31107 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. 1 O7
BUILDING PROJECT IDENTIFICATION
BUILIIINGADDRGSS: SANITARY NO. APPLICATION SUBMITTAL DATE
- v a Uoc. -P-e_
LWSHAME: L PH-NE: C NJ'RACfOR'S NA E:l AL LIC NOi N/C CONTROL It
AitCITITTECT/ENGIN UpR: TIC NU; ADDER...: ` 9b ❑
CONTACT. - PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG kIX PLUM c
LICENSED CONTRACTOR:S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm tam I ten license under provisions of Chapter 9(commencing JOB DESCRIPTION
„�,OZ th Section l000)of Division 3 of the Business and l'mfessions Code,and my license is RESIDENTIAL'
QUO ntfull fame enJ{Ike). �� PT:RMIT ISSUANCE
�U j [.icenae Class_1_. e��Lic.M ❑SFDWL ❑KRCHEN REMODCI.
Fzal Dame—Contactor APPLIANCES—RESIDENTIAL ❑ADDITION [I PLUMBING RF.PIPE
Fjy ARCHITECTS DECLARA N PANELS [I MULTI-UNIT ❑STRUCTURAL
y p E2 Wcmmnd my plans shall b u N a public co ds MODIFICATION
OZ.-O UPTO 200 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
FGN� t,7i Licensed Profevoon.l 201.1000AMPS IMPROVEMENT
G
OWNER-BUILDERmtireARATION OVER lots)AMPS ❑BATH REMODEUREPAIR (]DEMOLITION
p,CE'Q 1 hereby.(tion that 1 em exempt from the Contractor's Co License Law for the
p(a- station
following reason.(Smit t 9mate Business aprve.demolish,
Code Any city of county 410NS.h.CfRICAL []OTHER
F O['2 which requires u permit h+comwct,.her,improve,demolish,or repair any stremmae
.a71 prior it) issuance,also requires the applicant for such permit In lilcasigned statement SPECIAh CIRCUII'IMISC.
Mo
that he is license)Polsuantm the provisions of live Contmctnr'a Li¢nae Law(Chapter 9
W aO (commencing with Section 7000)of Division 3 of the business and Professions Code)tor TCMR METIER OR POLE INST. _ COMMERCIAL
4 qtr OL that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Section 9031.5 by any applicant for a permit subjects the applicant to a civilgenalty of POW.R DEVICES ❑TENANT ❑FOOD SERVICE
t mom than five hundred dollars($500).
CSQ (] I,nsowner of the property,or my employees with wages ax their wle compensation, SWIMMING POOL ELECTRIC IFIMPROVEMENT
will do~ the work,and the straure is not intended aroRored fur sale(Sec.104E Busineas ❑OTHER m and Professions Code:The Contracmrs License Law does not apply to an owner of OU'11Ef5—SWITCHES—FIXTU
6 3 property who builds or improves thereon,and who does such work himself or through M
his own employees,provided that such improvements arc not intended or offered for NEW RESIDENTIAL ELECI'R 1"
sale.If,however the building or improvement is sold within one year o(completion.the Q.FT.Fl. ft/SQ.FT.
owner-builder will have the burden of proving that he did not build or improve for par- /Qac
pose of sola).
