30514APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO , BUILDING - ELECTRICAL
BUILDING DIVISION APPLICATIONIPERMIT - PLUMBING - MECHANICAL
BUILDING PROJECT IDENTIFICATION
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SANITARY NO.
APPLICA ^TIIO11N/S.UUBMI'ITALDATE
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❑COBSBItant Pees Paid by Applicant (Initial)
BUILDING PERMITINFO
BLDG ELLC PLUMS MECH
C�
LICENSED CONTRACTOR'S DECLARATION
1 herehy uRirn thw um livaucd under provisions of Chaper, 9 (commencing
with Section 7")of Division 3nfthe Hnsinessand Professions Coulombs] my license is
U. full forc<anJo n. 6
U. = 2 p o
D:ae Convuctar
QTY.
ELECTRIC PERMIT
FEE:
.JOB DESCRIPTION
RESIDENTIAL'.
❑SPDWL ❑ KITCHEN REMODEL
❑ADDITION ❑PLUMBING RE-PIPE
OMUIIrl.UNIT ❑STRUCTURAL
MODIFICATION
❑INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT
C1 BATH REMOUEIJRIiPAIR ❑ DEMOLITION
❑ OTHER P A
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL
ARCHITECTS DECLARATION I
1 ondenund m plans shall he used as public reeoMS
- YP
PANELS
UPTO 2W AMPS
Licensed Prommiooul
OWNER-BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Carnations License Law far the
following reason. (Section 7031.5, Business and Professions Cade: Any city or county
which requires. permit m cooswet, olmn improve, dery ish,m repair any mature
prior it) its issuance, also requires the applicant for such Perrino File u signed statement
thal he is licensed pursuant a me provisions of the Cmunictuns License law (Chapter 9
(commencingw.NSem.O..AI,(p of Division 3 ofthe Business and Profecdons Codc)or
that he, is exempt therefrom and the basis for the alleged exemption. Any violation of
SCnion]OJLS by any applicant for upem,it subjects the upplicanuoocivil penally of
n more Nan live hundred dollars ($50a).
❑ Las owner of Ne property, or my employees with wages as their sole compensation,
will do the work, and the ermine is not intended oroffered fur sule(See.]0/4, Business
and Prob ninic Code: The Cranston, License Law does nut apply us an owner of
property who builds or improves thereon, and who does such war. himself err nh —tat
his own employees, provided that such improvements are not intended (u offered for
sole. If, however. the huilding or impruvemem is sold within one year ofcnmpletia ,,the
owner - builder will have the horden of proving shut he did oat build or improve for par-
pnxofsme.).
❑ I, act the project the Sec. I y,.B Business Professions Co&iceno Contactors m
construct rho project (Sec ]044. Business and contracting Cock) The Contactorly, to
come Law does not apply to all owner of property who builds err improves thereon , and
who connects for such p projects with a carnations) licensed pursuant to the Convectors
License Law.
❑ I um exempt under Sec. ,B& P C for this notion
201.1 N111AMP$ -
OVER ItNT0AMP5
SIGNS ELECTRICAL
SPECIAL Cl RCUI'T /M [SC,
TEMP. METER OR POLE INS
'
❑ IiW BLDG/ADDITION ❑ ,4IOLITION
�ul,l]b SERVICE
IMPROVfiMF10T
❑OTHER
POWER DEVICESTEI�I��I-
-
SWIMMING POOL ELECTRIC
O Lli'IS- SWI'T'CHES - FIX'T'URES
NEW RESIDENTIAL ELECTR - SQ Fr.
is
.�
-
SQ. EeI'. FLOOR AREA
��
/� /p/
0 �� 444 f(� 1'
I � k% �!I_'
�!
V f1[s
OV� �� 96
$ISQ. FI'.
TOTAL:
QTY. PLUMI31 'RMIT
FEE
PERMIT ISSUANC
ALTER - DRAIN &V A •Rf' )
-
BACK FLOW PROTEC7rD i
DRAINS - FLOOR, ROOF, AREA, CONE).
Q
Owner Dene
WORKERS COMPENSATION DECLARATION
I herchy affirm under penalty of perjury one .[,he following de,him ions:
Ihorinlwillmainmin. Certilicmeof Corwrato 9e11' -inure for Workers Compen-
�n, . provided for by Section 37W of the Labor Code, fur to perL,muance of the
work for which this permit is issued.
