31116 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY •
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMrr NO. O 116
BUILDING DIVISION APPLICA'FIONIPF.NMIT PLUMBING-MECHANICAL J
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS, �� ' ` SANITARYNO. APPLICATION SUBMITTAL DATI
N11C1=1UN1
I'!I i 'SN : LIC 32.0LJNIC COMI'HO--
INEEN: LIC NO: ADDRESS: ❑
CONTACT. PHONE: IF BUILDING PERMIT INFO
prl��5 ❑ ConsultantFmsPaidbyApplicant(Initial) BILyD�j� ELECT PLUMB MECH
O7 LJ— ❑ ❑ ❑
LICENSED CONTRACTOR'S DECIARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm Nat 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
Co0004 Z with Sareande1orD"' 3ofthe eusinnse dl' dm licensors�� in full force and effort, ons �yn y i enuis pERMTT ISSUANCERBSIDENTIAL
UF us ``7/ WL ❑KITCHIiN R1iMODEL
¢UU Licenu LIC.# as
APPLIANCES-RMIDC•NUAL []ADDITION ❑PLUMBING RH:PIPE
rFiiQa Dam�TSDECr
F.Dta ARCHITECTS DECLANATION PANELS ❑MULTLUNIT ❑STRUCTURAL
z O y Z I understand my plans shall Ine used as public records MODIFICATION
p4F- UPTD 200AMP5 [I INTERIOR [I CHIMNEY REPAIR
a u] Licensed Professional 201-1"AMPS IMPROVEMENT
tY Y ,4 OWNER-BUILDER m Ce Contractor's
ON OVER 1011IIAMPS 11 BATH REM E EP/s�R ODE. TION
S a ¢ I hereby affirm that I am exempt from the Contrunor's License Lew for the L[roT L
x�6V following reason.(Section 7071.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL �kq,'
W 3(L F^ which requires a pemdt to construct.Blur,improve,demolish,or repair any structures p e y I •1 N�
'or to its issuance,alsort requires the applicant for such Permit File a signed statement
P^ 9 pP ra 8 SPECIAL CIRCUITSMISC.
Q£ that hemlicensed pursuanttoN)provisions of the Contractor's License Law(Charter9
Wrp0 (commencing wird Section 7")of Division]of the Business anJ pmfeasiunsCode)or TEMP.MEIER OR POLE INST. COMMERCIAL:
It a n�' Nat he is exempt therefrom and the basis for the eHeard exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Section 7071.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES
^m []TENANT ❑FOOU SERVICE
not mom than five ft hundred dollars(empl. IMPROVEMENT
=6 0 Lo the work,
of the property, remyemplended m withwages as their sole 044.8 sins, SWIMMING POOL ELECTRIC
P.on will do lesions Bad the s o Cont is tors License La doesed of apply to an owner
of ❑OTHER
a3 m and Professions Cade:The Contmnur'e License Law does not apply m on owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves domino,and who dies such work himself or through a
his own employees,provided that such improvements am not intended or nlTcred for NEW RESIDENTIAL ELECfR 'SQ PU
sale.If.however,Ne building or improvement is sold within one yeurofemopletion,the Q.FT.FLOOR AREA VSQ,FT.
owner-builder will have the burden of proving am he did no,build or improve for Four. �u�
of.)I.),
❑ QAAR h m owner the propcny,um exclusively contracting with licensed cnmmcmm rs - TOTAL: �0 I
construct the project(Sec.704L$,Routines and Professions CndcJ Shu Canwno/s Li-
cense Law does not apply toanowner(if proprtywho holds orimproves thereon,and QTY. PLUMBING PERMIT FEE CITY UTuur-I: T1NU
who comrans for such projects with a coedraoous)licensed pnpLnnl lu the Cuntrucao's
License Law. IPERMIT ISSUANCE
❑I am exempt under Sec. ,B&PC for tbis mum
ALTER-DRAIN&VENT-WATER HEA) UALIIN
Owner Dunn VAI
/R9Q
._.
