S 1417APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING. ELFCTRICA L
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING -MECHANICAL
RPILDING PROJECT IDENTIFICATION
I'H IT NO.
� 1417
BUILDING ADDRESS:
SANITARY NO.
AI'I'LICATI N Sl1BM�TTA1. DATE
OW ER:S NAMIi:Sara
PHONE:
1
CON'I'RAC'1'(IR:SN ME: LIC NO:
NIC
❑
CONT ROLp
ANCHITECHENGINFER: 1.1
ADDRESS J
,1 r
CONTACT: PHONE:
BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant (Initial)
BLDG ELECT' PLUMB MECH
❑ 1:1 ED
LICENSED CONTRACTORS DECLARATION
I h rchy affirm that 1 am licensed ander provisions of chapter 9 mommearm,
QTY. FLECIAIC PERMIT FEE
JOB DESCRIPTION
,FRMIT ISSUANCE:
with Section]OyB of Division Sof the Busim,,ind l'r N.Wons Code,and my license is
in full succinct cifiect. ,] !iC q
RESIDENTIAL'
❑SFDWL ❑ KITCHEN REMODEL
APPLIANCES -RESIDEN'UAL
License Class �• rt Lic.p e)7�1 .1��
Dae Contractor
[]ADDITION ❑ PLUMBING RE PIPE
[I STRUCTURAL
MODIFICATION
EI INTERIOR [I CHIMNEY REPAIR
IMPROVEMENT 0SWIMMING POOLS
ARCI11TIiC1"S DECLARATIONPANELS❑MULTI-UNIT
I understand my plans shall be used as public recent,
US' T(12W AMPS
[,focused 11. fessimal
201-1000AMPS
OWNER -BUILDER DECLARATION
I liamby arm that 1 ono exempt from the Commmor's License Law for the
ffi
following awn. (Section 7071.5, 13usiness and Professions Code: Any city or county
re
❑ RATA REMODEIJREPAIR [I/'EMOI.ITION
❑ OTHER h Yl't P! a zI
I
OVER 1001 AMPS
SIGNS ELECTRICAL
which ruqu ms a permit to um,Vaet filter, III provu, demolish, or «pair any s,mcmor,
SPECIAL CIRCUITIMISC.
_
prior to its issuance, also requires the applicant for such permit to file a signed statement
that he is licensed manot to the provisions of the Contraao's License Law (Chapter 9
(commencing with Section 701 of Division 3 ofthe Business and Pmfessiom Code)or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
TEMP. METER OR POLE INSp.
COMMERCIAL'
❑ NEW BLDG/ADDITION ❑ DEMOLITION
Section 90315 by any applicant for a permit subjects the applicant to a civil Penalty of
POWER DEVICES
❑TENANT El FOOD SERVICE
not more than five hundred dollars ($SIX).
❑ Losowncndthapropuay,nrtnye,npinyeeswithwagesas Theirsole cn .Basi iess
will drive work, andthe stm0.amratetintended Business
IMPROVEMENT
❑OTHER
SWIMMING POOL ELECTRIC
appec.]614.
Law dual
and 1'rnfessions Cola. '1 he Gmtmaors License Law Anes Bat apply m an owner of
Of1T1.fTS - SWITCHES - FIX 'NHE
NEW RFSIDF.NTIAL FLECTR SQ FT.
property who builds or improves demon, and who dues such work himself or through
his own employers, provided th a such improvementsam not intended or offere l for
sale. If. however, The building or improvement is suite within one year Ofcampletion,the
SQ.IT.I'LOOR AREA
SISV IT.
owner-bailder will have the burden of proving that he did not build or improve lot pur-
paw of xfilc.).
[11. as owner of the property, am exclusively contracting with licensed contractors to
T(TTAL'
construct the project (Sec. 9614, Business and 1'mdessions CmIC:) 91.E Contractor's Li-
nseLa. does hot apply So an Owner of remedy who builds mimprove,thereon,and
QTY PLUMBING PI7RMIT FEE
who contrtwts for such project, with u contentious) licensed pnrsuunt Tui the Comentoe,
License Law.
❑ l on exempt under Sec. , R & 1' C for do,or.wo
PERMIT ISSUANCE
Owner Doc
ALTER- DRAIN & VENT- WATER (FA)
VALUATION
si* �-
WORKER'S COMPENSATION DECLARATION
I hereby anion under penalty of perjury one of the following declarations:
HACK FLOW PROTECT. DEVICE
'❑ I have and will l maintain u Ceatifieum ofConscnuo self -insure for WorUUx Continent-
s fawn, as provided for by Section 77W of the Laker Code, for the perfnmwnce of the
DRAINS- FLUOR, ROOR AREA, COND.