❑ I have unit will maintain Workers Compensation Insurnnce, as required by Section
37OB of me Lainarr�pCode, for the performance of the work for which this permit is issued.
My W Career $ (,p ratio Issuance wrier and Yalicy nyryby yeas l[lnyn
Policy NO. 'C.1RY7 1�0�4
CERTIIO( TE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section nerd not be rompleted able permit is for roehunmed dollars 0$100)
or less)
I cenify that itthe perfomtanceufthe work for which Nispermit lit smColshall
not employ any person in any manner so as to become subject m the Workers] Compen-
ration laws of Califuaia. Date -
Applicant
N3 ?Epn VALGATION
1Y
-
�NO
'I 'Y ONSTRUCI'IDN
FIXTURfS -PER TRAP
-
GAS - EA. SYSTEM. I INC. 4 OUTLETS
OCC GROUP
APN
GAS - PA. SYSTEM-OVER 4(EA)
GREASL %INDUSTIII, WASTE INTERCIIPTOR r
BUILDING DIVISION FEES
GREASETRAP
PLANCHECK FEE
SEWRIt- SANI3'A 11Y- STOIIM P.A.2(101ef.
ENERGY PP.E
WATER HEATER W /VENT/ELECTR
l
GRADING FEC
7•
NOTICE TO APPLICANT: If, after making this Cenifican of Exemption, you should
becomesuhjectm to Wakens Compcnxtion provisions of he Labor Code, you muss
forthwith comply with such provisions or this permit shall M deemed revoked.
CONSTRUCTION LENDING AGENCY
thonhereisacd(Ses. inn lending agency fnnhe performance of
Lo cams for which this pemtit is issued (Sec. 31 »'/, Civ. C)
Lenders Name
WATER SYS'fEM/TREATING
SOILS FEE
WATER SERVICE
PAID -
NEW RESIDENTIAL I'LMB. SQ. Ff.
Dom Receiptq
TOTAL:
Lindens Address
TOTAL:
- -
I corm y than I have read this application trod sam that the ahove information is
cnrxcn.l aga<m rontply with all City and county nMinances and rate laws reliningm
building constatimn,and herebyuutbodzerepre,oratives man, citym emerupanthe
nhnve- mentioned property for inspection purp:res'
(We) agree to save, indemnify and keep harmless the City of Cupenlro against
liabilities, judgments, coats and expenses which may in anyway accme against said City
in consequence of the gaming aft ispemN.
APPLICANT Ir ER$TAND. AND WILL COMPLY WITH ALL NONPOINT
SOURCE RE L 'IONS. ' '
_
BUILDING FEE
�.
QTY. MECHANICAL PERMIT
FEE
SEISMICFEE
tp
PERMIT ISSUANCE
ELECTRIC FEE
ALTER OR ADD TO MECH. �s
PLUMBING FEE
NREIANDLfNG UNIT(TO 10,(NO CPM)
MECHANICAL FEE'
AIR HANDLING UNIT (OVER )O,WCFM)
CONSTRUCTIONTAX
Signaut t me ,n Date
A2A cOUS MATERIALS DISCLOSURE
III the applicant or future building occupant store or handle hasnolous material
as defined by the Cupenino Municipal Cade, Chapter 9. 12, and the Health end Safety
Coda, Section 25532(M'!
❑ Yer
Will the npplicam or future building occupant use equipment or devices which
hazardous air contaminants as defined by the Bay Area Air Quality Managem ant
'or?
C� ❑Yes
I have read the huzanous materials baladmments under Chapter 6.95 of the Cali-
fart. Health Safety Code Lions 25505, 255]] and 25534.1 undenmnd Not if the
/'
buildmgd n nit m writ is my responsibility to notify Ncocrupam
of the rte yam us or to issuance of. Coma 0pancy.
/� 4_44-9f_
EXHAUST HOOD (W /DUCT)
HOUSING MITIGATION FEE
HEATING UNIT (TO 100.00) BTU)
HEATING UNIT (OVER I00,010 BTU)
PAID
Date Rweiptp
VENTILATION PAN (SINGLE RESID)
BOILER -COMP (3HP OR 1 0,ODO BTU)
BOILER - COMP (OVER I f0,000 BIG)
-
AIR CONDITIONER
ISSUANCE DATE
ISSUED BY: ,
NEW RESIDENTIAL MECH. SQ, PI'.
Own rauNo god :m _ Dam -T-
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OFFICE