S 2321APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN
CITY OF CUPERTINO BUILDING'
BUILDING DIVISION APPI.ICATIONlPERMYP PLUMBING.
BUILDING PR(1JE"
BUILDING ADDRESS'.
H(41 Ya(Lt/_SNIeE 1btZ
CONTACT:
❑ Consultant Fccs Paid by Applicant (Initial)
1 hereby vffimt that 1 out licensed under provisions of Chapter 9 r'commencing
Dao with Section 71X10) of Division 3 of the Business and Potassium Cale, and my limnse is
��� infall aa' r(em 1031$37
QUZU Licenseoas Lisp
yd ul Dvte Comm
0.
ABOUT EC'S DECLARATION
FO m Z 1 understand my plans shall he used as public records
Z,_
�.F.. W Licensed Professional
y,F,; OWNER -BUILDER DECLARATION
5 Q 1 hereby affirm that I am exempt from the Corral License Law for the
0. U following reason. (Section 7031.5, Business and Profession, Cale: Any city or cnumy
tL y which requires v permit to construct, alter, improve, demolish, or repair any umemre
�Q prior to itsissuance,also requires the applieem for such pernirto rile v signed statement
that he is licensed pursuantotheprovidonsoftheContmcmrsLicense Law (Clmptar9
(commencing with Section]0(10)ofDivisinn3oflhe Bmitmssand l'mfesnim Gyred Sar
d ner that he is exempt therefrom and the hasis for the alleged exemption. Any violation of
,-� Section]031.5 by any applicant rot a pemtii subjects the applicant tut a civil penalty of
not more than five hundred dollars ($500A
zC ❑ I, as owner of the property, or my employees with wages as their sole corn,unetion.
will do dor work, and the structure is not intended or offered for sale (Sm. 700, Business
Wa.. ass and Profession, Code: The Courtrai License Lew does not apply to an owner of
3.. property who builds or imprwes thereon, and who Jaes such work himself Sar @rough
his own employees, provided that such improvements arc not intended is, offered for
sale. IL howeem the building or improvement is sold within one year o eranplcium, the
cr-builder, will have the burden of proving that he indoor build or improve for par
pose ofsnIcA
❑ 1, as owner of the property, am exclusively contracting ssith licensed contractors to
onswct the project (Sec. 76I4, Business and Professions Code:) tnra
'Ibc Coi Li.
cent Law does not apply to an oxver of property who builds or imlmrves hereon, and QTY.
who contracts for uch projects with a comrwamen licensed purr om ut the Contractor's
License Law.
❑ I am exempt under Sec. . B & P C for his act
Owner Uv
_ WORKER'S COMPENSATION DECLARXI'[ON
t the ehy affirm under penalty of perjury one of the following declarations:
I] I hm :eld %i mainhin a Ceni tevte ofConsem m sd Ginsum for Workcr s Coiti en-
sation, as provided for by Section 37W of the Lahur Cale, for the performance of the
work for which this permit is issued,
❑ I have and mill maintain W'orker's Compensation Insurance, as required by Section
37W of the Labor Cale, for he pm ommnce of the work for which this permit is issued.
My Work is�o mpen�ation In u�ayce carrier and Policy n
Carrier lllllO-�M AI7U�V Pohey Na: �l 168 aitt
CERTIFICATE OF EKESIPB'ION FROM WORKERS'
COhIPENSXi'ION INSURANCE
Obis section need not be completed it he permit is for one hundred dollars R laid
M less.)
1 minify that in the performance ofthe wad for which this permit is issued, I shall
not employ any person in any manner sn as s.7 nyic •u ljem In Ibe Workeri Cnm en -
z cation Laws of CC fjo D '/
ZO Applicar�— �' P
fn NOTICE TO APPLICANT: If, after making 174, Ceniticate of Exemption, you should
become subject to the Worker's Compensation provisions of the Labra Cale, you roust
fnMwilh comply with such prmvWoo, or this permit shall he deened rmoked.
0. Q
CONSTRUCTION LENDING AGENCY
L) Q I hereby nfErm that here is a construction lending agency for the performance of
the work for which this permit is issued (Sec. EAT. Civ. C.)
O ULender's Name
ULenders Address
d I certify arm 1 have real this appl!eminn and one that the above inhmnmiou is
iFi Vi correct. I agree to comply with all city and county ordinunce.xand state lows relatingm QTY
L) Z building consauction, and hereby authorize representatives of his city at enter upon the
above-mentioned property for inspersion purposes.
