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APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING -ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMB NG - MECHANICAL
111111.DINGPItO.11iUFIDKN'ITFICAT'ION
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SANITARY IN
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ARC( IT,CT/ENGINEE : LIC NO,
ADDRESS: [, ]
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'CON Ai PHONE:
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Consultant Fees Paid by Applicant (Initial)
BUILDING PERMIT' INFO
BLDG IJ.T:C'1' PLUM N I
El El❑
LICENSED CON'TRACTOR'S DECLARATION
I heath, 1,111 mitt 1 alit lice cd tmdet pntdixioms.1 Chal mr 9 matmtwnamg
wilhSmlion 7Mxp of Dlvinon3ol my Busivess mW l'rofessionsGMe, andm licunsais
in fall force and tide e2o0p j g_'*
Lionise Class 1.10.M eY CJYr
Dam Connector
cZfY. ELECTRIC PERMIT PEC
„
JJ013DESCRIIaDESCRIPTION
RESIDENTIAL:
❑SPEW], 0 KITCHEN REMODEL
❑ADDITION [I PLUMBING RF, -PIPE
❑X111:1'[ -UNIT 0 I RUM URAI,
MODIFICATION
C3 INTERIOR ❑ Cl IIMNEY REPAIR
IMPROVEMENT E]SWIMMING POOLS
❑ BRI II REMOIIEIARIWA1R ❑DEh10LITION
❑ OfHlil2
PERMI'1'ISSUANCE
APPLIANCES -RESIDENTIAL
ARC11i'I'I iC'FS DI7CLAIIAI'RT4
I understand my plans shall be used as public records
PANELS
UPTO 201 AMPS
Licensed Professional
OWNLR-BUILDER DECLARATIONOVER
Lircme Law Ito nto
hereby (Seel mal I um exempt from the C..too, Code:
following reason. tScetiot ](131 S, construct. ail, and 11 wc. d moll h.or Any city county
which rcgairos v e. alt to quiesthealter. improve, demolish, or repair any t tement
thovisio so fur Contranch rminnicense ow statement
that M1a is licensed pursuant W the provisions of the e limintodx License Viol Law (Chapter 9
that hoitscenedpurs pursuant
(can nncnc comm thertiontanaltl Dlvisinor(he hueged lJan'tant. A., in'Coda)or
that be is exantpt thumfrom anal the basis for Thu alleged cxcntpnnn. Any vinmion of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil pcmahy of
nonnmedian Eve hundred dollars($500).
E] 1. as owner ofine propcny, or my employees with wages as their sale cmulanemion,
will do the work, ark Thu arnemin is mw hu,mlal otol'fend farxaln (So,, 7144, It I,,
and Professions Code The Contractor's License Law does not apply to ;at owner of
progeny who builds or improves thereon, and who does such work h tuself or through
his own employees, provided that such improvements am not intended or offered for
.sole. IT. however. the building or ingnovcment visold within one ycarofcnntplction,the
owm,t will h'avc the human of proving that hadid not build,, improve for put-
pose uI sale).
❑ I.ax owner of the pmpenY, stn exclusively amtmming with limtecd contractors to
ons reci the Noma, (Sec 7044, Rainiest, and Profession Code, I ne Conrmmor'a Li-
ceaseLuwdoesnotapplymanownerofpropenywhobuilda or lmpreves thereon,and
whher nd pmsvamt .the Contractors
License I,aw,
[:]I am exempt under Sec. , B .0 P C fonhis remail
201-I010 AMPS
10N) AMPS
SIGNS Ii1,liLTRICAI.
SPECIAL CIRCUIT/MISC.
TEMP. ME'T'ER OR i'OhIi (NST. Of
COMMERCIAL:
❑ NEW BLDG/ADDITION El DEMOLITION
❑TMNANT ❑ FOOD SERVICE
IMI'ROVFMENT
❑ OTHER
PfIWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS-SWITCIII:S-iIXTURI!S
NEW RESIDENTIAL ELECIR SQ FT.
SQ. F. PIOORAREn
$/SQ. FP.
TOTAL:
QTY. PLUMBING PERMIT FEE
PERMIT, ISSUANCE - 71f79'0
Owner Date
WOIt ad,,
COMPENSATION DECTAIRAI efallowin,
I hereby off nn undo penalty ufperjmy one ill the following dechtmlinnx.
❑ I have and will maintain a Cenficale of Comenl to self-inxcre far Warker.a Cornian,
,mum. in. provided for by Section 3704 of the Labor Cada for the performance of the
work for which This permit is issued.
❑ I have and will tnai ntain Workers Compen.adan Immature, as retained by Scenan
3700cf1he LaMrCale, fon�he uperarnli.v�cnca�nceeoi'mew,,rk for yrwRvhi,IhImi, perm, Issued.
