S 2431 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL
PERMIT NO.
,. BUILDING DIVISION APPLICATION/PERMIT PLUMBING -MECHANICAL
11 BUILDING PROJECT IDENTIFICATION
S 2431
6UILDING ADDRESS:
SANITARY NU.
APPLICATION SUBMI'17AL DATE
33 A
%NOm �AJ PHONE
J LACTOR'S NAME' LIC NO',
/'�.��2 �4 750
(0,(,(.yN
NIC
❑
CON9'ROLN
ARCHITECTANCINEER: LIC NO:
ADD�/[S I I ./%i1..F-I
'ONTACT - PHONE'.
BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial)
BLDG EILF.CyI'/ PLUMB MACH
J 14� ❑ ❑
LICENSE..CONTRACTOR 'S,j,mr, DECLARATION
I herion 70 vffirn that I nm of
under pmdsiona of Chapter 9 (eonrmmr,c is
)- with Sefull orce 91NN) of Division 3nf the Businesw and Profesdnns Code, and mylianseu--I-
Business
-PERMIT
, icensearcc and 1.
)V License Chis Lica I
QTY
ELECTRIC PERMIT FEE
JOB DESCRIPTION
RESIDENTIAL
❑ADWL [_1 KITCHEN
ISSUANCE 3
r
APPLIANCES -RESIUF:NTIAL
a Date Commetor
�fnn ARCHITECTS UECLARA
3 `Z I understood my plans shall he used as pulde moords
REPEL
[I ADDITION [_1 PLUMBING RE -PIPE.
El MULTI -UNIT ❑STRUCTURAL
ST U CTUR ION
El INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT
❑DEMOLITIONPOOLS
PANELS
UP TO 200 AMPS
ROl Wcenxed Pro[ecstnmJ
'�? OWNER -BUILDER UECLARA9'ION
-
201-1000AMP$
OVER I(ItN)gMPS
1 hereby affirm that I am exempt Gum the Contractor's License Law to, the
U following reason. (Sermon ]I13 L5, Business and Professions Cnde Any city or county
E" which requires a
�.�permit m mnstrur, alter, improve, demolish, or repaid" stmt,wrc
s� morto its issuance, also requires the applicant forsech permit to file asigned statement
that he is licensed Falkland ro the provisions of the Co dowtor's License Law (Chapter 9
(commencing with Section 9000) of Division 3 of rho Business and Professions CodG or O
j
li and tot, Maxis for the alleged exemption. Any violation of
that he Is exempt tang applicant
+a Section 90315n suhjedslhe applicant to panmty of
y hundred
not more than five hundred dollars($500).
LJ 1, as owner ofthe property, or my employees with wages as Their sole compensation,
7n,
Ie will do the work, and the structure is not armored or offered forsale(See. 9044, Business
❑ BATH RF:MODEUREPAIR ❑DEMOLITION
❑ OTHER
SIGNS ELECTRICAL
SPECIAL CIRCUI'VMISC.
TEMP. METER ON POLE IN59'.
COMMERCIAL'
E] NEW BLDG/ADDITION El DEMOLITION
kNANT ❑ FOOD SERVICE
IL.IMPROVEMENT
❑OFFER
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS -SWITCHES _FIXTURES
ao and Professions Code: The Contractor's License Law does not apply m an owner of
.r
property whe builds or improves thereon, and who does such work himself or through
his own employees, provided that such improvements are not intended or offered for
NEW RESIDENTIAL. ELECTS SQ FT.
sale.IL however, the building nrimprovemrn i.w soldwithinnneytomcdcrampleforlfild
cr-builder will have the harden of proving that he did not build or improve for pur.
pate of sada).
SQ. PT FLOOR AREA
$/SQ. FT.
❑ Las owner of the property, am exclusively contracting with licensed contractors to
mctruct the project (Sec. 9(44, Business and Professions Code:) The Contractor's Li-
QTy, PLUMBING PERMIT FEE
nseLawdoesnotapplymanownerofpropertywhobuildsorimprovesthereolt,and
who conwetw for such projects with terminators) licensed pursuant,,the Contractor's
PF,RMI'I'ISSUANCE
License Law.
C] Tam exempt under Sec. ,B&PCformismmon
DRAIN & VENT- WAT17R (PA)
BACK PLOW PROTECT. DEVICE
OwnerALTER-
Urate
VALUATION
Z :n
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
DRAINS- FLOOR, ROOF, AREA, COND.
