31243 (2)APPLICANTTO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN
CITY OF CUPERTINO BUIL ANG
BUILDING DIVISION APPLICATION/PERMIT PLUMBING•
I hereby afOmo Hm I am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 ufthe Business and Professions CCooddee, and on, license is
in full f Banda and efi 3J/
Lleste, las Lim. X
Date Convector
ARCHITECTS DECLARATION
1 understand my plans shill ec used as public recoNs
Licensed Professional -- --
OWNIIR-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractors License Law for the
fallowing reason. (Section 0031,5, Business and Professions Code: Any city or county
which requires a permit to construct, alrer, improve, Jcnmish, or repair any struemre
prior to its issuance, also requires the applicant for such permit to file a signed dammetn
that he is licensed pursuanuo the provisdion,of He Contractors License Law (Chapter 9
(commencing with Section 7wh of Division 3 of the Business and Professions Cale) or
that he is exempt therefrom sand the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil Penalty of
not more Nan foe hundred dollars ($509).
❑ I, us owner of the property, or my employees with wages as their sole compensation,
will do the work, and the structure is not intended or offered for sale (Sec. 7044. Business
and Professions Costs:
The Contractors 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 arc not intended or offered for
sale. If, however. the building or itnprovenunt is sold within one year of completion, the
owner -builder will have the burden of proving that he did not build or improve for pur-
pose of sale.).
❑ 1, as owner of the propeny, am exclusively contacting with licensed convectors to
construct the project (Sec. 7144, Business and Professions Code:) The Contractors U.
cense Law does not apply to an owner of property who tabula or improves Hereon, and
Who convects for such projects with a commends) licensed pumuanno the Connnemr's
License law.
El I um exempt under Sec. ,B& P C for this reason
e,4.1X
ryyp
.N4 J ACTOR% s�
DDRMS:
O,SV bM*
❑ Consultant Fees Paid by Applicant (Initial)
PTY ELECTRIC PERMIT IEE
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL
PANELS
UPTO 200AMPS
Owner Dam
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
I have and wil l maintain a Ceaideate of Consent to self mature for Worker's Compete
I.., ua provided for by Section 3700 of the Labor Code, for the perfomunce of the
ark for which this Permit is issued.
❑ 1 have and will maintain Worker's Compensation Insurance, as required by Section
37M of the Labor Code, for the performance of the work for which this permit is issued.
My War s Com ematiou/ leek r and Policy own r
Cartier. ��rg�QIC/dir/ Policy No:
CERTIFICATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE.
(This section need not hea+mplemA if the permit is for one hundred dollars (8110)
or less.)
I really that in the performance of are work fm which His permit is issued, I shall
not employ any Person in any manner so as to become subject to the Workers Cmdpem
Oz union Luws of California. Dam
Z Applicant
.Ni NOTICE TO APPLICANT: IL aper making this Certificate of Exemption. you should
abecome subject to the Workers Comptromman Provisions of the Labor Code, you must
W forthwith comply will, such pmvisinns or this permit shall be deemed revoked.
Z)z CONSTRUCDON LENDING AGENCY
U 0 I hcreby affimulem Hemi, act natmction lending agencn
y fohe perfmmanot of
ork
the wfor which this permit is issued (Sec. 3097, Civ. C.)
0 V Lender's Name
Lender's Address -
�" y 1 certify that 1 have mad this application and sum that the above information is
y c..,. I egrcen cnnhply wish alp city and ooumy oNinances end stone laws relating to QTY.
U building amswninn. unJ herchy mnhorize reprenenmtivcs of this ci,ym enmrupnn the
above-mentioned Property far inspection EnTswes.
(We) agree to save, indemnify it keep harmless the (:try of Cupertino agains,
liabili,ies,judgmems, costs and expenses which may in any way attme against said Ciry
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant minions huildingoccupan, store ar handle hasrdous araminal
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 25532(x)'/
❑Yea El No
Will the applicant or future building occupant use equipment or devices which
kit harardoua air connotations as defined by the Bay Arca Air Quality Management
❑Yes ❑No
1 have rand the hazardous materials eeyui emenu under Chapter 6.95 of He Cali.
fomia Health & Safety Code, Sections 25505, 2.5533 and 25534. 1 onderautnd that if the
building does not cmrnnlly have a tenant, that it is my responsibility to notify the mcripnm
of the mqu to menu which must be ton prior to issuance of a Cenificme of Occupm¢y.
