S 2426 (2)APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL,
PERMIT NO.
BUILDING DIVISION APPLICATIONgaERMIT PLUMBING - MECHANICAL
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BUILDING PRUJh1Cr IDENTIFICATION
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BUILDINGADDRESS:
C/ S
SANfI'ARY NO.
APPLICATION SUBMITTAL DATE
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OWNsR$NAME:
PHONE:
CON'TRACTOR'S NAME. LIC NO,
NIC
❑
COM'ROL#
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ARCHI I hCULNGINHER: LIC NO:
AUD i
CONTAcr: / PHONE:
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❑ Consultant Fees Paid by Applicant(Initial)
BUILDING PERMIT INFO
HI.M ELECT PLUMB MECH
f' ❑ ❑ El
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I em licensed under provisions of Chapter v (commencing
with Section 700(1pd Division3 ofthc Business and Professions Code, and my license is
intent force and effect,
LicenLie# //242.1y
] Das .c Clas
9r^. oN
QTy ELECTRIC PERMIT FEE
JOB DESCRIPTION
RESIDENTIAL:
❑SFDWL [I KITCHEN REMODEL
[]ADDITION El PLUMBING RE -PIPIT
❑MULTI -UNIT El STRUCTURAL
MODIFICATION
❑INTERIOR El CHIMNEY REPAIR
IMPROVEMENT
❑DEMOLIPOOLS
ElBATHREMODEIIRF.PAIR ❑ DEMOLITION
❑ OTHER
PERMIT ISSUANCE
APPLIANCESr RESIDIiNT1Al.
ARCHRECPS DECLARATION
T'S DELL RATION
I understand my plane shall be used as public records
PANELS
UP TO 2o0 AMPS
Leer sed Pmmeoroul
OWNER -BUILDER DE CLARATION
1 hereby uflirm that 10m exempt from the Contractors Licemc Law for the
following hours. (Section 7031.5, Business and Professions Code: Any city or county
organs' a permit to conswct, alter, impsvq demolish, m repair any suucwre
201-1000AMPS
OVER IIMNI AMI'3
SIGNS ELECTRICAL
Swhich
prior to its issuance, odor requires the applicant lir such permit to rile a signed statement
Nat he is licensed iar'uanno the prnommi o ml Contractors License Law (Chapsr 9
(commencing wird Sood..l0(Xpof Div,tes. 3 ofrhe Business and possessions Cde)or
4 that he is exempt therefrom and the basis for the alleged exemption, Any violation of
Section 0031.5 by any applicant for a permit subjects the applicant to a civil penally of
not more than five hundred dollars ($50%
SPECIAL CIRCUIT/M13C.
TEMP. METER OR POLE[NST.
COMMERCIAL:
❑ NEW BLDG/ADDITIONLJ DEMOLITION
[]TENANT ❑FOODSERVICE
POWER DEVICES
SWIMMING POLL ELECTRIC
GOTTEN S -SWITCHES- FIM URES
❑f ...... c, of the poopeny,rr my employees with wageses their sole compeh,wion,
will do the work, and the suucmre is not inteded oroBered for vale (Ser. T(ILt. Business
3 and Professions Cale: The Contractor's License Law aces not apply to an owner of
IMPROVEMENT
❑ OTHER
propery who builds or impmwez thereon, and who does such work himself or through
his own employes provided that such improvements am on intended or offered for
NEW RESIDENTIAL ELECTR SQ FT.
sale. If. however. the building or improvement is sold within one year ofcompletion,the
neobuilder will have the burden mf proving that he did not build or improve fir par -
pose of sale.).
SQ. FT. FLOOR AREA
5/SQ. FT.
TOTAL:
❑ I, its owner of the prnpmX am exclu.ively contracting with licensed conmanmrs to
on'vua rho project (Seo. FWJ. Business and Pmfeszlorn Calc:) The Conaaaor's Li-
_
QTY, PLUMBING PERMIT
censelaedoesnotapplytoanownerofpropcnywhobuildsorimprovesthemon.and
who contracts fo,m h projecrn with u cananctar(a) liccnved pursuant m the Contractors
1'ERMII' ISSUANCE
License law.
E]1 am exempt de
pt unr Sec , R & P C for this .,on
ALTER - DRAIN & VENT -WAI'ER(F.AI
Owner Dom
VALUAI'ION�
WORKERS COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declara ions
BACK PLOW PRtiT[Cf. DEVICE
DRAINS- FLOOR, RODE AREA, COND.
