99090011APPLICANTTO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
OFFICE
CITY CUPVISION BUILDING -ICALMICA
E TE TN
MECH
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BUILDING DIVISION APPLICATION/PERMIT PLUMBROJECTFIDENTIFICA
' BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS:
SANITARY NO.
APPLICATION SUBMITTAL DATE
1-LCo3
o
O E 'H N E: PHONE:
21-Y CpOR'S NAMLIC NO: 'r
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❑
CONTROLN
CHI1'�Cf/ENG
EER' ` LIC NO:
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ADDRESS: �r�G �~
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CONTACT: PHONE:
BUll.D G PERMIT INFO
�osEP► t A fel 1 R KHA-S6 -335-1
❑Consul and Fees Paid by Applicant (Initial)
BLDG ELP 19— Er
LICENSED CONTRACTOR'S bECLAdtATION
1 hereby mHrm Thal I am licensed under provisions of Chapter 9 (commencing
wiNSecroil")OfDivision3ofthe Businessand Professions Code,and myliceneeis
in full force and cRcnm
. .
Lac p
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QTY ELECTRIC PERMIT FEE
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JOB DESCRIPTION
RESIDENTIAL:
❑SFDWL ❑KITCHEN REMODEL
❑ADDITION [3 PLUMBING RE-PIPE
❑MULTI -UNIT []STRUCTURAL
MODIFICATION
El CHIMNEY REPAIR
IMPROVEMENT (] SWIMMING POOLS
❑ BATH REMODEIJREPAIR 0DEMOLITION
❑OTHER
PpEpRpMLIIATNISCSEUSA-NRCEE
SIDENTAL
ARCHITECTS
1 understand my plans shall he used as public recorda
PANELS
1 UP T0200 AMPS❑INTERIOR
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm Thal 1 um exempt from the Contractors License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to construct, alter, improve, demolish, or repair any structure
prior to its issuance, also requires the applatim for such permit,. file. signed statement3
tbar he is licensed pursuml r, the provisions of the Contractors License Law (Chapter 9
201-1000AMPS
OVER 10p(IAMPS
SIGNS ELECTRICAL
SPECIAL CIRCUTUMISC.
I TEMP. MP.'THR OR POLE INS1'. J
MMERCIAL-
'4
(commwming with Sw0.n71(No.f Division3ufth. Business and Professions Code).r
he, he is exempt Ihercl'rom nM the basis for the alleged exemption. Any violation of
NEW BLDG/ADDITION ❑ DEMOLITION
POWER DEVICES
ae kN.
IL
FSG
W m
tat
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
net more than five hunNed dnllnc(S.100).IMPROVEMENT
El 1, as owner of the property, or my employees with wages as their sole compensation,
will do the work, and the structure is not intended or ffered for sale (See. 70,14, Business
and Professions Code: The Cormacusrs License Law does nm apply to nn owner of
property who builds of improves thereon, and who does such work himself or through
his own employees, provided that such improvements an, not intended or offered for
sale. IL however. the building or improvement is sold within one year ofcompletion, the
ENANT ❑ FOOD SERVICE
❑OTHER
SWIMMING POOL ELECTRICJIF
OUTLETS -SWITCHES - FIXTURES
NEW RESIDENTIA ELECTR SQ IT,
SQ. FT. FLOOR AREA
$/SQ. PT.
owner -builder will have the burden of proving that he did not build or improve for pur-
pose of sale.).
1, as .wncr of Ne property, am exclusively contracting wird licensed commuctors to
TOTAL:
consumer Ne project (Sec. 704al. Business end Professions Code:) The Contractors Li-
censeLawdoesnotapplYmanawncrofpmpertywhobuildsorimproves Nerenn. and
QTY, PLUMBING FEE
whocomracts for such projects with a mnwetor(s) licensed pursuantto the Consracmrs
PERMIT ISSUANCE
License Law.
❑ 1 am exempt under See. B & P C for this reason
ncr Date
ALTER - DRAIN & VENT- WATER (EA)
BACK FLOW PROTECT. DEVICE
LUAT�IONM
O
WORKERS COMPENSATION DECLARATION
1 hemby nRirm under penalty of perjury on<Of Ne following declarations:
W
,❑
I have end will maintain a Certificate of Conscnuo self-moure for Worker's Comper-
sation. as provided for by Section 37W of the Labor Calc, for the performance of the
DRAINS- FLOOR, ROOF, ARIA, COND.