❑ L as owner of the poiam exclusively contracting with licensed contractors to TOTAL: y5
construct the project(Sac.9090,Business and Professions Cnde:)'Ibc Contractor's Li-
aseLaw docs nal apply m an owner of property who holds or improves theater.and QTY PLUMBING PERMIT FEE
who contracts forsuch puncets with a contmaor(s)licenvcd purmnnt m the Contmemrs U~`'
License Law. PURMIT ISSUANCE
1 am exempt under Sec. ,B&P C fm this.... V
Owner Date ALTER—GRAIN&VENT—WATER(EA) VALUATION
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE
I hereby affirm under penalty of perjury one of the following declarations:
❑I have and will maintain a Cenificam arcunsenuo self-insure for Workers Compen. DRAINS—FLOOR,ROOF,AREA,GOND,
sation,as provided for by Section 3700 of the Lhor Code,for the performance of the STORIBS TYPECONSTRUCTION
work far which Nis permit is issued. FIXTURES—PGR TRAP
El 1 have and will maintain Workers Compensation Lnaumnce,.s required by Section
3900 of the Labor Code,for the performance ofthe work for which this permit is issued. GAS—LEA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
my Wn r' C Minn l/ssym�acec rtier unit Pd,a pW^bcr
Cerrla re GBp -Policy No e]l.UsV�I�� OAS—EA.SY59'.M-OVER4(BA)
C.R NFICATE OP . EMPTION FROM WORKERS'
COMPENSATION INSURANCE GRVAMYINDUS'IRL,WASTE INTERCEPTOR BUILDING DIVISION FEES
,(TTisseelim neednntbecompletetlifthe permit is l'nreachundneddollars($IIXB GREASETRAP
or last PLANCHECK FEG
Iccnify thei in the perfnrmana uflhe work li+r which thin permit is issuW.l shall SEWER—SANITARY—STORM EA.2001T,
ret con
any person in any manner so as m reopens,
subject to the Workcr%Compen- ENERGY FEE
Z satin.laws of California.Data
Z O Applicant WATER HEATER W/VEFTP/ELECI'R GRADING FEE
N NOTICE TO APPLICANT-.If,after making this Certificate of Exemption,you should WATER SYSTEM/EREATING
a ; become .bjce, ..he Workers Compensation provisions of the labor Cade,you most SOILS FEE
DJ forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
24
Q
CONSTRUCTION LENDING AGENCY NEW RP_SIDENTIAL PLATE. SQ,Fr.. PAID
L) OIherehy offimHh.phere isrconstrvctiun lending agency(Dobe performance of Date Receipt#
P the work for which this permit is issued(So,.309),Civ.C.)
O E•' Lenders Name -- - TOTAL:
WLenders Address TOTAL:
I certify that 1 have road this.pplicnion and.some that the above information is BUILDING FEF.
h correct.I agree to comply with all city and county ordioanaes and state laws relating to QTY. MECHANICAL PERMIT FEE
L) z building codification, ad herehyautboriee uprcsenmtives of this city m rearupon the SEISMIC FEE
ahavcmentiane pmpery for inspection pugsous. ,
(We)agree to save,indemnify and keep harmless the City of Cupurinongainst PERMITISSUANCE ELECTRIC FEE
liabilities,judgment.costs and expenses which may in any way accuse against said City p1:fEN OR AUUTO MECH.I.consequence of the granting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IO.Oq(I CFM)
SOURC cEJ .TI SNS. MECHANICAL HE
AIR HANDLING UNIT(OVER W."CFM) CONSTRUCTION TAX
Sig/ImApplitranm' PXHAUS'I HOOD(W/DUCT) HOUSING MITIGATION FEE
IIA-LARDOUS MATERIALS DISCLOSUREhe applicant or future building MuLipant mom or handle harridans material H17AI'INC,UNIT(TO 100,000 BTU)
the Cupcnino Municipal Code,Chapter932,and the Health and Safety
n 25532(a)P . FIAT ING UNIT(OVER 100,0008'I'U)
❑Yes ❑No t
VIENEI LAI[ON PAN(SINGLE RFSID) PAID? .I
1IVV\\ f�eii.�b Rucipt
Wilt the air surnm or future building occupantuseAir uordeviceswhich -
Disti tzurduns air contaminants as defined by the bay Area Air Quality Management OOILGR—COMP(JHP OR 100,0(1(1 BTU)
District? TOTAL:
❑Yes ❑Nn BOILER—COMPIOVER 100,000 BTU)
I have rent the hazardous materials requirements anter Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
funis Health&Safety Cade,Swims 25505,25533 and 25534.1 understand that if the NEW RFS LDENTIAL MECH. SQ.FT.
building doeanm nil ha mnan1,that it is my responsibility to notify the occupant
nix h' prior to issuan�a Ce ' of pa
Owne umhnriuJ.gem ^ Dam TOTAL: ISSUED BY:
OFFICE