99100030 (2)APPLICANTTO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
�.IT,Y OF,CUPERTINO BUILDING-F.LF.CTRICAI.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING -MECHANICAL
BUILDING PROJF:CTIDENTIFICATION
D_�') PERMITNO.
o
BUILDING ADDRESS: .
SANITARY NO.
APPLICATION SUBMITTAL. DATE
a a
WNER'S NA 2 PRONE
lies
CHITECIE GINEER: LIC NO:
CONTRA OR'S NAME : LIC NO:
ADDRESS 13IV
N/C
❑
CONTROL is
CONTACT`. PHONE:
BUILDING PERMIT INFO
�s
- ♦��-Q�
❑ Consultant Fees Paid by Applicant (Initial)
BLDG ELECTPLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
later, mRral I am licensed under pmvisions of chapter 9 (commencing
I nem m
QTY, ELECTRIC PERMIT FEE
JOB DESCRIPTION
PERMIT ISSUANCE
with Seaton 700(uof Division 3af the Bmiresxand Professions Cafe, and my license 111\
sRFS�
in full force e t. ant
RESIDENTIAL'
❑SFDWL ❑ KITCHEN REMODEL
PTI
PLIANCES-RESIDENAL
Licene Cmrh
❑ADDITION ❑ PLUMBING RE -PIPE
❑MULTI -UNIT ❑STRUCTURAL
MODIFICATION
❑CHIMNEY REPAIR
IMPROVEMENT ElSWIMMING POOLS
ARCHITECT'S DECLARATION
1 understand my plans shall he used as pudic rccoNsMODIFICATION
pp y
UP 9'02 AMPS
Licensed Professional
201-I"Aft
OWNER BUILDER DECLARATION------
1 hereby affirm that 1 am exempt from the Contractor's License Law for the
following reason. (Section 7031.5. Business and Professions Code: Any city or coemy
El BATH REMODEUREPAIR [I DEMOLITION
1 VVIR f�
---
SIGNS ELECTRICAL
which requires a permit to construct, alter, improve, demolish, or repair any strvewre
r
prior to its issuance, also mquims out applicant forsuch Permit o file a signed gsument
SPECIAL CIRCUIT/MISC.
that he is licensed pursuant to the provisions of the Conuucmr's License Law (Ch-,.-. 9
(commencing with Section 7")of Division3 of the Business and Professions Code)or
TEMP METER OR POLE INST.
COMMERCIAL:
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
❑ NEW BLDG/ADDITION ❑ DEMOLITION
POWER DEVICES
Section 7031,5 by any applicant for a permit subjects the applicant to o civil penalty of
f are than five hundred dollars (SSW),
' El 1, as owner of the property, or my employees with wages n theirsom compensation,
1 will do the work, and the structure, is not intended or offered for sale(See7146, Business
❑TENANT ❑ FOOD SERVICE
IMPROVEMENT
❑OTHER
SWIMMING FOOL ELECTRIC
i and Professions Code: The Contractor's License Law does not apply to an owner of
property who builds or improves thereon, and who does such work himself or through
his own employees, provided that such improvements are not intended or offered for
sale. If, however. the building or improvement issold within one year of completion.the
OUTLETS -SWITCHES -FIXTURES
NEW RESIDENTIAL ELEM SQ FT.
SQ. FT. FLOOR AREA
S/SQ. FT.
owner -builder will have Ne burden of proving that he did not build or improve for put.
❑ L ra owner of the property, em exclusively commmins with licensed cantmema to
1,v
Ler ma theproject (Sea .o(ma Businessand Professions Code:)The Cs thereon, nd
cense Law data not apply roam of whosedpds orimprovu
TY. PLUMHINGP
Cmurm.nd
isuriamrty
who cammds for such projects with aamtmnor(s)licensed pursnanun the Cnntmemrs
with
N PERMIT ISSUANCE
License Law.
❑ I am exempt under Sec. . B & P C for this reason
saner Date
AL :R-DRAIN&VENT-WATER(EA)
VALUATION
WORKER'S COMPENSATION DECLARATION
BACK OW PROTECT DF ' -n
I theah, aft rrn under penalty of perjury one of the following declarations:
I have and will maintain a Cerificate of Consent to self -insure for Worker's Cmnpem
cation, as provided for by Section 37M of the Labor Cade, for the performance of the
DRAINS- R. ROOF, AREA, COND.