STORIES TYPE CONSTRU N
work for which this permit is issued.
FIXTURES - PER TRAP
1 have and will rtmmetio Worker's Compensation Insurance, as required by Section
37M of the Labor Code. for the Performance of the work for which this permit is sowed.
GAS - EA. SYSTHM-I INC. 4 OUTLETS
OCC. GROUP�� APN
-'
Worker's Compensation Insurance artier and Policy number arc:
My Workam
Carrier: Policy No.:
V
GAS - EA. SYSTEMOVER 4 (FA)
GREASFANDUSTRL WASTE INTERCEI'T'OR
CERTIFICA'1'EOFEXEMPTION MOMWORKERS'
' COMPENSATION INSURANCE
BUB.DING DIVISION FEfis
(This section need not he completed ifthe Permit is for one hundred dollars ($100)
or Lew.)
GREASETRAP
PLANCHECK FEE
,Z
7�7 O
Gy
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I cmily that in the Performance ofthe work forwhich this permit is issued, l.hall
not employ any person in any manner so as to become subject to the Workers' Compen-
cation La.sol' Culilbmia. Date
Appli ..I
SEWER - SANITARY - STORM EA. 2W IT.
ENERG 11 gain
WATER HEATER W/VENfIELEC IR
GRADI I E
SOILSjq
NOTICE TO APPLICANT. If,after ... king this Ceftifcam of Exemption, on should
become subject to the Wnrkcr's Compen.. him provisions of the Labor Code, you must
WATER SYSTEM/TREATING
0.Q
z
C.1Q
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W
a
forthwith comply with such Tons site. or this prout shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
k forthis Non,i ivsed(Sec.i3007, Cin, agencyfor the pertormanceof
the work for which this pewit is mated (Seo. 309?. Civ. CJ
Lenders Name
WATER SERVICE
SEP 199
PAID
Date Receipt#
s
NEW RESIDENTIAL PLMB, SQ. FT
o TOTAL:
Lenders AJdreas
TOTAL:
o
BUILDING FEE
1 certify tool 1 have read this application and state Nat the above information is
QTY. MECHANICAL PERMIT FEE
SEISMIC FEE
Vs
U Z
correct. l agree to comply with all city and county ordinances and slate laws relating to
building construction, and hereby authorize representatives ofthis city to enter upon Ne
PERMIT ISSUANCE
ELECTRIC FEE
ah.ve-mentioned proreny for inspection puryoses.
(We) agree m cave, indemnify and keep harmless Ne City of Cupenin, against
ALTER OR ADD TO MECH.
PLUMBING FEE
liabilities, judgments, costs ad expenses which may in my wayaccene against sand City
in consequence of the granting of this pewit
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
E
SOUR.REGUI TION.
AIR HANDLING UNIT (TO 10.0i CFM)
MECHANICAL FEE
AIR HANDLING UNIT (OVER 10.000 CFM)
CONSTRUCTION TAX
Signa. of ApplicanVComrnctof Date
HAZARDOUS MATERIALS DISCLOSURE
EXHAUST HOOD(W/DUCD
HOUSING MITIGATION FEE
HEATING UNIT GO 10/000 BTU)
Will the applicant r lot= building occupant store or handle hazardous material
as defamed by the Cupertino Municipal Cole, Chapter 9.12, and the Health and Safety
Code, Section 25532(x)?
HEATING UNIT (OVER 100,000 BTU)
❑Yes ON.
VENTILATION FAN (SINGLE RESID)
PAID
Date Receipt
BO THIP OR I00,(q/ BTU)
Will the applicant or future building occupant use equipment or devices which
nit hmmduus air mminans defiby the Buy Area Air Quality Management
amrs aned
TOTAL:
BOILER- COMP (OVER 100.00) BTU)
-
District? No
❑Yes ❑
AIRCONDITIONER
I have read the hozallons raincoats requirement under Ch6.95 of the Cali-
foods Hcalth & Surety Gide, Sections 25505, 25533 and 2.5534.1 understand that if the
ISSUANCE DATE
97
NEW RESIDENTIAL MECH. SQ. FT.
building does not carnally hover tenant, that it is my responsibility to n.tifythe«.Ante
��- ��
oft] .quint it, wble tet hem• nnu loneve or a Cenifcam of ecmpanc.
TOTAL
ISSUED BY.
Owner or auto zed ugem Date
OFFICE