S 0231 (2) I
APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.ELECTRICAL PP.RMII'NO.
BUILDING UrvI510N APPLICATION/PERMI-P PLUMBING-ntEcudnlcAl.
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
OWNS 'S NAME: PHONE: COM'RACfORS NAME: LIC NO: NIC CONTROL#
'J
ARCHITECT/ENGINEER: LIC NO: ADDRESS: �^^ ❑
1
CONTACT: � PHONE. BUILDING PERMIT INFO
❑ Consultant Fee#Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑
LICENSED CONT'RACTOR'S DECLARATION QTY (ELECTRIC PERMIT FEE
I hereby atHrm that I am licensed under provisions of Chapter 9(commencing 106 DESCRIPTION
with Section](KK)of Division 3 of the Business and Prnlessinns Code,and my license is RESIDENTIAL
I+1 O PERMIT ISSUANCE
in full force and t. ❑SFDWL ❑KITCHEN REMODF:1.
U��] Licrn' ass Lic.N
ZZW Uvte � Z Cr trued"6 22 APPLIANCPS—RI'SIDIENTIAL ❑ADDI'T'[ON F1 PLUMBING RE-PIPE
.,,as � El MULTI-UNIT ❑STRUCTURAL.
F.Dyn ARCHITECT'S DECLARATION PANELS
ZO 7J. lundctam
rsd my pDmshell heuued as public record. MODIFICATION
OZ-q UITO200AMPS ❑INTIiRIOK ❑CHIMNEY RI7PA1R
Licensed Prolexsinnal 201-1000AMPS IMPROVINEM' 0SWIMMING POOIS
PGOWNER-BUILDER DECLARATION OVER 1000 AMPS ❑BATH REMODEURITAIR DEMOLIT19N
. pl)errm 69V
I hereby affirm m that 1 aexempt titanium Connector',License Law for the
X3 iL U following reason.(Seciion](131.5.Business snit Professions Case:Any city al county SIGNS ELECTRICAL (]OTHI,R _ i
which requires..Penni.to condruc6 alte,imprnvx.demolish,or repair my sesame
F,LL.,Oa prior to its issuance,also ventures the applicant for such permit to file a signed statement SPECIALCIRCUIT/MISC.
that he lx licensed pmrsu.ntto the pmvisimuofthe Cmarn LicenwLm,(Chapter 9
1y tY�� (commencing with Section 7")of Division 3 of the Business and Professions Cocitor TEMP.METER OR POLE INS/ COMMERCIAL:
a L o that he is exempt therefrom and the basis for the alleged exemption,Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
X,^„ Section by any appiicam.for a Permit subjects the applicant to a civil Penalty of POWER DEVICES (]TENANT ❑FOOD SERVICE
I-„zynot more than five hundred dollar Hilg)). IMPROVEMENT
6 1,as owner of the property,or my employees with wages as their sole compcosation. SWIMMING POOL FI.CTRIC
' f0 will do the work.and the structure is not intended or offered for sale(Sec/](N4,Business ❑OTHER
It. and Professions Code:The Contracturs License Law does not apply to an owner of Dl1TLlff$—SW CHfS—ITXTU •S
property who builds or improves thereon,and whir does such work himself or 11 u h
his own employees,provided thin such improvements are not intended or off for NIiW RES, .NUAL ELELfz SQEL
sale.If.hownm the building or improvement is sold within one year ofcompletion,the SQ.FF.11-OOR AREA SISQ.ET.
owner builder will have the burden of pinking that he did not build or improve for pur-
pxe of sale.).
❑I,as owner of the properly,am exclusively contracting with licensed contractors to AL:
mnmmrt the project(Sec.7044.Business and Professions Code:)The Contractors Li. it W V
cerise Law does not apply In an owner of property whit builds or improves.hereon.and QTY. PLUMBING PERMi/ PEE
who contracts for such projects with a cordracmr(spicensed pursuant to the Contractor's T UN 25
License taw. 1117RMIT ISSUANCE
❑lam exempt under Sec. .B&P C for this recon
Owner Date ALTER—DRAIN&VEN —WATERQA) C' ITYgUF 06ftTI0HPV
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE.
