S 1255APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITYOF CUPERTINO REALIIINC - ELEC'I'RICV,
ItUI1=,PVISION APPIACATION/PERMIT PLUMBING -MECHANICAL.
ItUILDING PROJECT IDEM'IF'ICATION
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OWNERS
LIC NO'.
❑ Consultant Fees Paid by Applicant (Initial)
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GDale
I.ICI!NSIiDCON'rRACI'OR:SDECLARNr10N
hcrehy tuff rte firm I am IianseJ miner aloof Chapter 9 (ennmteneirg
with Stenon 70hum Division 3of NBess y license to
e usinand Professions Crtde, and mlice
in full finetund effect.
License Class Lic#
QTY
❑SIUWL
❑ KITCHEN REMODEL
Comracmr
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ARCHIrHLTS DECLARATION
1 understand my plane shall be teed vs public records
❑STRUCTURAL,
F LQ F W
Qcutved Professional
❑INTERIOR
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OWNER-HU1LDER DECLARA'I'[ON
1 herchy affr n Ihm I not exempt let the Canlmclurr, Licenw Luw fnr the
fallowing reason. ISeclion 703 I.S. Business and Professions Cade: Any city or county
which requires a permit to canstmel, alter, improve, dnnulkh, or repair any %fracture
prior to its issuance, also requires the vI)pfcand far such permiun file m signed suncmnn
that he is licevcd pursuant to the provsion'of the Contractor's License Law (Chapter 9
s
Ifi
See,
....... exem it duce from and the basis f r nDM1c alleged exemption,Anynm lalu,
hat he 37031.5 Ihcrefrnm andant the basis for the alleged exemrtion. Any t Penalty of
ant unne than by hundred doeirrtnmpermiteuhjects the applicanttoncivil penalty of
n tuna than five hundrcd dollar% y employers
0Lusowner hew... Nc pmpeny, or myempinyeca wiNsages as their sole compcnsainn.
willcldlhe work, andlhe eCen er', ded nraverdic, a... uteri,,UW, Business
Gelc imp Commerco Licem9 Law doer sol apply a if owner h
and perfPropect, who
who builds or improves thereon, and who roes such work himself or ehmugh
E]SWIModIHG POOH
❑ BATH RF,MODHUREPAIR
❑DEMOLITION
❑01'HI?k
t
his own art not intended or entered for
hiso own ts, prov Wed Nm such mens
owever, isancnw
sale. If, howorq the issoldwithinone yemofcompletion,Ne
ve[li burden of
crvhuilJm will M1uvC IM1e buMen of proving Not he did not build or imDmvc for para
e^).
Ry
' `w er of the propenr. ata exewri.ety <antm<M1vg with Been%ce canlmmaR m
n..buo Ibo project (Sec. 7044, Rosiness and Profcssimu' Code Hie Connumur's Li-
sclnwime, not apply manownerofpmpeny wM1nbuildsorompmvcsthsi and
QTY.
who contracts for such projects with a carmicni(s) licensed pursuant o the Contractor's
License Law.
l am trump, under Se<. . B & P C for this rcawn
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WORKER:%COh ENSArI N RATION
penmficof pesjor nflnefnunwhtr
ar'he
I6andwanilineaintain
"
❑ Ihave anawm maintain cenif<ate arenn%enfinedr-m%are for wrrktrs camper.
a Worker%thelanvCou
relies, us provided irz by Section ?71X1 al Wt Labor Code, fnr the perLsrmunce of the
wnrk for which this pemtif is issued.
n 1 have and will maintain Workers Compensation Insurance, as quired by Seminn
3710 of the Labnn Casle. fit, Ne perinnmmee of IM1e w,,,'k fn' which Ibis permit is issued.
My Worker's Compensation Imumnce carrier and Policy number arc:
Carrico I Itallcy No.:
CERT IIICATI? OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need nal bit cwvpleast iI Ili ,.if is lin ane hundred doll... (SIM)
m less.) I
I certify that in the vorliurnance of the work for which this venin is issued, l shall
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not employ any person in any numner x+as m hvvnn. m Thu Wers' Co ngten-
suhjem ork
%alien Law, at Califomia. Date
Applicant
NOrICH TO APPLICANT:: If, after making This Ccnifm of Esentp ian, you should
beenme subject to the Worker's Compen arine pmvlsiens of the Lattice Cod,. You must
fonhw'uh comply will such promaore or this #snout shall be deemed revoked.
CUNS'1'RUC'[ION LENDING AGENCY
l hereby mfftlnn that there is a cumtmctien lend ng m
g agency for the lirform�ce of
the work forwhi<M1•This pcnnil isissucd (Su. 3u9],Civ. C.1
Lender's Ni c
Landers Addresh
I certify that I have read this application and slate that the nose a information is
correct. l agree ut comply with all city and county ordinances aid n ate laws relining m
building consuumlon, and hereby amhorire representatives of this city to enter area the
above-nueminned pmisey fnr im'peniun im pe,s,
QTY.