(We) agree to save, indrsnnify and keep burndexs the City of Culwnino against
lisbllities,jmdgments, costs and expenses which may in any way acme against said City
in me,mante ofthe gramin, nfthis permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS.
Signature of ApplicunVCo tract Date
I IA9ARDOUS MATERIALS DISCLOSURE
Wil] the t"licom or future huddling ceeupant nlme or handle hnr.SaMons material
Sas defined by the Capmim Municipal Cale, Chapter Q.12. and the health and Safety
Cada, Section 25532m)7
E] Yes [:J No
�Will the applicant est ISome building accupam use equlpmmnt of devices which m' hazardous air contaminants as defined by the Buy Area Air Quality Managensnl
(district'!
E] yes E] ski
I have read the hazeni s malenals raiuineneents SanderChapter 195 est the Cram
Tama a He lth & Sa@ty Cale, Sections 25545, 25533 and 25534, 1 undead I (hal If the
huilding docs mmurrectly have a marl, that it Is my resrymsiNb by to notify the m<up:u r
of the re,marrenls which mull he met prier or Issuance of a Ceti Ocam of Occupancy.
Owner or otdhon zed agent Date
ELECTRIC PERMIT
PERM Ir ISS UA NCE
APPLIANCES - REST DENG Ah
PANELS
UP TO 200 AMPS
201-1003AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC.
TEAM METER OR POLH INS'i',
POWER DID11CFS
SWIMMING PULL 1:11101: VRIC
OUTLIUS-Ss ITIS -11 %TURNS
BE RESIDITNTA171iiR
PLUMBING
PERMIT ISSUANCE 11
ALTER - DRAIN & VIiNT- WATER HQG
BACK FLOW PROTECT. DEVICE
DRAINS - FLOOR, RO(lh, AHPsA. COND.
FIKTURfS - PER TRAP
GAS - EA, SYSB'I!M-I INC.4 OUTLETS
GAS - I!A. SYSTFM-OVI:R 4 (HA)
GREASHJINDUSTR1, WASTE IN'I ERCEK
GREASETRAP
SEWER - SANITARY - SI ORM E. I
WATER IE7AT17R WIVLNB'/ELECI'
WA'1'HR SYS 'I EM/IREXI'INC.
WAIT SERVICE t-;
NEW RIiSIDENTIAl. 1'LMO,
MECHANICAL. PERMIT
SQ T.-ir
PERMIT ISSUANCE „
ALI ER OR ADD 10 MECH.
AIR HANDLING U llI(TO 10.0g) CUM)
AIR HANDLING UNIT '1'(OVER 10,010 CITU
EXHAUST HOOD (W/DUCT)
HEAHNO UNN CID 100.0001111J) /2-
1 I EATING LINTT(OVER IOO.(Hill ITI'(B
VEN'I'I LAI ]ON FAN (SINGLE RESID)
1H (LER-COMP(311POR 100.000II7U)
BOIL( 0. -COMP (OVER I W,mun in'I'(B
AIR CONDITIONER
NEW RESIDENTIAL MECH. SQ. FI.
OFFICE
950
❑
11 ISMICFII
BUILDING PERMIT INFO
BLDG ELECT PLUMB ML�C{Ii
❑ ❑ ❑ Ll
FEE
JOB DESCRIPTION
RESIDFNTIAId
❑SFDWI, ❑ KITCHEN REMODEL
❑ADDITION [I PLUMBING RE -PIPE
❑MUUTLUNIT ❑STRUCTURAL
MODIFICATION
❑INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT ElSWIMMING POOLS
❑ BATH RFMODEIIREPAIR ❑ DEMOLITION
❑ OTHER
COMMERCIAL:
❑NIiW BLDG/ADDITION El DEMOLITION
01 HNANT ❑ FOOD SERVICE
IMPROVEMENT
❑ OTHER
FEF
KY.TIRYb#t
RYCUBIIM
FEE
FEF
BUILDING FEE
11 ISMICFII
ELECT RIC FEE
PLUMBING PGE
MECHANICAL DTH.
1.1
HOUSING MITIGATION PEE i
PAID
Date Receipt#
BY:IIY'
SISQ. P.