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APPI IrANT'TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING -ELECTRICAL
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING -MECHANICAL
BUILDING PROJECT IDENTIFICATION
1 PERMIT NO.$ 0292 Z sJ Z
SOOOI
BUILDING ADDRESS:
SANITARY NO.
APPLICATION SUBMITTAL DATE
6
O ERSNAME: - / HONE: `
.T% ,✓ Ally
CONT I R'S NAME: < LIC NO:
(01Y
N/C
❑
CON'TROLN
ARCHITECWNGI -ER: LIC NO:
ADDRESS:
CONTACT; PHONE:
BUILDING PERMIT INFO _
❑ Consultant Fees Paid by Applicant (Initial)
BLDGELIiCf PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
I hereby aRrm that I atm licemaed undo previsions of Chapter 9 (commencing
QTY ELECTRIC PERMIT FEE
JOB DESCRIPTION
PERMIT ISSUANCE � y+
V
with Section 9000) of Division 3 of Ne Business and Professions Cufe,and my license is
in full forte and effect.
RESIDENTIAL'
❑SFUWI. L1 KITCHEN REMODEL.
APPLIANCES- RESIDENTIAL
PANELS
UPT0200 AMPS
License Class Lica
Date Contractor
El ADDITION E) PLUMBING RE -PIPE
❑MULTI -UNIT ❑MODCTURAATION
El INTERIOR El CHIMNEY REPAIR
IMPROVEMENT 0SWIMMING POOLS
ARCHITECTS DECLARATION
I understand my Plans shall he used as public records
Licensed Pmtesurnel
201-10MAMPS
OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Law for the
following reason. (Section 7031.5. Business and Professions Code: Any city or county
�lTAI'H REMODELBEPAIN [.3 DEMOLITION
❑ OTHER
OVER l01N)AMPS
SIGNS ELECTRICAL
which requires u permit to construct, alcor, improve, demolish, or ,an any structure
prior to its issuance, also requires the applicant for such permit to rile a signed statement
SPECIALCIRCULUMISC.
that he is licensed pursuant to the previsions of the Cunt actoes License Law (Chapter9
s
(commencing with Section 7000) of Division 3 ofthe Business and Professions Code)or
'1'EMIs. METER OR POLE INST.
COMMERCIAL:
that he is exempt therefrom and the basis for the alleged exemption, Any violation of
❑ NEW BLDG/ADDITION ❑ DEMOLITION
Section ]031.5 by any applicant for a permit subjects the applicant to a civil penalty of
mat more than five hundred dollars ($510).
❑ Lazowner of the property,.r mycmployees with wages os their sole compenuuon,
will do the work. and the smrqure is not intended or offered for sale (Sec. 70,14 Business
POWER DEVICES
[]'TENANT ❑ FOOD SERVICE
IMPROVEMENT
[]OTHER
SWIMMING POOL ELECTRIC
and Professions Code: The Contractor's License Law does not apply to on 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, Ihehuildingorimpmvemem issold within ma yearofcompletion. one
OUTLETS -SWITCHES -FIXTURES
NEW RESIDENTIAL EL1ECTR SQ I.T.
SQ. R
$/SQ. IT.
mer -builder will have the burden of proving that he did not build or improve for per,
poseof xalcj)
Fj I, sea owner of fee pmporty, oro exclusively contracting with licensed counsel., to
JUL D 8 AMID
TOTAL
construct the project (Sec. 904k Business and Professions Cml'Me Convert.,', Li-
nmelawdoesnetapplytoanow.m.fpmperty who builds or improves thereon, and
wh.conlfucls for such p ... jece with., conwmorim licensed purs ... twlhc Cmmuvewrs
QTY, PLUMBING PERMIT FEE
Citi Ur VUI'[RI«VlJ
PERMIT ISSUANCE
License Low.
I am exempt under Sec. , B & P C for Nis mason
V V
Owner Doe
WORKER'S COMPENSATION DECLARATION
ALTER - DRAIN & VENT- WAT ER (EA)
BACK FLOW PROTECT. DEVICE
VALUATION
J�
a/
1 hereby reffien under permlty of perjury one of the following derh mrioas:
-
Ihavc and will maintain aCertificam of Conrenuo self -insure for WnrkeYs Compen-
provided for by Section 3]00 of the Labor Code, for the rfowmmce of the
cation, as prope
work for which this permit is issued.