Ctarrier:rAcrs Cot2A Ia Polcy NayZl:'�'!�
E rl C TE OP EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This scetinn nsnJ not he enmplGed if the Pafmit iµ for nnchundred Jnllmsl$ITOP)
or less.)
Ioyany marinthe tperformance oymannero the workas tolaomeforwhichthispermitisissual.lshall
urn anplay tont person in any mannnsnnm Mcnmesubjectuvhe Worked Compeo-
vtion Laws of Callturnie. Dam
Applicant
ALTER - DRAIN A, VEX'- WATER QiA)
VALUATION
SACK PLOW PROfECI'. DEVICE
DRAINS-I71.00R,ROOF,AREA,C(1ND.
STORMS
TYPE CONSI'R11C1'ION
FIXTURES - PER TRAP
CAS-i7A.SYS'I'EM-I INC401J'TI.H'IS
OCC.GROUI'
Mo
GAS -I°A. SYSTEM OVER 4(EAT
GREAMANDUSTRI, WAS'T'EINTERCEPTOR
BUILDING DIVISION FEES
GREASE 'TRAP
PLANC111SCK FEE
SEWER -SANITARY -STORM EA 2(xl Ff. ®
ENERGY FEE
WAI EI2 1II7N'I ER W/VENT/F.LECTR
GRAVING PEP.
NOTICE. TO APPLICANT If, after making this Certificate of Exemption, you should
hecntne snbR us the Wudea', Compensation provisions of the Lrbur Code you nuts
forthwith comply with such provisions or this Permit shall be deemed revoked,
CONSTRUCT ION LENDINGAGENCY
Iherebyalfirintltanhereanconstactiomandingagencyl'or the Wifomorce of
.he work fur which this pemtit is issued (Sec. 3097. Ci, C.)
Lender's Name
WATER SYSTF,M(TREA'I INC,
SOILS FEE
WATER SERVICE.
-
PAID
Date Rec tM
NBW RESIDENTIAL TIMI. SQ, FT,
TOTAL:
Lender's Address
T
BUILDING THE
I certify that I have it this a,plicmion and state Out the above lnl'mnrnlov is
mi l agree to comply with all city andenunry nNinanees and.mm laws relating to
building contraction, and hereby a thorire mi nemntatives of this city totimer ulsm the
aMve-mentioned progeny for inspection parpases.
(We) agree to Nava, indeninhy and keep hurtnlevs the fairy of Cupertino against
liabilities,adgmvnts,cnstsand exisrsca wh,hnnty many way nemealmint mid Cily
meyuence nfthe ranting of 111%Permit.
APPLICANT UND STANDS AND B'If COMPLI' WITH ALL ON- DINT
SOURCE REGUL NS. -
(f� -
O
Sitcom of pli t(ontmclor Dat
HAZARDOUS MATERIALS DISCLOSURE
theapplicmm or future Milking occupant store or hankie Lazallous material
n defined by the Cupertino Municipal Code, Chal,le, 9.12, send the Health mal Sulmy
Calc, Section 2553200? 1
Yes r,JNn
1 Will me applicant or future building occupant use equipment or devices which
emit In,ankns air cunntativand mcalmed b rho Be,Area Air Cathay Manntruamt
y
D"o'cl7 Yes �o
(]
I have read,hc Msallousmaterials reyuitemcmts under Chapter 6.95ofthe Cali-
fnmiu Hulth & Sul'cty Cakes Section 25505, 25539 and 25594. undcamntl thm if the
oftheng 'an al a:n ml l4, have ant, that it ismyresryonsihililymsalifyihunavpunt
of me ircments rich nm primto mutual ofa Ccnilicmc of Occupancy.
QTY MECHANICAL PERMIT FEE
SEISMIC FEE
PERMIT ISSUANCE -��-'-'
ELECTRIC FEE
ALTER II�i ADD Ty MECH. /�
PLUMBING PEE
AIR HANDLING UNITPI 111, 1'MI I
MECHANICAL PIiE
AIRHANDLINGUN I VERT WCFM j
�, Y � 1
CUNS'I'Itl1CT10N TAX
EXHAUST GOOD IW ) C'f) Ill
HOUSING MITIGA'r1(IN PEE
HEATING UNIT CTO 1),6) BTIB
i (EATING UNIT (OVER IIF1sP(1 B'$'us
PAID
Date Receipt# h
VENTILn'I ION FAN (SINGLE RESID)
BOILER -COMP(3HI'OR IM).(1(10 B'TIJ)
'It I'AL
COM P(OV 1111 , ITT C)
BOILER- C(HqOW
AIR CONDI'1'IONF.R
ISSUANCE DATE.
3—� r
ISSUED BY:
NEW RESIDENTIAL MECH. SQ. ET
r amM1orin ug t Dam
TOTAL:
V
OFFICE