I hereby in.under penalty oeperjury one of,hc
veli following Wodecision.,kerCm
❑(haveand wie maintain sCertificate ofConsion to
Labor
ode,for the Worker's Compen- DRAINS-FLOOR,ROOF.AREA,COND. S'1'ORIliS TYI'F.CONSTRUCTION
work(as provided for by Section 3](Ifl of the Lahr CMe,for the penformence of the
work for which this permit is issued POSTURES-PER TRAP
,have and will coeoWorker's Compensation Insurance, inquired by Section
3700 of the Labor Conde.
for
r the performance of the work for whit.h this Pennit is issued. GAS-EA.SYS'FEM-I INC.4OUTLETS OCC.GROUP APN
My Worker's Compereation Insurance carrier and Policy number are:
Carrier: Policy No.: GAS-EA.SYS'FF.M-OVER 4(EA)
CERTIFICATE OF EXEM PEON FROM WORKERS' GREASEIINDUSTRI.WASTE(V_/CEPTOR COMPENSATION INSURANCE HOLDING DIVISION FEES
(This section died not bei completed ifthe permit is for one hundred dollars($100) CREASE']RAI'
or less) PIANCI IECK FEE
I.yanythat inia Pc��fO 'w�rkf�h 71 ismeW isers'Co ,en-sued.I shut gF.WiiR-SAN I'PARY- 'ORM EA.200 IT
notemployany personhe anyandm d.¢65yk Yy/b mthe Workers'Compen- ENERGY FEE
z scion Le C Inmiu )ate s WATER HEATH VENT/ELllC R
C z .,ifn Las GRADING FEE
try ICE TO APPLICANT:If,alter making this Certificate or Exemption,you whould WATER SY :MTREATING
("' ? become subject to the Workds Com irsawinn provisions of Ne labor Cale,you must SOILS FEE
forthwith comply with such Puri or this permit shall ha deemrxl revoked. WATE .CRVICF
�z CONSTRUCT ION LENDING AGENCY S NEWRESIDENI$At,PLMB. SQ.PF PAID pate Receipt#
V Q (hereby affirm that there is a construction lending agency for performance of
the work for which Nis permit is issued(Sec.3097.Civ,C.) 1,
Ai
0 Lender's Name k. TO'T'AL:
LUA Lxmixes Address ^ TOTAL:
1 certify that I have read this application and state that the above information is BUILDING FEE
Lary correct l agree mcmmply with all city and county ordinances and mate laws relating to QTY MECHANICAL PERMIT FEE
V z building construction,and hereby authorize representatives of this city to enter upon the SEISM IC FEE
stove-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmlcas the City of Cupcnino against • ELECTRIC FEE
liabilities,judgments,costs and expenses which may in any way acerae against said City ALTER OR ADD TO MECH.
in cnewtim id:of me granting of this permit PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL NON-PAINT AIR HANDLING UNIT(TO 10.000 CFM) MECHANICAL FEES hQLRC1i.REGULATIONS. I
AIR HANDLING UNIT(OVER I0,W CEM)
CONSTRUCTION TAX
gnature of Applicant/Contramar Dart EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant nr(mere building occupant pore or handle hazardous material HEATING UNIT CFO 100,000 BTU)
as definad by.he Calcium,Municipal Chale,Chapter 9.12,an I the ifedN and Safety _Jr1A Ind
Cale,DYes 25532m)? ❑No HEATING UNIT(OVER 100.000 RU)T ����
VENTILATION FAN(SINGLE.RESID) ('AID i
Date Receipt#
Will the aircount or imatum building ce the by Are.
AirQmity or Maceswhich BOILER—COME(3HP OR 100,000 BTU)
emit hnaoNous nit conwminanwax AeBnoJ by the Huy Aree Air Qmdity Management ^L TOTAL:
District?
E]Y. ON. BOILER—COMP(OVER 100,003 BTU)
I have most the hinardous materials requirements muter Clhapter 6.05 oftha C.16. 7
AIRCONOITIONER ISSUANCE DATE
form.Health&Safety Cods.Sections 25505.2!533 and 25534.1 midersmml that if Nc NEW RESIDENTIAL MECH. SQ.FT.
building does na io mntly have a tenant,thea it is my resgmsibil'uy is notify the occupant
ofthe remitteem,whi met prior to items of Cer ificia fOxe ncy.
1 1 Z007 Ir
Owner nr sutainum'agem Lane TOTAL • ISSUIiU BY:
OFFICE