S 0169APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CITY OF CUPMRTINO BUILDING . ELECTRICAL PIiRMrr No.
BUILDING DIVISION APPLICKI'ION/PFRMIT I'I.Insa;,MECHANICAL �I
I4UILDIN . I'RuuOJE.C'1IDFINI BACATION 0 1
1 ❑
AR 'H11'ECTIENGINIiER: LIC NO: /Ilj)R�liSS:
OFFICE
CONTACT: PHONE:
BUILDING PERMIT INFO
IiLEC'1' PLUMB ME
❑ Consultant Fees Paid by Applicant (initial)❑LUG
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LICENSED CONTRACTOR'S DF.CLARA'I-ION
1 hereby affirm that I am licensed under provisions of Chapter 9 of turning
wise Scmion'IaXB ufDivisnmlaflhe Ha.lnes. an 1 y� mylmcnxc i.
�'
on full force andeecl. io tV
License Clas Li'.N
Ume Cornmemr
Cry ELECTRIC PERMIT FGF
JOB DESCRIPTION
RESIDENTIAI;
❑SFDWI, ❑KITCHEN NEhIODlil.
❑ADDITION [D] PLUMBING RE -PIPE.
❑MULTIANI'I' C1 STRUCTURAL
h10DIFICATION
❑INTO ri ❑ w....EY RIiR11R
IMPROVEMENT C3SWIMMING POOLS
ElBATH REMODIJIREPAIR El DEMOLITION
❑OTHER
1117RMI I'ISSUANCIi
AI'1'LIANCIiti—RESIDIiNI'IAI.
ARCHITECTS DECLARA 10
1 understand my plan.uhall W used as public records
1'nNIJ
Oil 10 HXI AMPS
Licensed Professional
OWNER -BUILDER DECLARATIONOVIiR
I hereby affirm that 1 am exempt from the Contractor's License Low, fire the
following reason. (Section ]ill I.S. Business and Professions Cade: Any city or county
which minims a permit to construct, after, improve, demolish, or repair any structure
malmr
prior to its issuance, also requires the applicant for such permit to file a signWmen
that he is licensed pursuant o the provisions of the Contractors License Law (Chapter9
(commencing with Section 7")of Division 3 o the Business and Professions Code) or
'hat he in exempt therefrom and the basis for the alleged exemption. Any violation ofas
0031.5 by any applicant for a permit subjects the applicant to a civil Penalty of
no' ...,him five hundred dollars (85(X1,
01. as owner of the property. or my employees with wages as their sole compensation,
will do the work. and the rwctum is not inmMed or offered for sale( es. 2044. Business
and Professions Cada The Contractor's License Law does not apply to an owner of
property who builds or improves thereon. tad who does such work himself ar'hrough
his own employees, provided that such impmoural am nm intended or indent for
afmpledon.the
,site If, Wwever. the building or improvement is sold within one yearm
ver-Wilder will have the burden of proving that he did not Wild or improve for Fur.
201-IINNIAMPS
❑XX)AMP$
SIGNS ELECI'RICA],
SPECIAL CIRCULI'/MISC.
\
TIiMP. MITER OR ('OLE (NST.
I .
rW BL.IR{/ADDITION ❑ DEMOLITION
❑TENANT El FOOD SERVICES
IMPROVEMENT
❑Q1 H1.H
POWER DIiVICIS
SWIMMING POOL ELEC'DUC
OGGI*Lj.7S—SWI(CMS—FUKRIS
NEW RESIDENTIAL HLIiCfR SQ Pr.
Sy-ir. l'LOOR ARBA
p•
_ W'
$ISQ.I•f.
l OTA(_
pose of sale.).o
racrs to
n I. as owner of the property, am exclusively contracting with licensed eomm
conswc' me project (Sec. ]f W. Business and Professions Cude:) Till Commuters Li-
i-c se Law does not apply to an owner of propcny who builds or improves themun.and
sense,
118 w_
QTY. PLUMBING PERMIT FE
who contracts for such projects with a conclusions) licensed pursuant the Comma T's
License law.
❑ 1 son exempt under Sm. . B & P C for this reason
PERMIT ISSUANC17
/'jQ�`j^-9y
yUN V
ALTER — URAIN&VIiM'— NATER (IiA)
VALUATION
opts
Owner
WORKER'S COMPENSATION DECLARATION following
I hereby affirm under penalty oeperjury one of the following Worker's
Coo❑(have and will mainmina Certificate of Consent to std -insure for Wnder's CompereDRAINS
BACK FLOW PROTECT. DEVICE:
— FLOOR. RUDE. AREA. COND.
