S 0668 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PE IT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL 0668
BUB.DING PROJECT tDENTIFICATIUN-
BUILDING ADDRELESS: SANITARY NO. APPLICATION SUBMITTADATE
�19 ,11
NER'S NAME: ONE: CONTBJIfOR'S N E:
NIC CONTROL#
AR CHITECT/ENGINEER: NO', ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDGPL,ECf PLUMB
LICENSED CONTRACTORS DECLARATION QTy ELECTRIC PERMIT FEE ❑ ` ",
I hereby affirm that 1 a.,licensed under pmdsions of chapter 9(commending JOB DESCRIPTION
WOO with Sevime (NNBdf)lvision3oOhe Buslnaes anti Pmfe lonsC de,and mylieense is RESIDENTIAL:
F lyr in full force Una eficer. PERMIT ISSl1ANCF. ❑SFDWL ❑KITCHEN REMODEL
�UZU License Class Lin#
0. Dam Contract... -APPLIANCESRESIDENTIAL
y Q ❑ADDITION El PLUMBING RE-PIPE
ARCHITECT'S DECLARATION ❑MULTIUNIT ❑STRUCTURAL.
G Z� .. I understand my plans shall be used us public records PANELS
MODIFICATION
UPT02MAMPS
O ❑INTERIOR ❑CHIMNEY REPAIR
P4Licensed Professional 201-1000AMPS MPROVEMEW EJ SWIMMING POOLS
a OWNER-BUILDER DECLARATION (NI(IAMPS H REMODEUREPAIR TODEMOLITION
I hereby affirm that 1 am exempt formmthe Contractors License Law for the OVER I
�j d U following reason.(---lion]Ul LS,Business and Pmfcssions Code:Any city or county SIGNS ELECTRICAL OTHER
(' 3 O yFy which requires a permit to amstrum altea improve,denmlish,or repair any swmure
prior to its Issuance,also mquims the applicant for such permit to rile a signed smlvemat SPECIALCIRCUI'PMISC.
yQ� that he is licensed pursuant In the provisions of the Contractor's License Law Chapter
apo (commencing with Section 7")of Division 3 of the nosiness and Professions Code)or TEMP.M ETER OR POLE I)V� COMMERCIAL:
0.y a t6 that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Wim Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
FZis a.,tame than five hundred doll.,,(S50d. 471non7 IMPROVEMENT
QF1 1,as owner of the pospedy,or my employees with wages as their sole comperealion, SWIMMING POOL ELECIRK 4_71
will do the work and the stmcmm is not intended muffetea fersale(Sec.]044,Busin.ss OTHP.R
4i 3m and Profession,Cc&:The Contmdors License Law does not apply man owner of OUTLETS-SWITCHES-FIXTURE
.. property who builds or impmves thereon,and who does such work himself or through
his own employees,provided that such impmvemndts are not intended or offered for NEW RESIDENTIAL EJECTS
sale.Jr.however.the building or improvement is sold within one year of completion,the
5(,�Pf.FLUOR AREA $/SQ.FT.
owner-builder will have the burden of proving that he did not build or improve for p n, P✓ apY
Is of soled.
of the property,..exclusively outtraeting with licensed emitracmn to TOTAL:
nas,N��me prpiem-sen 7044.Baxmexrs,ma anreaxidnx eneeH The enmranor.Li-
cense Law does not apply to an owner of property whe builds or improves thereon,and QTY, PLUMBING PERMIT FEE
who contracts for such projects with a commcums)licensed pursuant o the Contractors
License Law. PERMIT I--DANCE I f �ll"'
E]l am exempt under Sec. ,B&P C fn this reason (,UNtHr'1
NQ
ALTER-DRAIN&VENT-WATER(PA) VALUATION
Owner If
WORKER'S COMPENSATION DECL ATION BACK FLOW PROTECT.DEVICE OA1/1 1
I thereby.111.under penalty of parJury one of the following decl.mtion: lV/�V
el
0 lhave and will maintain a Certificate of Consent toself-insure for Worker's Comped- DRAINS-FLUOR,ROOF AREA,COND, STORIES TYPECONSTRUCTION
salon,as provided for by Section 37M of the Labor Code,for the performance of Nc
work for which this permit Is issued. FIX9'URES-PER TRAP
❑ I have and will mitimain Worker's Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My Workers Compensation Insurance carrier and Policy number are.