STORIES
TYPE CONSTRUCTION
work far which this permit is issued.
FIXTURES - PE TRAP
❑ I have and will maintain Worker's Compensation Insurance, as required by Section
3900 of the Labol Cale, for the performance of the work for which this pemtitis issued.-
My Wmk atfgn%Q and Policy nu W
Carnet:=3C�r'k�'Y Policy No.:
I
GAS -EA. SYSTEMNC.4 OUTLETS
OCC. GROUP
APN
GAS-EA.SYSTEM-OV 4(EA)
GR E•ASF/INDUSTRL WASTE ERCEPTOR
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
-
BUILDING DIVISION FEES
(Thissecomr read not becomplered Hurt perurd is furore hundred dollar(SIM)
or less.)
GREASETRAP
PLANCHECK FEE
I crafty dhaln the performance of the work for which this permit is issued, Ishvll
not employ any person m any manner so as to become sahjauo the Warkerd Compars
SEWER -SANITARY -STORM EA.2 FL
ENERGY FEE
WATER HEATER W/VENT/ELECTR
OR FEE
' cation Laws of California. Date
Applicunr
NOTICE TO APPLICANT: IL after making this Certificate of Exemption, you should
become subject to use Worker's Compensation pmvisions of the Labor Code, you must
WATER SYSTENUTREATING
SOILS FEE
forthwith comply sodowch pmvisions or this permit,hell he deemed revoked.
WATER SERVICE
CONSTRUCTIONLtioDING AGENCY
� Thereby affirm lhauhemem isisaconstruction lending agency for the performance of
NEW RESIDENTIAL PLMB. SQ. PL
PAID
Date Receipt
TQTAI:
, the work for which this permit is issued (Sec. 3097, Co, C.)
' Lender's Name
TOTAL
Address
Lenders
is
-
BUILDING FEE
1 certify that 1 have read this application and sum that the above information
1 correct. I agree to comply with all city and county oninances and stare lows relatingto
building construction, and hereby authorize representatives of this city m enter upon the
QTY, MECHANICAL PERMIT FEE'
SEISMIC FEE V
PERMIT ISSUANCE
ELECTRIC FEE
above-mentioned property for inspection purposes.
(We) agree m save, indemnify and keep osmosis the City of Cupertino again
PLUMBING FEE
habilites,judgmems. costs and expenses which may in any wayvicemeagiinstsaid Uly
consequencein of the gamingt of this Permit.
ALTER OR ADD TO M ECH,
AIR HANDLING UNIT (I0 10,00) CFM)
MECHANICAL FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
CL REGU .ATIONS.
AIR HANDLING UNIT (OVER 10,1100 CFM)
CONSTRUCTION TAX
MEOU
4✓
Signature of ApplicaoVComtrast Dae
EXHAUST HOOD T WMUC)
HOUSING MITIGATION ME
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (T0100,IX100TU)
Will the applicant m for.. building oecsparl gore or land hanardous mmeri
as define) by the Capture. Municipal Cole, Chapter 912, and the Health and Safety
Cala, Section 25532(.)7 /
❑Yes ,(1,1 No
HEATINGUNIT(OVER 100,000 BTU)
PAID Dam Receiptp
VENTILATION PAN (SINGLE RESIDI
BOILER -COMP (3HP OR 100,000 BTU)
WII the applicant or future Wilding ..Paul use rquipmear m devices which
emit hauMous air contaminants as defined by the Bay Arca Air Quality Management
qL;
BOILER - COMP (OVER 100.000 BTU)
Dana?
❑Yes �No
AIR CONDITIONER
ISSUANCE DATE
I have ... ddie homarkas mammos requirements under Chapter 6.95 of the Cali-
NEW RESIDENTIAL MECH. SQ. pt.
Famous Health & Safety Code, Sections 25505, 25533 and 2553. 1 understand that if me
d ing does not c.mendy have a tenant, that it is my responsibility to notify the occupant
is n mquben rs which mu t be met pnm to issuance of ihcam of Or
ISSUEDBY: u�1,1'
TOTAL'
Owner or ... hammed .g.I Dart
OFFICE