(We) agree to sins, indemnity and kelp harmlesv the Ca, of Cmienim, vguinsl
Imhildies,judgmenls, cans and expenses which may in any way accrue against said City
n<nnsCl u. of l be Somalia, of l hie #emit.
APPLICANTVUNDERS'IANDS AND WILL COMPLY WI'I')I ALL NON -POINT
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building cecupant.mrc or handle haevdous material
as defined by the Cupcnino Mnn wipal Cuda, Chnpmr 9.12, and the Health um! Safety
Cale. S«tion 25532m)?
❑ Ya I] No
Will the applicant or future building necuponl use e9uipment or devices which
Fruit heaths at, to tarn euros us Icfincd by the Bay Ama Air Cast it, Managemen,
Diseia2
Yes ❑ Not
1 have read the hamnlous mmeri.1% m9uint under Ch.,,,, 6.95 of the Cali -
Rama I health & Safny Cede, Sect ions 25505. 25533 nod 25534. 1 unrkmmW Nut if NC
building dins not cunemly have a mast, It., i, is my reslxmrituhly to ratify he occorymt
of me requternbu s which m u he met prior m issuance of a Cmilico a of Cecupaney.
Owner or ant taimdagent Dam
ELECTRIC PERMIT
1117RM IT ISSUANCE
APPLIANCES—RESIDENTIAL
PANELS
IIP TO 20I AMPS
2111-1000AMT'S
OVER 1000 AMPS
SIGNS EI,1!CI'RICAL
SPECIAL CIRCUIT/MISC.
TEMP, METER OR POLE INST
P(IWIiR DEVICES
SWIMMING POOL ELECTRIC
OUT _ SWITCHES — IBX]
Nli W RESIIIEN'I IAL ELECT R
ALTER — DRAIN&VENT — WATT li
BACK ROW PROTECT DEVICE
DRAINS— FLOOR, RODF. AREA. COND,
FIXTURES —Plitt TRAP
GAS — HA. SYSTEM -1 INC. 4 OUT LETS
GAS — IiA. SYS"FENI-OVER 41EA)
GREASI%INDUS HiC WASTE INTERCEPIOR
GREASE TRAP
SEWER —SANITARY —STORM ITA. 210 FI'.
WATER HEATER W/VENDELECIR
WATER SYS 'FEMTRLAI'ING
WATER SERVICE
NEN' RESIDENTIAL PLMB. SQ. FT
MECHANICAL PERMIT
PERMfIISSUANCE
ALTER OR ADD TO MECH.
AIR I (ANGLING UNIT (10 I0.11W CFM)
AIR HANDLING UNrf (OVER Io,O(IO CFM)
EXHAUST FOOD(W/DUCT)
HEATING UNIT (TO 100.000 Ed HE)
HEATING UNIT (OVER I W,BIO BTU)
VENTILATION FAN ISI NGLE REST D)
MOILER — COMP (3111' OR 100,000 BTU)
BOILER—COMP (OVER 110,0MIE
AIR CONDITIONER
NEW ITUMIDENT1AL MECIL SQ. FT.
OFFICE
PHIS T NO. 1255
NI'rARY NO. APPLICATION SUBMITTAL
21 Ill Q
NIC CONTROL#
BUILDING PERMIT INFO
BLDG ELECT PLUMB MUCH
❑ �r, ❑ ❑
JOB DESCRIPTION
RESIDENTIAL:
❑SIUWL
❑ KITCHEN REMODEL
❑ADDITION
❑PLUMBING REPIPE
❑MULTI-UNIT
❑STRUCTURAL,
MODIFICATION
❑INTERIOR
❑CHIMNEY REPAIR
IMPROVEMENT
E]SWIModIHG POOH
❑ BATH RF,MODHUREPAIR
❑DEMOLITION
❑01'HI?k
t
COMMERCIAL:
❑ NEW HLDG/ADDII ION ❑DEMOLI'LEON
❑TeNANT ❑POOH SERVICE
IMPROVEMENT
❑O HER
FEB 17 ANS'D
VALUATION
CITY Ur uurcn 1 Bvv
STORIES
BUILDING DIVISION ITIS
PLANCHECK FEE
ENERGY FEE
GRADING ITE
SOILS FEE
PAID
Ilam
BUILDING IgiI.
FEESEISMIC FE:i
GLECTRIC PEE
PLUMBING FEE
MECHANICAL PTE
CONSTRUCTION TAX
1 LOUSING MITIGATION
PAID
Date Receipt If
yr