STORIES
TYPECONSTRUCTION
work for which This Innnit is Issued,
FIXTURES - PER TRAP
❑ 1 have and will maintain Worker's Compensation Insurance, as required by Section
3700of the Lamer Cale, for the scrfommncenf the work l'oyrpw� hichh this is iilswed.
GAS - F. A. SYSTEM, I I NC. 4 OUTLETS
OCC. GROUT'
ABi6
spermit
My Worker' C grout ^ organ Policy Noand y ic�jrC��L�%LIQ
GAS - LA. SYS TEM-OV13R4(EA)
CERTIFICATE OP EXpMPI ION FROM WORKERS'
COMPENSATION INSURANCE
V
GRFASIANDUS'TRL WAS 117, IN]ERCEMOR
13UILIIINO UIVI SION_FEES
(To,wain ineedno, be completed ifthe p'raniT is forum hundred dollars (S 1 No
or lees.)
GREASETRAI'
PLANCHECK FEE
I ccnify firthBteperfnmwncenl the work furwhiGubispornitivissued.]shut
hot employ any ream in any manner so Us m hecome mthb, to the Workers.' Compete
SEWER -SANITARY- STORM EA. 400 FI'.
-
ENERGY FEE
WATER DEAL ER W/VENVELECTR
GRADING TEF,
moon Laws o1 California. Dae
Applicant
NOTICE TO APPLICANT: If, after making this Cer iBcate of Exemption, you should
hecnme subject I. The Worker', Cmnpmtsmion provisions oldie Labor Code, you most
WATER SYSTEM/1'RFATING
SOILS FEE
forthwith comply with such p,.ei,iam or this permit shale, deemed revoked.
WATER SERVICE
CONSTRUCTION LENDING AGENCY
I hey affirm that there iso contraction leadingageacy for the perfatmanaeof
hereby
NEW RESIDENTIAL PLMB. SQ,FT.
PAID
Dae Receipt If
The work for which this permit is issued (Sea. 3097. Ci, C.)
Lenders Name
TOTAL':
Lender's Address
TOTAL:LIZ
BUILDING FEE S-00
L ccnify that 1 have read this application and state and the above information is
Q'pY. MECI IANICAL PERM ITP FEE
SEISMIC FEE
correct. l agree to comply with all cityantl county nrdlnanms and cam laws relating it)
building construction, and hereby authorize representatives of this city to enter upon the
PERMIT ISSUANCE
ELECTRIC FEE
akwe-mentioned Proprny for inspection purposes'
(We) agree,. save, indemnify and keep handles, the City of Corson. against
ALTER OR ADD TO MECH.
PLUMBING Hit;,
liabilities.judgments, costs and expenses which may in any way acme again,, said City
in cmwilocace of the graf ing of this permit
AIR HANDLING UNIT (TO 10,00 CFM)
MECHANICAL FEB
APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL1. NON -POINT
SOURCE REGULATIONS.
AIR HANDLING UNIT (OVER 10,W0CFM)
CONSTRUCTION TAX
. n m�n^�/r�L�� C_�_(][y
1
Sigwuuc mApplicanUConommr Damm
HAZARDOUS MATERIALS DISCLOSURE
EXHAUST HOOD(W/DUCT)
HOUSING MITIGATION TRE
HEATING UNIT (TO 100,001 BTU)
Will the applicant or future hackling occupant store or handle hazardous material
as defined by The Cupertino Municipal Code, Chapter 9.12 and the Health and Safety
Cole, Section 25532(.)'!
HEATING UNIT (OVER 10,000 BTU)
pYe, *Nn
will the aP,fcanwr future building eocupant Use equipment or devices which r
emit transitions contaminants as defined! the Bay Area Air Quality Management
Di,trictTX
C1 Ye, �No
R PI
DTTA ,-/O
VENTILATION PAN (SINGLE RFSID)
BOILER - COMP (3HPOR 100,000 BTU)
BOILER- COM [I NOV 11 100,001 BTU)
AIR CONDITIONERISSUANCE
I have mail the Immidous ttumrids requirements under Chapter 695 of the Cali-
DAT.
NEW RESIDRNTIAL MECH, SQ. IT.
fund, Health & Safety Cale, Sections 255115, 25533 and 25534. 1 Undreamt] that near
building does not currently have a tenant that it is my responsibility m notify The receptor
of the recruitments which mast Im met prior m issuance of a cenircale of occupancy.
By
Iss .D Y:
'TOTAL:
Owner or authorized agent Dam
OFFICE v