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC.
'PIMP. MfilPR OR POLE INST.
POWER DEVICES
SWIMMING �POOL ELECTRIC
OUTLETS—SWITCHES 09X_7
SQ
PLUMBING
PERMIT ISSUANCE
ALTER— DRAIN & VENT— WATER (EA)
BACK FLOW PROTECT, DEVICE
DRAINS — FLOOR, ROOF, AREA, CONED.
FIXTURES—PERTRAP
GAS — F.A. SYSTEM�I'INC. 4 OEM LETS
GAS —EA. SYSTEM OVER 4 (EA)
GREASFANDUSTRL WASTE INTERCEPTOR
GREASETRAP
SEWER—SANITARY—STORM EA, 200 FT.
WATER HEATER WNENTIELECTR
WATER SYSTEMO REATING
WATER SERVICE
NEW RESIDENTIAL PLMB. SQ. FT.
MECHANICAL PERMIT
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT TO 10,0011 CFM)
AIR HANDLING MIT (OVER 10,000 CFM)
ME IAUST HOOD (W/DUCT)
HEATING UNIT (TO 100,000 BTU)
[MATING UNIT (OVER I(gk(ID013TU)
VENTILA'nON FAN (SINGLE RESID)
BOILER = COMP (3HP OR 100,009 BTU)
BOILER — COMP (OVER 100.000 BTU)
AIR CONDITIONER
NEW RESIDENTIAL MECH. SQ, ER.
OFFICE
31243
NITARY ND. APPLICATION SUBMITTAL DATE
�#
N/C CONROLp
BUILDING PERMIT INFO
El T PI.UMR MECH
7fL(Yt` ❑ ❑ ❑
JOB DESCRIPTION
RESIDENTIAL:
❑SFDVIL
❑ KITCHEN REMODEL
❑ADDITION
❑PLUMBING RE -PIPE
❑MULTIUNIT
0STRUCfURAL
' MODIFICATION
❑INTERIOR
IMNEY REPAIR
IMPROVEMENT
/ 1
❑ BATH REMODEIJREPAIR C DEMOLITION
❑ OTHER
COMMERCIAL:
❑NEW BLDG/ADDITION ❑DEMOLITION
❑TENANT ❑ FOOD SERVICE
IMPROVEMENT
❑OTHER
SQ. IT FLOOR AREA I $/SQ. Pf.
PA
PEE
UG 6Ion
STORIES
BUILDING DIVISION PEES
PLANCHECK FTiE
ENERGY FEE
GRADING FEE
SOILS FEE
PAID
Dam Reca,,, X
TOTAL:
BUILDING FEE
FEE SEISMIC FCC
ELECTRIC FEE
PLUMBING FEE.
MECHANICAL FEE
I HOUSING MITIGATION FEE I I
PAID
Date Receipt#
• SUBJECT: REROOFING POLICY FOR THE CITY OF CUPERTINO BUILDING DEPARTMENT
PRIOR TO ISSUANCE OF PMMIT AND INSPECTION PHASE.
1. Prior to permit issuance, you must agree to comply with U.B.C. standards and manufacturers spec's
on reroofing.
2. New roof coverings shall not be applied without first obtaining all inspection and written approval
from the building inspector. A final inspection and approval shall be obtained from the building
inspector when the reroofing is completed.
3. All types of roof shall be inspected prior to any roof being installed.
4. In order to receive a final, you must complete steps 1, 2, and 3.
1,) Preinspection or tear off approval.
2.) In progress inspection approval.
3.) Final inspection approval.
a.) Operable smoke detector verification
• b.) Spark arrestor installation
5. If plywood is installed, a plywood nail inspection is required.
6. If any roof is applied without first obtaining an inspection, you will be required to remove all new
material down to the sheathing and a building inspector will inspect all sheathing at that time.
WE UNDERSTAND THE ABOVE POLICY ON REROOFING AND WILL COMPLY WITH THE
POLICY p \
HOMEOWNERS NAME:
�Ci> DAF'l�Kt �'f'�2d$'Tl� J UNt�� G-7v✓Lffh9
ADDRESS: 7CDR�i c��L gL�i
REROOFING COIvfPANYNAbIE:
APPLICAN'rS SIGNATURE:
CITY OF CUPERTINO
BUILDNG DEPARTMENT
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