STORIES
TYPE CONSTRUCTION
..tion, as provided for by Section 3700of the hent CMB. for'he performance of the
work for which thio permit isissued.
FIXTURES — PER TRAP
GAS — EA. SYSTEM-] INC. 4 OU'111..75
1 have and will maintain Workers Compensation Insurance. as required by Section
37M of the Labor Code, for the perfomancc of he work for which this permit is issued.
(ICC. GROUP
APN
GAS — U.N. SYSTEM"OVER 41EA)
el
,�aWorkers Compensation Insurance carrier and Policy number art:
Carries Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GRIiASU1NDUSTHL WAS Go INI'ERCIiYI'OR
BUILDING DIVISION FEES
GREASITRAP
1'L\NCHIiCK PEE
(This section need not be completed ifthe permit is for one hundred dollars(5Emd
or less.)
Ioyary'hm in the any manner of work which thisdneW res Cw shall
not employ any peoon in any manners am In Mcomc sxxeject o'he Workers Cumpen,
SEWER—SANITARY—STORM {iA.2IX1IT.
ENERGY IRE
WAIERHEATERW/VEiNTAFLECI'R
WATER $YSTF,M/TREATING
GRADING FEE
OZ
Z Q
gill
np
a
7 z
U2
sation Lim Idomla. Da f•C �Y
Applicant �n (.L.�
NOTICE TO APPLICANT: f�making this C�eme of Exemption, you should
become subject to the Workers Compensation provisions of the Labor Code. You most
forthwith comply withsueh provision, am this permit shall W dmmed revoked.
CONSTRUCTION LENDING AGENCY
I hereby arm that there is a construction lending agency the performance of
ffi
the work for which this permit is issued (Sec. 8091, Civ. C.)
Name
SOILS PEE
WATER S17RVICE
('AID
Uute Hcccipta
NEW RESIDENTIAL PLMB. SQ. Pf.
TOTAL:
I(TfAI..
QLender's
U
>- OW.
tt" In
U Z.
Lender. Address
BUILDING FIRS
1 certify that 1 have read this applicntion and stale that the above information is
correct. l agree to comply with all city and county oNininces and sate laws reining to
Wilding construction. and hereby authorise representatives ofthis city to enter union the
QTY. MF.CBANICALPERMI'p FEE
SIISMICITE
PERMIT' ISSUANCE
ELECTRIC I:L'E
above mentioned property for inspection purposes.
(We) agree to rove, indemnify aced keep hamdess the City of Cupertino against
Iiahilities,judgmetns,costs and expenses which may in any way some against said CityALTER
OR ADD TO MECIL
0__�
PLUMBING FEC
in consequence of the granting of this permit.
APPI.ICANT UNDERSTANDS AND WILL COMPLY WI"rli ALL NON -POINT
MECHANICAL Itlili
AIR HANDLINGUNI'I'1'TO 1 QJXXICEM)
SOURCE REGULATIONS.
_
AIR HANDLING OMIT (OVER IO(NN) CFM)
CONS'I'RUCTION 'fAX
Signadm AppllandCnntacmr It
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building ramistn tore or handle hasardou.s material
as defined b'W Cupertino Municipal Code . Chapter 9.12, and the Health and Safety
Code. Section 355321)?
EXHAUST HOOD(W/DUCT)
HOUSING MITIGATION FEE
BEATING ON] I'(fO 100,001 111' U)
HFAfINC. UNIT (OVER I00.0n)11'1'U)
V IN' I'lLAAION PAN (S INGLE RESI D)
L3 Yes E] No
PAID
Dna Reedit it
Will the applicant or future building occupant time equipment or devices which
emit hazardous air comaminunu as defined by the Bay Arca Air Quality Managmucnt
HfIILER — COMP (.(IIP ()if lIX1,IXX1 BTU)
T( "Ad,
BOILIR—COME' (OVER I PF,p I BIG)
District?
E3 Yes, No
I have mail the haiardaterialsL' under Chapter (JS I tile Call-
Nmaim GrainGraint & Safety Code Scf .-25505 25513 and 25594.1 hasound th t he
AIR CONDI' I'IONlilt
F�E.
ISSUANCE 1) 7i
�1
NEW BESIDES I'[At, MSCI I. SQ. PT.
building dnot curre lly have it mount, tht it is nly reNorimmilityt many tile "p' d
u1 the autumnal which mune W met prior to ssuame el a Ccm1 s.a tf OswpunyI
ISSUED BY'.
(lwnarmauthoriodegent . Dna
OFFICE