99110092APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL
LIC NO:
ADDRESS:
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OFFICE
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,TRACTOR'S(DDECLARATION
❑ ConsuBant Fees Paid by Applicant (Initial)
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LICENSED CONTRACTORS N�
I hereby affirm that l am licensed under provisions of Chapter 9 (commencing
with Section 7000)ofDivision Sof the Business an s' C mylicense is
io full face and effect. s, pdp /
License Class Lictt 1Wx�Ll�
Dem Conuanm
ARCHITECT'S DECLA ON
I understand my plor,, sill housed as public records
QTY ELECTRIC PERMIT FELT
_
JOB DESCRIPTION
RESIDENTIAL,
❑ SFDWL ❑ KITCHEN REMODEL
[I ADDITION L1 PLUMBING RE -PIPE
[_1 MULTI -UNIT L1 STRUCTURAL
MODIFICATION
PERMIT ISSUANCE
APPLIANCES—RESIDENTIAL
PANELS
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UPg0200AMPS
❑INTERIOR El CHIMNEY REPAIR
IMPROVEMENT SWIMMING POOLS
El BATH REMODEL/REPAIR DEMOLITION
El OTHER
Licensed Professional
OWNER -BUILDER DECLARATION
[ hereby aRtm that I am exempt from the Contraoter's License Law for the
following reason (Section ]031.5, Business and Professions Cede: Any city or county
which requires a permit to consuuct, alar, improve, demolish, m repair any structure
prlorm itsissuance, also requires the applicant for such permit to file a signed statement
thatheislicemsalpursuant to the provisions of the Commetors License Law (Chapter 9
(cummencin th Section 7000 of Division 3o fine Business and Professions Code)
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that is exempt li and the basis for the alleged exemption. Any violation of
201-IOOOAMPS
OVER IOWAMPS
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC.
TEMP. METER OR POLE INST.
COMMERCIAL:
❑ NE BLDG/ADDITION ❑DEMOLITION
POWER DEVICES
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Section 70315 by any a liceut far a permit evbjws thea applicant m a civil penally of
io any applicant
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not more than five hundreddollars
❑1, as owner ofthe pro,eny, or my employeeswages as their compensation,
will do the work, and the structure is not intended or offered for sale (See. 70", Business
EANT FOOD SERVICE
IMPROVEMENT'
L1 OTHER
SWIMMING POOL ELECTRIC
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and Professions Code: The Contractor's License Law does not apply to an owner of
property who bond, or improves thereon, and who does such work himsdf or through
OUTLETS—SWITCHES—FIXTURES
'
his own employee,, provided Thar such improvements are an intended or oBeced fur
sale. IL however, the buildin6 or impmvemem is sold within we year of completion,the
NEW RESIDENTIAL ELF.CTR SQ PT.
SQ. FT. FLOOR AREA
E/SQ. FT.
owner -builder will have the burden of proving that he did nut build or improve for
,,a oxide).
❑ 1, as owner of the property, am exclusively contracting with licensed contractors to
TOTAL:
construct the project (Sec 7044, Business and Professions Co.., The Commnora
cense Law does not apply to an owner of property who milds or improves thereon, and
QTY. PLUMBING PERMIT FEE
.
who contracts for such projects with a contractor(s) licensed pursuant to the Contractor
PERMIT ISSUANCE
License Law.
❑ 1 am exempt under Sec. , B & P C for this reason
Da
ALTER — DRAIN & VENT —WATER (EA)
VALUATION
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w WORKER'S COMPENSATION DECLARATION
BACK FLOW PROTECT. DEVICE
1 hereby affirm under penalty of perjury ane of the following dcclamions:
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DRAINS—FLOOR, ROOK AREA, COND.
❑ I have and will maintain a Certificate of Consent to self -insure for Worker's Comfort,
sation, as provided for by Section 37M of the Labor Code, for the performance of the
w o for which this permit is issued.
STORIES CTION
//
FIXTURES — PER TRAP
I have and will maintain Worker's Compensation Insurance, as required by Section
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afthe Labor CCSoddeeffor the affirmative afthe work foorr whichh{odsss .,, is issued.
Policy
Came,,My pk r/(,iLJp_I/In once tunic Polcy Nc.:A* %`0�
KCERTIFICAALTE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This watmained make completed ifthe permit is become hundred do)[. SUSSnnqq
or less.)
GAS—_ SYSTEM -I INC. U
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GREASP ND ST m�mp QC
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GR A r OWIs4
OCC. GROUP LAPN
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BUILDING DIVISION h'EES
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NCHECK FEE
I certify that in the performance of the work for which this Permit is issued, l shall
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no, empluy any person in any manner m as m beton subject to the Workers' Compen-
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ENERGY FEE
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sadon Laws of California. Data -
Applicant
NOTICE TO APPLICANT. If. after making this Certificate or Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Cale, you most
comply with such provisions or this permit .shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
there is lending agency for performance of
IhereM1y affirm that w
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the work for which this permit is issued (Sec. 3097• Co. C.)
Lenders Name
Lenders Address -
WAT W/V IQIIS on
WAT EA 1
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WATEq print. 1 dap
NEW i A�j Q. FT
GRADING FEE
SOILS FEE
PAID
Data • Receipt#
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'TOTAL:
I certify that I have read this application and state that the above information is
correct. I agree to comply with all city and county ordinances and state laws relating to
building construction, and hereby mulaiee representatives of this city to enter upon the
app
QTY. iS tl}WI. PEE
O
SEISMIC FEE
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep hamdess the City of CuKr int against
PERMIT ISSUANCE
CFE
liabilities, judgments, costs and expenses which may in any way name against said City
a. unn'tionce of rhe granting of this permit
ALTER OILA
PLUMBING
AIR HANDLING UNIT (TO 10,0011 CFM)
MECHANIC E
APPLICANT UNDERSTANDS APID WILL COMPLY WITH ALL NON -POINT
SOURC •. REGULATJB IS.
AIR HANDLING UNIT (OVER 10,t3W CFM)
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CONSTRUCtitNEAMLIV 16
Sign(re Appllcan Contractor Dat
HAZARDOUS MATERIALS DISCLOSURE
EXHAUST HOOD fW/DUCT)
HOUSING I IGATION FEE
I theapplictim or future buildingocoupamaoreoc handle lembodous material
as defined 1, the CuPoona Municipal Code, Chapter 9.12, and the Health and Safety
Cade, Jeylfi{t 25532(a)Y
HEATING UNIT (TO 100.000 BTU)
HEATING UNIT (OVER 100,00) BTU) .
�[ C] No
Will the applicant or future building occupant use equipment or devices which
mit hazardous air comonamorts as defined by the Bay Area Air Quality Management
Disuict'( CJs
[7( �No
PAID
Date Receipt if
VENTILATION FAN (SINGLE RESID)
BOILER — COMP (3HP OR 100,000 BTU)
TOTAL:
BOILER — COMP (OVER I(q,Ofq BTU)
CONDITIONERmcnts
,he haous materials requirements under Chapter 6.95 of the Cali-
I have readvN
forms Health & Safety Code, Sections 25505, 25533 and 25534.1 m adermmtd that if the
building does not currently have a le m,thatlt is my respansibilayy�m notify the receptor
SSUANCE DATE
(- /
NEW RESIDENTIAL MECH. SQ. FT.
of the teem eenkcrlL lIl�rci�pi�/,r/us, be , nm to mance.d.6 /LG/�i($?mpae,
/ I `
Owner lcis on" atzW ant a�
TOTAL';
ISSUED BY.
OFFICE