Carrier: Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASETSIDUSTRL WASTE INTERCEPTOR
finis section need not be,completed Ifthe permit is for one hundred dollars($100) BUILDING DIVISION PUBS
or IesxJ GREASG'BAP PLANCHECK FEE
I-edify that in the performance ofthe work derwhich this permit is issued,Ishall SEWER-SANITARY-STORM EA.200 FT
not employ any person in any manner so as m become subject m the Wnrkerx'Compcn- ENERGY FEE
O Z satins Laws of California.Date WATER 1{ET/
ATER W/VENELECTR
Z Q Applicant GRADING FEE
tr VI NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTFXFTREATING
a [' become subject to the Wnrkerx Compensation provision of the Labor Code,you nun SOILS FEE 1101
W ry forthwith enmpy,with such provisions or this permit shall he deemed revoked. - WATER SERVICE
Q
CONSTRUCTION is.e o LGNDINGAGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
V I for
rwhich rte that there issed(Sec.30lending agency for the performance of D -cele#
Iz.0 F the Leaders Name
which this permit is issued(Sec.309],Civ.CJ
Lender's Nume TOTAL:
w Lender's Address TOTAL:
1 certify that 1 have read this application anA stale that the above infomtation is BUILDING ti
ZV7) correct.l agree marmply with all city and county ordinances and state lmv,,micang a. QTY, MECHANICAL PERMIT FEE
V building construction,and hereby outer representatives of this city to enter mann the SEISMICFEE
a oo e-mentioned p.,dy for inspection pareses.
(We)agree 1.save,indemnify and keep harmless the City of Cmpedlm against PERMIT ISSUANCE ELECTRIC FEE
liabilities,judgments,casts and expenses which may in any way acerae against said City ALTER OR ADD TO SUCH.
in mrsequence of the granting of this permit. PLUMBING FE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CPM) 71
SOU�RsCE!l,9PULATIONS - w ? " IOMECHANICAL. 'EF.
// w �� /Lim .2?- AIR HANDLING UNITVER I0JA0CFM) CONSTRUCTION TA
Madmen plerm/Contmemr 111 7 Date 7 EXHAUST HOOD(W/DUCT) HOUSING MITIGATION PEEN
MATERIALS DI Of USURP
Will the applicant or future building occupant smrc or handle hacanluvs mannal HEATING UNIT TO I Of(IOft BTU)
as defined by the CuPer im Municipal Cede,Chirpier 9.12,and the Health and Safety
Gale,Section 25532(.)1 HEATING UNIT(OVER 100,0110 BN)
E]Yes ❑No VENTILATION FAN(SINGLE RESID) PAID --
Date Receipt#
Willes aircappintamiant rfmure building occupier Bayse Area
Air Qualitment(it y
.nagees ant BOILER-COME(3HP OR 100,000 BTU)
emit haaordnus air contaminants as Aef sed by the Buy Area Air Quality Mnnagemem TOTAL:
Dislricf?
❑Yes No BOILER-COME(OVER I00,00013'put
1 have mad the hazardous materiels requirements under Chapter 6.95 of the Call- AIR CONDITIONER ISSUANCE DATE
fnmia Health&Safety Cade,Section 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL.MECH. SQ.FP
building docs not carnally have a tenant,that it is my responsibility to notify the occupant
of the c,tournarts which most be mel prior to is....ce of.Cediticate of Occupancy.
Owner or authorized agent Date TOTAL: ISSUED BY:
OFFICE