S 1070 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY y/
CITY OF CUPERTINO BUILWNG-ELECTRICAL PERMITNO. ,X O 1 O
BUILDING DIVISION APPLICATIONIPF,RMIT PLUMBING-MECHANICAL. S Il
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: - SANITARY NO. APPLICATION SUBMITTAL DATE
OWNER'S NAM`:, PHONE: ONTRACTOR'SNAME: �TR LT/b LIC,O.
NIC CONTROLN
A HIT /1!NGINEE LIC O: AUDKelY ❑
v� 6
CONTACT. PHONE: BUILDING PERMIT INFO
h U '�n ❑ Consultant Fees Paid by Applicant(Initial) BLDG LEC'1' PLUMB MECH
GIC zC C�� Cif OY�VA ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE JOB DESCRIPTION
I hereby alfrm That I am licenmd ander pmvisions of Chapter Y(commencing
oaZ with Semion]0W)of❑ivisiun tofthe Bminns and PrefessiansCode,and ylicense is
RESIDENTIAL,
u1 O O PERMIT
IS
F-W.. infill force vnJ effec�AICIU �IS`DECLARA
❑SFDWL ❑KITCHEN REMODEL.
License Class Lic.p gPPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE
W Dam Corac'or
ZCQ' ON PANELS ❑MULTI-UNIT ❑STRUCTURAL
�2 1undershindmans sh M used a public records MODIFICATION
OZ O UPTO200AMPS ❑INTERIOR ❑CHIMNEY REPAIR
P:4 :WWW Livened Professional 201-1000AMPS IMPROVEMENT E)SWIMMING POOLS .
S y OWNER-BUILDER DECLARATION OVER IgOAMPS [I BATH RF•MODEIJREPAIR El DEMOLITION
L a 1 hm ereby eM.that I aexempt from the Contractor's License Luw far the
O 6 U following reason.(Section 7031.5.Business and Professions Calc:Any city or county SIGNS ELECTRICAL ❑MH17R.
which m,mr,,a pem'il o,conswcn,almr,impmve,demolish,or repair any fracture
prior to its is...smalso requires the.ppticant for such permit to file.sigmedumemem SPECIAL CIRCU ITM ISC.
'!,!s�1� that he is licensed pursuant to the provisions of Ne Conuudors Licen.w law(a ter9
W^00 Icommencingwith Sedion]O00)nfDivisionJof the Business and Professions Gde)or TEMP.MITER OR POLL INST. OOMMFHCIAL;
CL y pC that he is exempt headman and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
LLX1 uy
Section 7031.5 by any applicant for a permir"objects the applicant o a civil penalty of POWER DEVICES C1TENANT ❑FOOD SERVICE
rs � not more than Eve hundred dollars(S50B. IMPROVEMENT
❑I,os ownerol the propeny,or my cmpinyees with wages as thcirwdc mmpensmion, SWIMMING POOL ELECTRIC OTHER
will do the work,and the slmLlure is net intended ari fferW for sale(Sec.7010.Business
G a� and Professions Cade:The Contractor's License law does not apply In ua owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon,and who does such work himself or through
his own cmployecs,provided thin such improvements am not intended or offered for NEW RESIDENTIAL ELECfR SQ IT
sule.ILhowever the buildingorprom
improvement is sold within one year ofcompletion,the - SQ. FLUOR SISQ.IT.
• .