❑ I have and will maintain a Certificate of Comenrso sclr-insure for Workers Compch-
nation, as provided for by Section 37M of the Labor Cale, for the performance of the
STORIES
TYPE CONSTRUCTION
FIXTURES -PER TRAP
work sof whall his permit iN Izsud.
[I I have and will maintain Worker's Compensation Insurance, as required by Section
370(the Lahr Code, forme performance of the work for which this permit is isrd.
Worker's Cumpensaim. Insurance cr rrier and Policy number are:
GAS - EA. SYS'T'EM -I INC. 4 OUTLETS
OCC. GROUP
MIN
GAS - LA. SYSTHM-OVER 4 (ITA)
Carrico Policy Na:
CERTIFICATE OF EXEMPTION FROM WORKERS'
OREASE(INDUSTRL WASTE INTERCEPTOR
COMPENSIO]ON INSURANCE
section ncd not M1emmplesd him, permit is micro hundred dollars (S 100)
or les .)
Irmify thet in the performance of the work for which this permit is issued, ].shall
not employ, any person in any manner m as to become subject m the Workers' Co ntim-
slash Laws of California. Dam
Applicant
BUILDING DIVISION FEES
I GREA$ETRAP
PLANCHECK FEL'
SEWER - SANI'T'ARY - ST IA. 21X1F.
GY ITE
WATER HEATER W/VENT ' ' R
DING ITE
NOTICE TO APPLICANT. If, after making this Cli iGcate of Exemption, you should
hernme subject to the Worker's Compensation previsions of the Labor Chole, you must
WATER 3YSTEh1/I'RFATI
LS PEI:
forthwith comply with such provisions or this farm, shall he deemed revoked.
WATER SERVICE
CONSTRUCTION [.ENDING AGENCY
1 hereby affirm that is a conswctinn lending agency lir Ne performance of
TO
Receipt a
NEW RESIDEM'IAL PLJFPV SQ. IT.
the work for which this permit is issued (Sec. 3ala,, Civ, C.)
Lenders None
TOTAL:
Loader'' Add...
TOTAL:
_
BUTT.
17,
I renify that I have read this application and slate dual she above information is
MECHANICAL PERMIT FEF.
creel l agree to comply with all city and county ordinances and state lows relating mQTg
building consoucdon, and hereby uniform representatives of this city it) enter upon the
SIiISMIC I> '
O
above-mentiond property for inspation pumxmes.
(Wo) agree 41 save, indemnify and keep harmless. the City of Cupertino against
PERMIT ISSUANCE
171-EMRl . FEE
liabilities,judgments, costs and expenses which may in any way arcane against said City
in consequence of the granting of this permit.
ALTER ORADDTO MECH.
I'I.UMBI FEE
A IR HANDLI NO UNIT TO 10010 CFM)
APPLICANT UNDERSTANDS AND WILL COMPLY WHH ALL NON -POINT
SOU RCE REGULATIONS.
MECHANIC FETE
AIR HANDLING UNIT (OVER 10.000 CIM)
CONSTRUCTION TAX
EXHAUSTHOOD(W/DUCT)
Signet Ap icans/Consmcmr Date
HAZARDOUS MATERIALS DISCLOSURE.
HOUSING MITIGATION FEE
I (EATING UNIT(TO 100,000 BTI[)
Will ase applicant or sutura building occupant sore or handle haaardsus material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code , Section 25532(0)7
HEATING UNIT (OVER 100,00D BTU)
❑Yes To
I
Will the applicant or furore building ache pt. me equipment or devices which
chairDam
el havadmi
uus air enntanamx as defined by the Bay Area Air Quality ManagementT
Digria!
PAID
ENTIL
VATION PAN (SINGLEkIS1U)
Rccc' N
.
IIOILFR-COMP (311P OR 1001( i BT'U)
BOILER - COME (OVER 100,0110 BTU)
[I Yes, I`11�y-
AIR CONDITIONER
W
I have read the ha oes masseurs
I5, 2553 an under , 1 and 6.95 of Cali-
(oris.,dre, Health &Safety Cde,Section.25505,2sor,and25531.1 un deny ththatifthe
building dues not cuwhich have are nons, that o is my ce of a billly s notify the per,
of the rryuiremrnu which rams bo met prior to issuance of a Cenificas of orrupancy.
ISSUANCE DATE
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//
ISSUED BY:
NEW RIiSIUfiNT1AL MECH. SQ.IT.
d
Owner or authonaagent Date
TOTAL:
OFFICE