31361APPLICANT.TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL
PERMIT NO. a
1
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: L
o � Safi
SANITARY NO.
APPLICATION SUBMITTAL DATF
[o. 5 6
OWNER'S NA 3 PHONE:
CONTRACTOR'S NAME.: LIC NO:
NIC
CONTROL
'
❑
%RCtfITECT/FNGTNEE : LIC NO:
ADDRESS:
CONTACT: PHONE:
BUILDING PERMII INFO
❑ Consultant Fees Paid by Applicant (Initial)
BLDG ELECT PLUMB MECH
- LICENSED CONTRACTORS DECLARATION
1 hereby air". thin 1 nm licensed under provisions of Choler 9 (commencing
QTY. ELECTRIC PERMIT FEE
JOB DESCRIPTION
withll fincn7WO)ef Diviainn3 of the Businessund Pnsfessinns Cnde, OnJ my license ie
effect.
L License
License Class Con
] Date Cnmrecmr
PERMITISSUANCE
RESIDENTIAL:
CSFDWL C KITCHEN REMODEL.
[]ADDITION ❑PLUMBING RE -PIPE
El MULTI -UNIT ❑STRUCTURAL.
MODIFICATION
APPLIANCES — RCSIUF:NTIAL
ARCHITECTS DECLARATION
I ves.land my Floss shall be used as public records
ed
PANELS
T❑
UPT0200AMPS
INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT
❑BATH RL•A1QQj�l[TION
C OTHER
] LicennW Professional -
p] OWNER -BUILDER DECLARATION
f I hereby i fl'imt that I am cantata from she Common" License Law for the
] following reamer (Section 70313, Rusin& and Professions Code: Any city or county
which requires a permit to conatuct, altar, improve, demolish, or repair any &human
201 -IOW AMPS
OVER IOWAMPS
SIGNS HLECTRICAlI.
prior to its issuance, also occurs the applicant for such Permit o file a signed statement
SPECIAL CIRCU 7MISC.
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
TEMP. MM 17.11' ST,
_
UMMER IA
(commencing with Section 7000) of Division 3 of the Businesiand Professions Code) or
had he is exempt therefrom and the basic for the alleged exemption. Any violation of
❑NEW BLDG/ADDITION C DEMOLITION
POWER DEVIE6
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not mom than five hundred dollars T$500).
❑ I, as owner M the pmpeny, or my employees with wages as their sole compensation,
will do the work. and the structure is no, intended oroffcred forsule (Sec. 7044, Business
❑TENANT ❑ FOOD SERVICE
IMPROVEMENT
[]OTHER
-
SWIMMING POOL ELECTRIC
OUTLETS — SWITCHES — FIXTURES
NEW RESIDE! LEL CTR SQ FT.
i and Professions Code: no Compactor's License Law does not apply to an owner of
property who builds br improves momon, end who does such work himself or through
his own mnployees, provided that such improvements arc not intended or affercd for
-
sale. If,however, me building or improvement is sold within one ycarof completion, the
SQ. PT. FLOOR AREA
sISQ. FT.
ter -builder will have the burden of proving that he did not build or improve for pur-
Nut fsalr.)L
C 1, as owner of the property, am "elusively contracting with licensed commolum to
s� A
TAL:
onsT,uet The proJcet(See.7lW4, Business and Prnfessions Code:) The Catamount's U-
IIS dY
come, law does not apply In an owner of property who builds or improv. thereon,and
QTY, PLUMBING PERMIT FEE
who contracts for such pro tx with a contractor(&) licensed pursuant to the Counselors
PERMIT ISSUANCE
cense low .
C lamexemptund Sec. .B& P C for this reason
OCT®CAw�
�'
19
'ALTER — DRAIN &VE!— WATER (BA)
er_ Oate/O
f1 v,, f,pp
Uf yyr�l(IyV
BACK FLOW PROTECT. DEVICE
YORKER'S COMPENSATION DECIARATIOV
I hereby affirm under penalty of perjury one of the following declarations:
DRAINS— FLOOR, R(i AREA. COND.
❑]hove and will maintain a Cethficate of Consent to self -insure for Worker's Compen-
sation, as provided for by Section 3100 of the IaMr Cale, for the performance of the
STORIESTYPf?CONSTRUCTION
work for which this permit is issued.