owner-builder will hthe burden of proving N.,he did not build or impmve fur pur-
poseofseleJ. ave rd
S.� P A 1 D
I,as owner of the propeny,am exclusively contracting with licensed contractors to 'TOTAL:
❑
nsuua the project(Sec.70,10,Business.rad Professions CMe:)'I no Contmcmrs Li-
momLawdoesnotapplytoanownerofpmpenywhobuildsorimprovesthereon,and QTY, PLUMBING PERMIT FEE OCT 24
who commas for such projects with a conavcmr(s)licensed foutront oche Contracme, D[' V
License law. PERMIT ISSUANCE R[
1 am exempt under Sa. .B&P C far Nis reason r ��qv pN
Owner Date
ALTER-DRAIN&VENT-WATTiRTGA) "l"MItyu
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby off rm We,penalty of is jury one of the following declarations:
❑I have and will maintain aCeniticam of Consent toself-insure for Workers Contpen- DRAINS-FLOOR.ROOF,AREA,COND. STORIES TYPE C(INSTRUCI'ION
ration,ua provided rot by Secrinn 37M of the Ubsur Code,for the.....ratan..of the
work for which this permit is issues. FIXTURES-PER TRAP
❑I have end will mostrim Worxers Compensation Insurance,as required by Section
3700 of the Jaber Code,for the pedomaneeufthe work far which this permit is issued. GAS-F.A.SYSTEM-I INC.,OUTLETS OCC.GROUP APN
My Worker's Compensation Insurance corner and Policy number am:
Carder: Policy No.: GAS-1!A.SYSTEM OVER 4(EA)
CERTIFICATE OF EXEMPTION MOM WOR KERS GRBASIIINDUSTRL WASTE IN UIRCEPPOR
COMPENSATION INSURANCE BUILDING DIVISION PLEB
(Thus sectionnced nmbe completed iflIm Matto is fimmuchundreddolDrs(f1IX) GREASETRAP
PLANCHF.CK FEE
m less.)
Imitify that in the perforrommeofthe work for which this permit is issued,Isholl SEWER-SANITARY-S IORM RA.2001T.
non employ any person in any manner so as to become subject to the Workers'Compen, ENI!RGY PEC
,z onion Laws of California,Dam WATER HEATER WNLNT/ELECTR
z Applicant l GRADING THE
y NOTICE TO APPLICANT:If,after making this Cenifcate of Exemption,you should WATER SYSTEMORCATING
a become subject to the Worker's Compensation provisions of the Labor Code,you must SOILS FEE
fonhwith comply with,dm pmvisions or this permit shall be deemed rooked. WATER SERVICE
Pr CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.Fr. PAID I te ceipt
L)Q Ihereby affirm thin the.is vcsnrsauction lending agency terrific Performance of
rthe work for which this permit is issued(Sec.3107,Civ.C.) ig
I..) Lenders Name
W lender's Address TOTAL:
4 I certify that I have read this apphcmion and smte rhm the abuse information is BUILDING FEE
".w Ncoram.l agree to comply with all city and county ordinances and shim laws relining rat QTY. MECHANICAL PERMIT FEE
U G building construction,and hereby auNmise mlimsenlativesof this city to enter upon the SEISMIC F'.
7
above mentioned propeny for inspection purposes. PERMIT ISSUANCE ELF. IC FEE
(We)agree to save,indemnify and keep harmless the City of Cupenin r against
Hid ilities,jidgmems,crosrs and expenses which may inany way accroeripinf said City ALTER OR ADD TO MECH. PLOMNI EC
in consequence of the gmn0ng of'his pemtit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNITOOHLO0CFM) MECHANICAL E
SOURCE REGU T
AI R HANDLING UNITUVER I0.0(0CF7,I) CONSTRUCTION
Signature of pplicaDDate EXHAUST HOOD(WIDDCT) HOUSING MITIGAI'I FEE
HAZARDOUS MATERIALS DISCLOSURE
i Will the applicant or fuwmbuilding occupant.tore or handle haswdous material HEATING UNIT(TO I00,00I1 BTU)
ss defined by the Cuperino Municipal Cade,Chapter 9.12,trod the Health and Safety
Code.Section 25532(a)t HEATING UNIT(OVER 1'XI,0016'IV)
❑Yes ❑No VENTILATION FAN(SINGLE RESID) PAID -'
Date Racip'X
Will the applicant or future building occupant use eynipmem ur device,which BOILER-COMP(3HP OR100,00X1 BTU)
emit hamNm airucnmw
umints as defined by the Bay Area Air Quality Management TO'T'AL:
District] BOILER-COMP(OVER oLMOBTU)
❑Yes ❑No
I have read the brerdous mnmriala mcparemenes under Charter fi95 efdre Cali. AIR CONDITIONER ISSUANCE DATE
forma Health&Safety Code,Sections 25505,8533 it 25530.1 understand that if Ne NEW RESIDENTIAL MECH. SQ.FT.
building Jaen rad curen0y has a moan',that it is my respormibilhy m ramify the secupam
of the rgeiremen's which mustbeton priormissu�nee afv Cenifcme nr Occupancy.
Owner or amhori and agent Date TOTAL:
ISSUED BV:
OFFICE