DRAINS- FLOOR, ROOF. AREA, COND.
STORIES
' TYPE CONSTNUCTION
FIXTURES - PER TRAP y
have and will maintain Workees Compensation Insurance, as required by Section
-
10ofthe laborCode, forthe p dor mnce of the work for which this permit is issued.
r"
GAS - EA. SYSTEM- I INC. 4 OUTLETS
OCC. GROUP
APN
My Worke?ComBenmtim In;y e�rrie Pondy N.,=
Comer. a, /I'DicZ
GAS-EA. SYSTEM-OV1iR 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GREASEIINDUSTRL WASTE INTERCEPTOR
BIIILUING DNISION PEES
(This section Dead not be completed iOhe permit is home, hundred dollms(SIM)
m less,) (This
GREASETRAP
HE, 6 v
leenify1tramlhe perlameaneeoflhe work for which thispeout is issuNJshall
not employ any person in any manner so as to become subject t. the Workers' Compen-
SEWER - SANITARY - STORM EA. 200 FT.
ENERGY FEE
WAT ER HEA'T'ER WNENT/ELECTR
WATER SYSTEMITREATING
satin. Laws of OOiformix. Date
Applicant l
NOTICE TO APPLICANT: If, after making his Cenificam of Exemption, you should
bee ne.whject to the Worker's Compensation pfovisions of the Lalnf Cade, you must
GRADING FTE
SOILS FEE
WATER SERVICE
f rmhwith comply with such provisions or or, permit shill W domed revoked.
CONSTRUCTION LENDING AGENCY
j Ihcreby effinn thanhere is acanswction lending agency for the ped.nnance of
NEW RESIDENTIAL PLMB. SQ, Fri.
PAID
Date Reccipma
I the work for which Oce permit is issued (ger. 3097. Ci, CJ
Lender's Name
1 Lender's Address
the information is
TOTAL,:
TOTAL:
BUILDING FEE
I certify that 1 have mad this application and swat that above
I comet. l agree to comply with all city and county ordinances and nam laws relating to
bt ilding ammorah n, and hereby uuthmirc reptesematives.l' this sky w rote, upon the
above-mentiomd prpeny for inspection purposes.
(We) agree to save, indemnify and keep mundess the City of Cupertino against
QTY, MECHANICAL PERMIT FEE
SEISMIC FEE
IVRMIT ISSUANCE
I
I ELECTRIC FEE
liabilities,judgments. costs and estimates which may in any way sucme against said City
in comequenea ofthe granting of this permit.
AL OR ADD TO MECH.
PLUMBING FEE 0
AIR HA LING UNIT(TO I0,0MCFM)
MECHANICAL FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WIFE ALL NON -POINT
SO - EREGULATIONS.
AIR HANDL GUNIT(OVER 111,1110 CPM)
CONSTRUCTION FAX
Si tore of ApplicanVCommemr are
HAZARDOUS MATERIALS DISCLOSURE
EXHAUST HOO Wmucri
HOUSING MITIGATIONIEE
I(EATING UNIT TO N,000 BTU)
Will the applicant or future building.ccupent store m handle hazvdous material
as defined by the Cupertino Municipal Code, Chapter 9. 12, and the Health and Satiety
Code. Section 25532(x)?
HEATING UNIT(OVER 1 (100 BTU)
El Yes F1 No
VENTILATION BAN(SINGLE 'SID)
PAID Date fteceipma
BOILER -COMP (31 if OR IOq(01 TU)
Will the applicant or future Wilding occupied use equipment m devices which
emit haseNous sir contaminants as defined by the Bay Arca Air Quality Management
TOTAL:
BOILER - COME (OVER 100,000 BTU
Di'°nct?
❑Yes ❑Nn
r.
AIR CONDITIONE0.
I love out Ore hw Nous materialsnyvirenenu under Chapter 6.95 of the Cali-
ISSUANCE DATE
NEW RESIDENTIAL MEC((. SQ.I
forma Health & Safety Code, Sections 25505.25533 and 25534.1 undemmnd that tithe
Ifo g d,xsnm curtendy have v ten ,that it is my responsibility tat notify the ovemem
of n, whichAtus'be t prion.' s of a Cenificam oJak
ISSUED BY:
TOTAL:
r motorman agent I I Date
C.,7— OFFICE