVI3R I(KKIAMPS
SIGNS ELECTRICAL
SPeC1 AL CI RCUIT/MISC.
MET1iR OR POLL INST.
POWER DEVICES
SWIMMINGPOOLFLECTRIC
OU'ILI!'fS-SWI TCHES-FIXTURES
his own empluyetrs, provided Thal Loch inaam,cmunts arc npl intended or uttered Iter
NEW RESIDEN'T'IAL ELECT'R SQ FT
111 ENAN'T
sale. It.howevee the building or improvement is,eld within one yce of completion, the
..IMPROVEMENT
erhuilder will have the burden of proving that he did not Wild or improve, for pur-
pne ofsaleJ.
TOI'Al,
E] 1, as owner of the property, am exclusively contracting with licensed contractors to
mamet tlm project (Sec. 7044, ihuinms and Proleuions C del) The Contractor's Li-
QTY PLUMB ING PERMIT
cense Low does not:mply to an owner of mapcnr who hnids or itttprave% thereon. and
.It,, contracts far suer projects with a comm emgs) IicenuN pursuant m the Contractile,
PERIATE ISSUANCE
Liceosle Low.
C) I am exempt under Sec. , B k P C for this reason
ALTER - DRAIN k VENT'- WAr17R (1!A)
Owner Date
'
WORKER'SCOMPENSATIONDECLARATION
I hcrchy nllirm under penalty of perjury one of the following dedmabnns
HACK FLOW PRUIECT. DEVICE
DRAINS- FLUOR. RODE AREA. COND.
D l have and will maintain a Cenilicate of Camenuo.air-insure to Worker's Compen-
.urian, a% provided for by Section 3901 of the Lahr Code, far the performance of the
FIXTURES - PER TRAP
work On which thin plemill is issued.
D 1 have and will mviontin Wallace, CamPensatinn huunmce, as required by Section
390(lol'the ll,ver Code an, the perromunceofthe work for which Ibis petntil in i ... r&
GAS - EA. SYSTEM -1 INC. 4 OUTLElS
My Wele"s Cumponslinn Inson creamerand Policy moule, are
icrl:l Policy No.:2Z� JEZ/1%�/47y'cj
GAS - GA. SYSTEM-OVER4(I!A)
CHBEIFiCATE OF EXEMPI[ON FROM WORKERS'
GREASIANDUSTRL WAS'T'E INTERCEMOR
COMPENSATION INSURANCE
nnu.cs('Otis seclum need not he completed if the permit is [,),an, hundred dollars (51 Mi,
)
GBFAS AP
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I verilytha!in lhe)erLhnnanccofthe work Eresvhichfihis permit is issued. Ishall
he, employ any person in any manner m a. m become subject to the Workers' Cnnhpen-
emipn Low. of Calilkunia. late
Applicant
Bµ'ER- Nll'ARY-STORh1
WATER HEATER W/VFNDI3LECTN
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NUI 'IC17'TO APPLICANT: If, after making this Certificate of Exemption, you shook!
m
heeo on s.b c,l n, the Workers Cnmpetmti m pre.inn, of We Laser Code. you moa
farthsith comply with such provisions onhin penult shall bedmmv
ccud oLml.
WAIAR SYSTEM/TREATING
WAfCR SI!RVICE
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CONSTRUCTION LENDING AGENCY
there isaennswer30 Pen dine agency ren me peramnamem.hr
Iherebyich 61
- IUGNTIALI'LMB. SQ.FI'.
work fnr which Nis pennil is issued tSuc. 30')). Civ. CJ
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Isnders Name
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IsnJch Address
1 eerily that I lure read thin application and same that the sere information is
emalI riper, to eamply with all city and aomty prdinancus ami sane haws minting m
wildingcontinence, and hereby aathodrc mpmverhaves of this city to enter apmtw
QTY. MECHANICAL PERMIT
above.mcnlinmd property Ear r,Feaian pmpn.e,s.
(We) agree to save, indemnify and kerp Sainlcs fire City of Cuperni egninxl
Fabilisce judgment., costs and expenses which may in any way acerae against said City
in nnwyucnce of the gumbo, of his pc mhi 1.
PERMIT ISSUANCE
g1;1'F,R OR ADD TO MECH.
APPLICANT llllLLJJii STANDS AY WILL COMPLY WITH ALL NON POINT
SOURCfiRhh'�LATION
AIR HANDLING UNIT PTO 0.000CI'M)
AIR HANDLING UNIT( OVER I0k0(NICION)
Signal re of APPl real antracmr "Dam
HAZARDOUS MATERIALS DISCLOSURE
EXHAUST IIOOD(WNUCi)
HEATING U Nil (To I BO,BEE 13 011
HEAD NO UNIT (OVER Ihu.ned RI ill
will the applicard or future wilding occupant store or handle hazardous material
as let! red ey the Cupen inn Municipal Code , Chapter 9.12, and the Health and Sofey
CWe, Sectio 25512(v)9
❑Yes [-3No
VENTILATION FAN (SINGLE BESIDE
Will 'be lc for luturc Witin Em 1 -pm color
( mil hazardous uu cnnmtninant, as defined b the Hay Area Air tQualit aManagemen
Y Y ) gement
Di.vin?
BOILER -COMP 3HPOR IIIgE(013TU
( )
NOILER-COMP(OVEN IIXLf1IX1 H'I'll)
❑Yes DNo
AIR CONDITIONER
1h:rve rant the hmaMons motaials npuircmcne under Chupmr n.l5 of the Cali-
foie Health & Salcty Calc. Sections 25505, 25533 and 25514. I t nderstand then d the
holding does not comely hall, a renal. that it is my rclismumdity to purify the occipital
of he mgaircmetns which must be, me prim m i.,.m:hna of a ecnhieam mraaapaner.
NEW RE51U13N i'1AL MECH. SQ. Pf
Owner nr mummireA a8ent Dene
TOTAL
OFFICE
FEE
0
.._ ...............................
S-a.�
BUILDING PERMIT INFO
I BLDC -ELECT I'L IM MECH
11 El E]X ❑
JUI DItSCKIFI'ION
RESIDENTIAL
D SFDWL
D KITCHEN REMODEL
11 ADDITION
❑PLUMBING RG -PIPE
D MUCU-UNI'1'
11 SI
MODIFICATION
C1 INTERIOR
CF41MNEY REPAIR
IMPROVE MENT
SWIMMING POOLS
D R ATH RI:MOpF�?PA111'M(
D OMER
COMMERCIAL
❑NEW BLDG/ADDITION
DDEMOLITION
111 ENAN'T
DFOOD SERVICE
..IMPROVEMENT
SQ.
P W Q
APR 15
BUILDING DIVISION FEIS
PLANCHF,CK PE[
ENERGY PEE
GRADING IBE
SOILS 113E
PAID
Date -__F_miptY
1 OTAI.t
I3UILDIN'C FEC
FFF,
SEISMICFEE.
ELECTRIC FEE
PLUMBING PTF.
MECHANICAL IBC
C'ONSTRUCI']ON "TAX
HOUSING MITIGATION FEE
PAID
j Date Receipt Or
ITOTAL:
BY:
DAI H
iY