FIXTURES — PER 3'RAP
C 1 have and will maintain Worker's Compensation Insurance, as nalaired by Section
37W of the LOM,Cnde, for the perturmance of the work fur which this pemtiu is issued.
My Worker's Compensation Insurance carrier and Policy number are:
Cance Policy No.:
-CERTIFICATE
GAS— HA, SYSTEM.I INC. 4 OUTLETS
OCC. GROUT'
-
APN
GAS — EA. SYSTF:MOVER 4IGA )
OF EXEMPTION FROM WORKERS'
' COMPENSATION INSURANCE
(This section need a., la, completed if Ne permit,, fusion e bandreddellart(SIW)
or less.)
GREASEANDU,STRL WASTE INTERCEPTOR
BUILDING DIVISION FL'BS
GREASETRAP
I'LANCHECK PEE
SEWER—SANITARY— STORM EA. 200 FI'.
I sunif nate in Neperimmuncenfthewark fol -which thr,scrouniaeucd.1s1ha0
not employ any person in any manner sot as to become subjecta the Workers' Caia,wv-
ENERGY FEE
WA'T'ER HEATER WNENTICLECTR
satins laws of California. Dole
Applicant
GRADING PEE
NOTICE TO APPLICANT,. If, after making this Certificate of Eemption, you should
become subject to the Worker's Compensation provisions of the Labor Coe, you must
WATER SYSTEMfTREATING
-
SOILS FEE
forthwith comply with ..,h provisions orchis permit shall be deemed revoked.
WATER SERVICE
CONSTRUCTION LENDING AGENCY
I botchy affirm that then is a construction lending agency forhe pe,furmanceof
NEW RESIDENTIAL PLMB. SQ. PC
PAID
Dote Roceipt0
Ne work fm which Nis Fermis is issued (Sec. 3097, Civ, C.)
Lender's Name
TOTAL:
Lender's Address
TO'TA1,;
BUILDING FCE
I certify that I have read this application and state that the above information is
correct I agree mcomply withal] city and county ordinances and state laws mining to
building construction, and hereby outharim mansenmtivos of this city m cater upon the
QTY, MECHANICAL PERMIT FEE
SEISMIC PEE
above-mentioned propcny for inspection purposes.
nify and keep harmless the City of Cupeni no against
(We) agree m save, indemrm
PERMI IISSUANCR
ELECTRIC FEE
liebilitko,judgmems, costs and expenses which may in any way accrue against said City
nse
coquc a of the granting of this permit.
ALTER OR ADD TO MECH.
PLUMBING FTFEE.in
AIR HANDLING UNIT(TO 10,000CFM)
MECHANICAL FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL1. NON -POINT
SOURCE REGULATIONS. -
AIR HANDLING UNIT (OVER I0,007, CPM)
CONSTRUCTION TAX
Signature of Applicant/Comncmr Date
HAZARDOUS MATERIALS DISCLOSURE,
EXHAUST HOOD(W/DUC13
HOUSING MITIGATION FEE
HEATING UNIT(TO IW,oIp BTU)
Wlluheapplicanrorfmure muldingocaa ion store mien abotmdnusnmturiul
as definal by the Cupertino Municipal Cole. Chapter 9,12, and the Health and Safety
Cole, Sermon 25532(c)7
HEATING UNIT (OVER 100,000 BTU)
❑Yen ❑No
Will the applicant or furore building oreupam use equipment n1 devices which
unit limardous air contumi wants as definM by the Bay Area Air Quality Management
PAID
Dale Receipt M
VENTILATION PAN (SINGLE RESID)
BOILER—COMP DHP OR I00,000 BTU)
District?
'TOTAL:
F7 Yes CNu
BOILER—COMP(OVERI00,000BTU)
AIRCONDUIONER
I have read Be ha.ednus materials requirements under Chapter 6.95 of the Cab.
main Health & Safety Code, Sections 25505.2.5533 sad 2.5534. I undentund that if the
building daemon currently haven hemon, past it is my re&jmnsibilhy m notify the occupant
of the waimmrson, which must he met prior to malamute Comficstenf Ov,rpancy.
ISSUANCE DATE
ISSUED BY:
NEW RESIDENTIAL. MECII. SQ. FT.
Owner or authorized agent Data
TOTAL:
OFFICE