WORKER'S p COMPENSATION Dfthefollow[ON BACK FLOW I'I10TIiCT DEVICE
I hereby u1Rrm ander penalty of perjury nnc of the following declarations:
I*Olhave and will maintain uCertilicnte of Cnnnem In sal Linsurc for Worker's Comport- URAINS-FLDUR.ROOF,AREA,GOND. STORIES TYPECONSTRUCTION
motor,os provided for by Section 371X)of the Luhor Code,for Ne lsahvmance of the
or
which this pernit is issued. FIXTURES-PER TRAP �7
va and will mountain Worker's Comrcomlinn Insurance,os requited by Section
3700of Ne Lah rCede,to'the pertermone ofnbe work for which this permit
tis'issued. GAS=HA.SYSTEM-I INC.4OUTLETS OCC.GROUP APN
MY Werke' fpgittsuran¢e/u^terad`Icy Nn.Y.5`r"t-�77 GAS-EA.SYSTEM-OVER 4(EA)
mu l 44''4411as�-��//
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEIINDUSTRL WASTE INTERCEPTOR
(This section need not be,completed ifthe permit is feline hundred dollars($100) BUILDING DIVISION PHU
ar Ic..) GREASE TRAP
PLANCHECK FF.F.
Loy any that inthein Perforanynommmcofthe work for subject
ich jetho thePermitWRcisC,Isha11 SEWER-SANITARY-STORM EA.200 Ff.
not employ any person in any manner so as to become nuM1jen to the Wndet%Compero ENERGY FEE
Z union Lows of C.1iform..Dae
WATER HEATER WNENT/ELF.CI'R
O Applicant GRADING FEE
yNOTICE TO APPLICANT:IL after making Ibis Certificate of Exemption,you should WATER SYMMTREATING
a , become mhject to the Workers Compensation provisions of the Lahr Code,you must SOILS FEF.
forthwith comply with such provisions.,,his permit shill be deemed revoked. WA'IERSERVICE
Q
UO CONSTRUCTION is.e at].ENDING AGENCY NF.W RPSIUFMIAL PCMB. SQ.FL PAID
I hertbyalErm sbauhere iseconswc.30 lending agency for the Performance of Date Receipt#
D. (, the wed for which this pennil is issued(Sec.31197.Civ.C.)
0V Lender's Name TOTAL:
Lender's Add.. TOTAL:
1 certify than 1 have mad this application and mate that the above information is BUILDING FEE
0 correct l agree to comply with all city and county ordinances and state laws relining to QTY. MECHANICAL PERMIT FEE -
C.J Z building construction,end hereby authorise exprsentatives ofthis city to enter upon the SEISMIC FEE
above-mentioned property for inapenion purples. PERMIT ISSUANCE
(We)agree so rove, end indemnify keep harmless the City of Cupeni no against ELECTRIC FEE
habilities,judgmems,costs and expenses which may in any way secure against said City ALTER OR ADD TO MECH.
in consequence of the granting of Nis permit PLUMBING FEE
APPLICANT UNDERSTAN S AND COMPLY WITH ALI.NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
SOUR UL O MECHANICAL ME
Q� AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCTIONTAX
nam fAppIicanUCons r Orae EXHAUST HOOD OVDUGG
HAZ US MATERIALS DISCLOSURE HOUSING MITIGATION PEE
Will theapplicant future building occupant store or handle hazardous material HEATING UNIT GO 100,000 BTU)
as defined by the Cul inu Municipal Code,Chapter 9.12,and the Health and Safety
Coda SeeOon 2557 a)7 HEATING UNIT(OVER 100,000 BTU)
❑Yes ❑No VENTILATION FAN(SINGLE RESID) PAID
Date Receipt#
W II the id,cont no future building occupaB use .Air Qu or devices which
emit homrduus Bir contaminants nx JeOneJ by the Boy Arcu Air Quality MonagcmemBOILFik-COMP(3HPOR 100,!100 BTU)
TOT
lot Lbuildiogdoostrot
BOILER-COMP(OVER 100,"BTU)
AI
s No
move mail the lormdous materials mquiremmrts under Chapter 6.95 or the Cull. AI R CONDI'f10NER ISSUANCE DATE
&Safety Code,Saninns 25505,25531 and 25534,1 nnd...oned that if the NEW RESIDENTIAL MECH. SQ.FT
trot currently haven mnanL that it is mymsp tmild lty m unity rhooccupummems which mum he met prior to....c nee ol'a Ccrificam of Occupancy.lunised.gcut Uate T'OTAI-: ISSUED BY:
OFFICE .