❑ [have and will maintain a Certificate of Consent to self-insum for Workers Conpen-
�stien, ns provided for by Section 3700 of the Labor Code, for the performance of the
ST IP.S
9'YP[CONSTRU{]'ION
FIXTURES - PER TRAP
GAS-EA.SYSTEM-I INC.40TITLETS
Tk for which oris permit Is issued.
1 have and will maintain Workers Compensation Insurance, as required by Section
37004the Labor Code, fol the penormram oflhc work for all hill peJq)ttj; ueI
My We f Ya aur�tn[e�yp/�/�d Policy number ata: 1.9Tr
Grriee� �'n I"(1EMPTAO yNo.: i{wrd dY10l�QI1Z
_
OCC CROUP
.ver I(Vll�
APN
GAS - EA. SYSTEM -OVER 4(F;A)
ERTIFICAI F: OF EXE.MPI'ION FROM WORKERS`
GREASFANDUS'I RE WASTE INTERCEPTOR
COMPENSATION INSURANCE
(This seclinn need not he armpleteA ifine permit is far mnahundrW dollars Slop)
or less.)
in Din any manner
of he as
'Toy any person mefarwhabubjecd stheW rkesuCompall
not employ any person in any manner.an us to become subject 10 the Workers' Compen-
.cation Laws of California Date
Applicant
BUILDING DIVISION FRES)
GREASE TRAP
PLANCHECK FP.E
SEWER - SANITARY - STORM EA. 200 FT.
ENERGY FEE
WATER HEATER WNENT/ELECTR
GRADING PPA
yNOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
subject to the Worker's Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall he deemed revoked.
WAFER SYSTEM/TREATINGformat,
WATER SERVICE.
SOILS FEE.
teNa
NEW RESIDENTIAL PLMB. . FT.
z CONSTRUCTION LENDING AGENCY
I lterehyaffimt that there is u amstin titan Undingagenay fan he offinrmanen.f
ID
a Rocelpta
-r the work far which this permit is island (Sec. 3097, Civ, CJ
TOTAL:
Lender', Name
Lender's Address
yt lenity Nat 1 have read This application and stare that the above information is
A correct. l close m comply with all city and county omirmums and stem laws [elating 1m
Z� building construction, and hereby authorize representatives oflhis cilymenter upon the
A
QTY, MECHANICAL PERM FEE
DI Er
SEISM[
above-mentioned property for inspection purposes.
(We) agree Io save, indemnify and keep harmless the City of Capenim against
PERMIT ISSUANCE
ELECTRIC F P. 2
liabilities, judgments. costs and expenses which may in any way name against said City
consequencein of the grandn, of dds permit.
ALTER OR ADD TO MECH -^
APPLICANT UNDERSTANDS AND WI LI. COMPLY WITH ALL NUN -POINT'
SOI ENEGUL TIONJ. (r
AIR HANDLING UNIT (TO IO,WO CPM)
MECHANICAL FEE
CMn�YIW_Y +
'I�' h�
AIRHANULINOUNI'f(OVERIO,OIXCFM)
CONSTRUCT ION TAX
S n A liennl/Con¢mtor Data
HAZARDOUS MATERIALS DISCLOSURE
EXHAUST HOOD (W/DUCT)
DOUSING MITIGATION FEE
HEATING UNIT (TO 100,00) BTU)
Will the applicant tar Farre buildingrvvupinl stare m handle hazardmns material
as defrol by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 25532(o)P -
I[EATING UNIT (OVER 100,000 BTU)
ED Yen Nm
PAID
VENTILATION VAN (SINGLE RESID)
Will the applicant [mute building occupant use equipment or devices which
mi
elhtzardous air cuntamininanLc vc fined by the Bay Arml Air Quality Management
I
District?
_-
Date Receipt#
BOILER-COMP(3HP OR IfNL000 BTU)
TOTAL.
BOILER -COMP (OVER 100.000 BTU[
❑Yrs No
I have read the huwrsloua materials reyuiremmns wNer Chepler 6.95 of ihu Cnli-
fomiu He:J1h &Safety Codq Se 'ons 255( 5, 2553) and 2594. 1 understand that if me
building dos nm currently( sant, tit is my respmnaibility nr notify the xcupam
of me rcymrement. et9t r1. aaarr nraeenir ate arra �pn �.
AIR CONDITIONER
ISS
/ ISSUANCE DATE
/ _ 2 S E
(/
ISSUED BY:
NEW RESIDENTIAL. MEED. SQ. FT.
'
Owner maemnriud idem - .Date
TOTAL:
OFFICE